A variety of hazards can precipitate the full or partial collapse of occupied structures. The rescue of entrapped survivors in these situations can be complex, require a multidisciplinary approach, and last for many hours.

The modern discipline of Urban Search and Rescue, which includes an active medical component, has evolved to address such situations. This case series spans several decades of experience and highlights the medical principles in the response to collapsed structure incidents.

Recurring concepts of confined space medicine include rescuer safety, inter-disciplinary coordination, patient protection, medical resuscitation in austere environments, and technical extrications.

Strategies have been developed to address the varied challenges in the medical response to collapsed structure incidents. (Disaster Med Public Health Preparedness. 2014;0:1–10)

In 2005, a seven-car commuter express train collided with an apartment building in Japan. The crash left 107 passengers dead and 549 injured. This paper highlights confined space medicine mat was provided for three survivors and introduces the current approach for training Japan Disaster Medical Teams (JDMATs) and/or rescue professionals.

A retrospective analysis of confined space medicine provided after the train crash and a study of training of JDMATs and/or rescue teams.

Three medical teams and search-and-rescue teams rescued three survivors whose bodies were trapped in the tangled wreckage of the first car. The medical teams secured intravenous lines and provided oxygen and approximately 4L of fluid before extrication. A 46-year-old woman was extricated in 14 hours, a 19-year-old man in 16.5 hours, and an 18-year-old man 22 hours after the crash. All three worsened at the final moment of extrication. Their crush syndrome required resuscitation at the scene, and intensive care such as hemodialysis and limb amputation in hospitals. Two patients survived and one patient died on me fifth day due to multiple organ dysfunctions.

Now, the curriculum of the JDMAT training course includes lectures and introductory exercises with rescue teams to learn the importance and difficulties of confined space medicine at the scene.

Confined space medicine was provided successfully after the train crash. Knowledge of confined-space medicine is essential to medical and rescue teams. Further education and training curriculum must be created.

On the morning of 25 April 2005, a Japan Railway express train derailed in an urban area of Amagasaki, Japan. The crash was Japan's worst rail disaster in 40 years.This study chroniclesthe rescue efforts and highlights the capacity of Japan's urban disaster response.

Public reports were gathered from the media, Internet, government, fire department, and railway company. Four key informants, who were close to the disaster response, were interviewed to corroborate publicdata and highlight challenges facing the response.

The crash left 107 passengers dead and 549 injured. First responders, most of whom were volunteers, were helpful in the rescue effort, and no lives were lost due to transport delays or faulty triage. Responders criticized an early decision to withdraw rescue efforts, a delay in heliport set-up, the inefficiency of the information and instruction center, and emphasized the need for training in confined space medicine. Communication and chain-of-command problems created confusion at the scene.

The urban disaster response to the train crash in Amagasaki was rapid and effective.The KobeEarthquake and other incidents sparked changes that improved disaster preparedness in Amagasaki. However, communication and cooperation among responders were hampered, as in previous disasters, by the lack of a structured command system. Application of an incident command system may improve disaster coordination in Japan.