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(To see both the Japanese transcript and the English translation, click here.)
The ICU of the Acute Medicine department in the Tokyo University Hospital. The treatment that took place here about a year and a half ago was unprecedented in the world.
He is Dr. Kazuhiko Maekawa. He has been involved in the emergency care for about 30 years. It was the first time that he encountered a patient who had received a massive amount of radiation.
"In the accident that occurred at the Tokaimura plant of JCO, three workers were exposed to radiation..."
The criticality accident occurred at the nuclear fuel processing facility in Tokai village and two workers were killed by a heavy exposure to radiation.
He is Hisashi Ouchi, the first victim of nuclear accidents in Japan. He was exposed to radiation that was about 20,000 times more than the permissible annual limit for ordinary people.
This team was in charge of the treatment of Ouchi. They applied all the latest medical technology to the treatment that the world had never seen before. However, they were overwhelmed every day by the horrible effects of radiation exposure.
"Simply put, our pride as medical professionals was broken into pieces."
"I think keeping him alive as long as possible was just like an agony for him."
"I don't want him to thank us. I would accept his resentment. All I want is the answer whether we did the right thing."
These are the 83-day records of Ouchi's treatment. The records are disclosed for the first time because his family hopes his death should be of help to someone else. You can see the medical team's anguish as well as his family's desperate hope for his recovery. We are going to follow Ouchi's 83 days with his medical records and the interviews of his medical staff.
Dr. Maekawa, who specialized in emergency care, first heard of the accident early afternoon on that day.
"I heard something had apparently happened in Tokai village and I watched TV to see something terrible had actually happened there. While I was watching TV news, I noticed the staff of the NIRS (National Institute of Radiological Sciences) wore protective suits and masks. Therefore I suspected the degree of the contamination might have been quite high."
Because of his massive exposure to radiation, Ouchi was transferred to the Tokyo University Hospital in order to receive the most up-to-date treatments. Dr. Maekawa became the leader of the medical team due to his central role in a professional group of the radiation emergency medicine.
"The amount of radiation that Mr. Ouchi had presumably received was fatal. That was obvious to everyone in the team. However, Mr. Ouchi looked very well at that point and we didn't have an impression that he had been exposed to such a high level of radiation. Therefore we determined to do everything we could."
The first patient who had had a radiation exposure was quite different from what the nurses had imagined.
"The doctor brought him up, on the stretcher as usual, to the private room in the ICU, like an ordinary patient. I met him there. His skin was reddish as if he had got a terrible sunburn. His arm was badly swollen and he said he had a pain in that area."
"I thought at that time that he wouldn't have to die, I mean, he would be well enough to leave the hospital."
This is Ouchi's right arm which received the highest radiation exposure. At this time, the arm was only slightly reddened and swollen.
On the day of the accident, Ouchi was handling radioactive materials according to the company's instructions. The task was to enrich uranium using a bucket. He was never told about the possibility of criticality. His co-worker was pouring uranium solution and Ouchi was holding a funnel with his right hand. On the seventh pouring of uranium solution, a blue flash was suddenly emitted. A criticality, or a nuclear chain reaction, had occurred. The radiation penetrated the chromosomes of his cells.
Chromosomes are the blueprints of a human body that contain all the genetic information. Each pair of chromosomes has a number and can be arranged in order. However, it was impossible to arrange Ouchi's irradiated chromosomes. They were broken apart and some of them were stuck to each other. The destruction of the chromosomes meant that new cells would not be generated thereafter. At the moment of the radiation exposure, Ouchi lost the blueprints of his body.
"From the fact that his chromosomes suffered such catastrophic damage, we inferred that his liver cells and bowel mucosal cells were also severely damaged and they might not be able to regenerate themselves."
The first abnormal symptom due to the chromosome destruction appeared in his blood cells. The number of his white blood cells, which acted as a defense mechanism of the body, was decreasing dramatically. He was in a perilous condition where viral and bacterial infections were likely to occur.
Ouchi was transferred to a sterilized room in order to prevent infection. The number of his white blood cells had decreased to one tenth as compared with healthy people. Dr. Maekawa and his medical team discussed the treatment strategy. The only way to handle this situation was to transplant cells that produce white blood cells.
To perform the transplantation, they had to look for a person whose white blood cell type matched with that of Ouchi. They found that Ouchi's sister was the person. Using this apheresis system, they immediately began collecting blood from her. The white-blood-cell-producing cells were extracted from her blood. The blood collection took more than nine hours over two days.
Her cells were transplanted into Ouchi. His future condition depended on whether his sister's cells could produce white blood cells in his body. It would take ten days to get the result.
Around that time, Ouchi was able to talk with his family and the nurses.
"I asked him how he had got married to his wife. He told me that they had known each other since high school and they had married after quite a long ... about seven years ... relationship. I was impressed by his story and said, 'You married with a passionate love!' or something like that."
Dr. Maekawa explained to Ouchi's family about his condition and treatment every single day. This is the reception room where the explanation took place. Dr. Maekawa candidly told Ouchi's family that his condition was expected to get worse in the future.
"I tried to have his family accept the truth by at least letting them see him every day. I don't mean to be idealistic. However, he suffered damage from enormous radiation and his appearance was changing drastically, so I had his family see his condition in order for them to accept the truth."
The radiation damage also appeared on the surface of his body. About a week after the accident, scars from removing surgical tape became no longer able to heal.
"At first, we used surgical tape as usual. However, it became more and more frequent that his skin was ripped off along with the removed tape. Eventually, we couldn't use surgical tape anymore."
Healthy skin cells divide rapidly and new cells replace old ones. However, in Ouchi's irradiated skin, new cells were no longer generated. His old skin was falling off. Intense pain in his skin. The battle against infection. He had developed fluid retention in his lungs and he began to experience difficulty in breathing.
These are Ouchi's words in his nursing records.
(I can't stand it!)
(I wanna go home!)
(Stop it!)
(Mom!)
The medical team considered putting him on a respirator to help him breathe easier. That meant he would become unable to have conversations with his family. Ouchi talked to his wife who visited him.
"At that time, Mr. Ouchi was probably feeling weariness and heaviness, and he seemed to need to gather strength just to speak. In spite of that, he was smiling slightly and said to his wife 'I love you' in a tender tone. Seeing that kind of scenes made our hearts ache. It was true that nobody knew for sure what would happen to him, but we were able to imagine that his condition would get worse and worse. I guess he himself was also aware of that. In that situation, he told his family of his love. I wonder how he felt when he said to his wife 'I love you.' I think it was a heartwarming moment, but ... I don't know what to say ... I think his words represented what he wanted to tell his family."
Next day, Ouchi became unable to breathe. Endotracheal intubation was immediately performed. That is, a tube was inserted into his windpipe. Ouchi's silent battle began.
His family visited him every day. In this room, his wife, son, parents, and brothers waited to see him.
"When I came to see them for some reason, they were intent on folding paper cranes. That made a strong impression on me."
These are paper cranes that Ouchi's family folded. They wished that they could put at least one crane by his bedside. However, it was not allowed to bring one in the sterilized room due to the risk of infection. His family continued to fold paper cranes.
Ouchi's blood was tested to see whether the white-blood-cell-producing cells from his sister were living in his blood. There were two red dots in a cell. The dots indicated the existence of female chromosomes. His sister's cells were living in his blood.
"Everyone felt relieved at the result. We managed to get over the first hurdle, even if only temporarily. I thought we would be able to keep going because his white blood cells had increased significantly."
It was the first time that the transplantation of white-blood-cell-producing cells had succeeded in the treatment of radiation injuries. The number of his white blood cells increased at a good rate and recovered to the same level as that of healthy people. Ouchi responded to his family's calls with his whole body even though he couldn't speak.
A week later, however, subtle mutations were observed in his blood cells. These are the chromosomes from his sister's cells that just took root in his body. In some of them, abnormalities were found. The chromosomes were damaged. The medical team presumed that the radiation was also responsible for the damage. When penetrated by the radiation, substances in his body were mutated to emit radiation on their own. It was inferred that the radiation from inside his body had caused the chromosome damage.
"There are a lot of patients who have blood diseases and receive a bone marrow or peripheral blood stem cell transplant. However, it has never been observed that cells transplanted to the patients have that kind of abnormality. We were shocked by the post-transplant chromosome damage and we realized once again the horror of radiation exposure. We keenly discussed the possible causes of the damage. However, we couldn't reach any conclusion because there was no evidence."
The aggravation of his condition was not limited to his blood and skin. This is an endoscopic image of Ouchi's intestines. The dead mucous membranes turned white and drooped down. Voluminous diarrhea began. It is said that radiation injury patients often die due to digestive tract disorders. Dr. Maekawa's worst fear had happened.
Investigational new drugs were administered with the consent of Ouchi's family. However, the amount of diarrhea increased day by day to more than three liters per day. Three weeks after the diarrhea had begun, his intestines started bleeding. His intestines were filled with blood that oozed from the wound where mucous membranes had fallen off.
This is the record of Ouchi's blood transfusions. One blue sticker corresponds to one transfusion. There were days when more than ten transfusions were performed in half a day.
"It was almost impossible to provide a scientific basis for the treatment of him who had received such a high level of radiation. We tried every possible treatment and medicine. I think, even in hindsight, we could hardly take further measures against the bleeding in the digestive tract."
Ouchi was transferred to a bed for critically ill patients. The bed tilts 55 degrees. It was intended to improve systemic circulation and to reduce pressure on his skin. His condition was further deteriorating.
This footage shows his treatment at that time. His blood and fluid were oozing from the area where his skin had been lost. His almost entire body had to be covered with gauze.
"Day after day, there was a lot of exudate in his skin. It took almost half a day to treat it. He was surrounded by many doctors to receive skin treatment, but he seemed to feel severe pain. We administered large doses of narcotics to put him to sleep, but he looked very painful."
"His eyes were easy to dry and bleed. He was bleeding from his eyes. It looked like blood tears."
Ouchi's body was covered with a lot of gauze. From the area whose exposure level was high, the damage spread throughout his body. He was losing about 10 liters of fluid a day through his skin and intestines. It was necessary to constantly replenish the same amount of fluid.
The medical team decided to do skin transplantation in order to prevent fluid oozing. This is a piece of cultured skin prepared by cultivating human skin cells in vitro. The transplantation of cultured skin, which was one of the latest treatments for burn injury, was conducted almost every day.
"He had already lost his own skin, so we rubbed the surface of his body with gauze to expose the bleeding layer and put the cultured skin on the area. That was not so extensive treatment. We did the transplantation as soon as we got some pieces of cultured skin. However, unfortunately, the cultured skin did not adhere to his body. I guess it might be because of his general condition."
This is Ouchi's right arm one month after the accident. The radiation destroyed his chromosomes and his cells were being lost one after another.
At the meetings about the course of treatment, the doctors' remarks had become fewer and fewer. Dr. Maekawa always decided the course of treatment. After the successful transplantation of the white-blood-cell-producing cells, there had been no visible progress.
"It was obvious to everybody that the chance of his survival was very slim. Nobody didn't say that aloud, but I think everybody shared the same feeling. However, if somebody had said that aloud, if somebody had had doubts about the active intervention in his life and the doubts had spread across the team, we would have lost sight of our purpose. What the hell are we doing? For whom? For what? I guess we were afraid of having that kind of thought."
"After his condition began to get worse and worse, I wondered WHAT this person was, rather than WHO this person was. He was in such a terrible condition. There was a body in front of us. The body was not remotely healthy but was severely battered and surrounded by a lot of equipment. That was like a continuous battle to preserve the body. We had to keep his corneas from drying out. We had to cover his body to prevent his skin from coming off. That kind of treatment continued endlessly. We almost lost sight of what we were striving for. Our purpose was not to protect his corneas. I couldn't have endure doing the treatment if I hadn't had the conviction that I was doing it to protect his life."
Nearly two months had passed since the treatment started. Massive blood loss and repeated blood transfusion. Ouchi's heart was beating wildly to pump blood throughout his body. His heart rate was over 120 beats per minute. His heart was working as hard as when running a marathon.
On this day, Dr. Maekawa started making rounds about seven a.m. as usual. Right after that, he saw the monitor and rushed into Ouchi's room. Ouchi's heart had suddenly stopped.
"I hastily rushed into his room and the medical team immediately started cardiopulmonary resuscitation, that is, cardiac massage."
Ouchi's heart started beating again, but stopped again. His heart repeated start and stop three times. The medical team performed cardiac massages and administered cardiotonic drugs minute by minute.
"I had no idea what had happened. I got all the team members together and we massaged his heart hoping that his heart would start beating again."
About an hour later, Ouchi's heart started beating again on its own.
"I was so relieved when he came back. I couldn't think of anything at that time. I was desperately hoping his coming back. When he came back, I felt relieved that he was alive."
However, the stoppage of his heart had serious effects on various organs throughout his body, such as the brain and the kidneys. Ouchi's condition was deteriorating rapidly.
Ouchi no longer responded to his family's calls. His life was supported by medical equipment and medicines.
"After a long period of treatment, some of the staff members, including me, had a feeling that we shouldn't continue the treatment anymore. However, Mr. Ouchi's family didn't give up hope for his recovery until the very end. I think that was the main driving force that supported us."
These are his family's words at his bedside. His mother called his name.
(Hisashi, hold on.)
His father spoke in his ear.
(Never give up!)
A new situation arose in Ouchi's blood. These ameba-like things are his immune cells. Immune cells fight bacteria and viruses and get rid of them. His immune cells became abnormal and were attacking his normal white blood cells and other cells. Blood transfusions and hematinic drugs were administered repeatedly.
"The number of his white blood cells was decreasing rapidly. Eventually, the number decreased back to almost zero. Under those circumstances, there was nothing left we could do. We were sort of stuck in a stalemate. I don't know how to describe my feeling at that time. We could move neither forward nor backward. There were no workable solutions. My honest feeling was that we were in a complete deadlock."
Ouchi's abnormal immune cells were attacking even the white blood cells that were produced by his sister's cells.
On the 81st night after the radiation accident, Dr. Maekawa called Ouchi's all family members together. Dr. Maekawa told them that even if Ouchi's heart stopped again, any further resuscitation attempts shouldn't be made.
"His family agreed to my suggestion, and I gave the medical team strict instructions not to perform cardiopulmonary resuscitation if his heart stopped again."
His family left the room quietly.
Next day, Ouchi's wife spoke to him. She wanted to ring in the new year with him.
His family continued to fold paper cranes in the waiting room. The number of the cranes was almost ten thousand.
On the 83rd day after the radiation accident, his wife visited him with his son. They saw him without gauze covering his face. His son, who was an elementary school student, spoke to him.
(Dad, hang in there.)
"His wife cried for the first time. As far as I could see, that was the only time she cried. Apparently, she was trying to suppress a cry. I thought she didn't have to do that."
That night, Ouchi passed away. The 83-day battle of Ouchi, his family, and the medical team ended.
Radiation exposure destroys human body from the inside. The effects of radiation spread throughout Ouchi's body.
This photograph shows his muscle tissue. Muscle tissue is considered to be the least vulnerable to radiation damage. However, most of the muscle fibers were lost by a massive amount of radiation. Among those, only one organ remained intact without its muscle tissue damaged. Heart. Only his heart muscle was not destroyed by radiation.
"Of course, there are differences between heart muscle and other muscles. I studied various medical literature, but for now, I'm not quite sure why his heart survived in contrast to other muscles. We discussed whether that was an effect of radiation or an effect of various treatment such as medicines. Both opinions are plausible and I haven't yet reached a conclusion. However, considering the fact that his heart survived the radiation exposure, I think this is one of the issues that we, medical professionals, should address in the future."
Ouchi's heart stayed alive even though all other cells in his body were destroyed.
Doctors and nurses continued to devote themselves to the treatment of Ouchi in this ICU. Those days left profound questions that still remain in each team member's mind.
"This case made me painfully aware that the system made by human beings could cause terrible disasters with one wrong move. There is nothing mere doctors like us can do about that. With any latest technology and equipment, we have no chance against the catastrophic effects of radiation. We learned that the hard way."
His encounter with Ouchi was a major turning point for Dr. Maekawa. This spring, Dr. Maekawa reached retirement age and left the hospital. He has decided to work on establishing medical systems for treatment of radiation exposure.
"People who passed away will never come back again. There will be no next time for people who passed away."
This is a letter from Ouchi's wife to Dr. Maekawa.
"Maybe I'm too pessimistic, but I can't help but think that a similar accident would occur again as long as nuclear energy is inseparable from our daily lives. My distrust of nuclear energy will never go away because it is handled by human beings. If people who are involved in the nuclear industry cannot protect themselves, the medical field should learn the lessons taught by my husband and his colleague at the sacrifice of their lives. I hope that wretched victims, like my husband, can be saved in the future."
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