Wako, Saitama Pref. – 

A gush of hot, muggy air rushes through the emergency room of Saitama Hospital one searing afternoon in late July as a stretcher carrying a bloodied elderly woman is rushed in.

The 80-year-old patient is bleeding from her forehead, arms and knees. Earlier in the day, she was found lying on the street after falling twice. When paramedics got to her after a call from a passerby, she was half-conscious and ran a temperature of 39.1 degrees Celsius.

The woman is suspected of having heatstroke — and the emergency room staff knows there is not a second to waste.

“Can you tell me your name?” a doctor shouts as other staff quickly attach a pulse oximeter, take her blood pressure and tie her to an IV drip while cooling her by spraying water all over her limbs and abdomen. “Can you tell me your birth date? Do you know where you are?”

The condition of the woman, who was initially breathing heavily and struggling to speak, improves soon afterward, and her temperature drops to 37.4 C. “It hurts!” she cries out, as the nurses try to draw her blood for testing. It means that she is conscious now.

“She was fortunate because somebody called her an ambulance soon after finding her on the street,” says Ichiro Hirayama, chief physician at the hospital, after she is whisked away for a CT scan to check if she suffered any fractures. “Her temperature and heart rate have dropped to their normal ranges. I think we are pretty much done with our initial response.”

A doctor at Saitama Hospital sees a heatstroke patient, a 12-year-old boy who got sick after playing table tennis, on July 24. | Anna Petek

As temperatures soar to record levels across Japan, cases like this woman’s are becoming more common. Rising heatstroke cases are weighing on the nation’s health care system, which is already wrestling with the growing burden of a rapidly aging population.

According to the Fire and Disaster Management Agency, the number of people taken to hospitals by ambulance for heatstroke has significantly increased since around 2010. With more frequent and extreme heat brought on by climate change, the number is projected to rise further, despite an expected population decline.

According to a recent simulation by the Nagoya Institute of Technology, the number of people transported to hospitals by ambulance would be double the level in 2010 in three prefectures — Tokyo, Osaka and Aichi — by 2040 based on 2 C of warming compared with preindustrial levels, a level that the world is expected to exceed by some margin based on current policies.

Last summer, Japan’s and the planet’s hottest ever, saw 91,467 people in Japan call an ambulance complaining of heat-related illnesses, the second-highest figure on record. That compared with 23,071 in 2008, when the agency started releasing weekly statistics.

The number of people dying from heatstroke has fluctuated, but has averaged over 1,000 annually in recent years, with those age 65 or older accounting for a majority of the deaths, according to health ministry statistics.

Nearly 40% of heatstroke cases take place in people’s homes — often due to the insufficient use of air conditioning by elderly people. Their condition tends to worsen gradually over several days. Such cases are harder to treat than young people, who typically get sick in public, such as when exercising outdoors, and also tend to recover quickly.

Saitama Hospital has seen a surge in heatstroke patients in recent years. | Anna Petek

Saitama Hospital has also seen a surge in heatstroke patients in recent years. The number of people taken to its ER for heatstroke or suspected heatstroke symptoms rose to 92 last year, up from 67 in 2022 and 33 in 2021.

Elderly patients are a particular source of concern, says Yoshiteru Tominaga, head of ER at the hospital.

“With more elderly people living alone, heatstroke often goes unnoticed,” he says. “Their cases are harder to detect early also because they are less responsive to heat stress. By the time they arrive at the hospital, their condition is often pretty severe.”

This summer, high temperatures have coincided with another wave of coronavirus infections, which means health care workers must be extra careful to determine whether patients are suffering from heatstroke, COVID-19 or both.

Yuki Honma, a nurse practitioner at the hospital, agrees that the ER response has been complicated by the effects of extreme heat, the coronavirus and other conditions older patients are saddled with.

“It’s getting hotter and hotter by the year,” Honma says. “I feel we are seeing more people who are brought here after collapsing on the street due to a heatstroke, but who are later found to have contracted infectious diseases. ... And if they have fallen and hit their head, we must follow up to see if they are OK from that injury. We must keep many things in check even when we see a single heatstroke patient.”

As for treatment, quick cooling is crucial, says Junko Yamaguchi, associate professor of acute medicine at Nihon University and head of ER at the affiliated Itabashi Hospital in Tokyo.

“The longer the patient’s core temperature remains high, the worse their prognosis becomes,” Yamaguchi says.

A doctor holds a saline bag used for heatstroke patients at Saitama Hospital on July 24. | Anna Petek

Doctors treating severe patients use a variety of tools and equipment to cool them. One common way is to place ice bags around the neck and against underarms and the groin, where thick blood vessels are located.

In addition, they sometimes use medical devices that allow cold water to circulate through cooling pads attached to the patient’s body. Spraying room temperature water on the patient’s body and cooling them with fans is also effective in releasing the body’s heat as water evaporates from the skin's surface.

“If the patient arrives with a temperature of 40 degrees, we aim to lower it to at least 38.5 degrees as quickly as possible, because the outcome is known to worsen if temperatures remain higher than that. So we use a mix of methods to bring the temperature down,” Yamaguchi says.

In life-threatening situations, some institutions use a temperature management machine where catheters are inserted into veins in the neck or the thighs to cool the blood directly, she says.

Yamaguchi stresses, however, that prevention and early detection are most important, noting there’s a limit to what the health care system can provide.

“Even if we allocate all the resources we can to treat a severely ill patient, there’s a high chance that they will die,” she says. “Even if we manage to save their lives, they may be left with severe aftereffects, requiring all-out care just to sustain their life.”

These include long-term damage to the brain affecting memory, attention span and thinking. Problems with balance and walking, swallowing difficulties and symptoms similar to those of Parkinson’s disease have also been reported.

The operations of emergency rooms have been complicated by the effects of extreme heat, the coronavirus and other conditions older patients are saddled with. | Anna Petek

To help enable an early response by ordinary people, Yamaguchi recommends JoinTriage, a smartphone app (currently in Japanese only) developed by the national association of ER doctors. The free app helps people judge whether to take somebody with heatstroke-like symptoms to an ER by putting in demographic info such as age, underlying conditions and symptoms. It also shows maps and routes to the nearest hospitals.

The national action plan on heatstroke prevention, drawn up last year and to be updated in 2028, outlines measures government agencies should implement to reduce the number of heatstroke deaths by half by 2030. It urges fire departments nationwide to call on people to use ambulances “timely and appropriately,” so as not to strain hospital ERs.

The action plan also urges government agencies to disseminate information about heatstroke prevention and first response in multiple languages and promote the use among inbound travelers of the disaster info app Safety Tips, which issues heatstroke and other alerts in 14 languages.

Back at Saitama Hospital, Hirayama is asked which heatstroke cases he remembers most. He pauses for a moment. Cases that linger on his mind are the lives that couldn't be saved, he says.

A couple of years ago, at the height of a COVID-19 wave, he dealt with a patient in his 60s or 70s who had been left lying outside for several hours. Because hospitals were filled with coronavirus patients, the ambulance crew struggled to find a hospital that would accept him. That’s how the man, who collapsed in Suginami Ward in Tokyo, ended up at the Saitama Hospital with a temperature of over 40 C.

The hospital staff did everything they could think of to save him, which included putting him on an artificial respirator and giving massive blood transfusions, Hirayama recalls. He had escaped the worst scenario, it seemed — until hours later, he fell into a state called disseminated intravascular coagulation, where the blood coagulation system breaks down, leading to bleeding from all over the body. The man died during his first night at the hospital.

Yoshiteru Tominaga, head of ER at Saitama Hospital, says that, with more elderly people living alone, heatstroke often goes unnoticed. | Anna Petek

“Heatstroke is often considered a nonfatal illness, but many people die,” he says.

“I want people to do what they can do beforehand — making sure elderly people stay in cool environments and they are checked on by families and others, as more of them will be living alone.

“If the number of heatstroke patients doubles in the future, I don’t think we will have the capacity to see twice as many patients.”

Culled from Japan Times