To clarify problems in the cardio-pulmonary arrest (CPA) cases that occurred in a bathroom, we investigated the medical care and results in 32 cases of CPA (14%) out of the 215 patients carried into our emergency center with CPA from August 2002 to July 2003.
The ages of patients ranged from 43 to 91, indicating a high incidence of CPA in ages over 70 but with no difference between sexes. Most of the cases (21/32, 65.6%) occurred from November to February. Through the exact time of onset was unknown because it was in a bathroom, it took an average of 8.4 minutes from receiving a 119 call until arrival of the ambulance. Average time at the site was 17.4 minutes, and it took an average of 11.0 minutes to transport the patients from the site to the hospital. Out of 32 patients, only six patients (18.8%) received cardiopulmonary resuscitation immediately after the onset. Advanced treatment (mainly airway management) was applied by paramedics on 23 out of 32 patients (71.9%). When carried into the hospital, patients were in CPA and electrocardiogram indicated asystole. Though advanced cardiovascular lifesaving means were applied promptly, most patients (31 cases) were already dead when carried in with one exception whose heartbeats resumed. Causes of onset estimated from clinical findings included 14 drowned, three with subarachnoid hemorrhage, one with trauma, one with aortic disease, one with respiratory disease, and 12 with suspected heart disease and/or unknown causes. In four cases in which subarachnoid hemorrhage or aortic disruption was detected, CT diagnosis clearly indicated that the cause of CPA was an internal disease
It is important to perform a sequence of lifesaving measures consisting of early access, early basic life support, early defibrillation and early advanced cardiovascular life support (ACLS). In the case of onset in a bathroom, in particular, it is highly probable that detection is delayed and that prognosis might be poor. However, it is possible to resuscitate patients with CPA that occurred due to an internal disease without any accompanying lethal influence on the respiratory and circulatory system, so it is important to provide training in cardiopulmonary resuscitation techniques. In addition, prudent bathing is required in winter seasons for the elderly who have some disorders.

 To clarify present status of outpatients related to bathing in the emergency critical center located in the hot spring area, medical records at the emergency room were analysed.  In last year, 162 cases (1.2%) related to bathing of 13,386 patients who visited our emergency critical center from April, 2009 to March, 2010.  There were limited because of poor records related to past history and hot spring, our data showed as follows: ①cases related to bathing were only 1.2% (162/13,386 patients), ②incidence of patients related to bathing was peaked December, ③two peaks were showed both 0-10 years old and 60-90 years old, ④males were dominant, ⑤physical diseases were accounted for 75% of diseases related to bathing, ⑥physical diseases mainly included cardiopulmonary arrest were suspected by drowned, syncope, and acute coronary syndrome, ⑦trauma mainly included hits and contusions treated by orthopedic surgery and neurosurgery, ⑧transportation was performed by ambulance account for 66%, ⑨outcome at discharge of emergency room were mainly stable condition including 69% of patients who returned home, and only cardiopulmonary arrest cases were dead.  Although children and older people who had past medical history regarding cardiology and neuroloy suffered from diseases related bathing, self checking system was not sufficient to prevent all sickness except for sudden death. It had better not take a bath alone.

It has often been pointed out that introduction of early rehabilitation programs may convey a considerable risk of cerebral hypoperfusion, presumably due to dysautoregulation. Cerebral blood flow (CBF) was measured in six patients with cerebrovascular disease using ^99mTc-hexamethyl propyleneamine oxime single photon emission computed tomography (99^mTc-HM-PAO-SPECT) to investigate whether warm bathing with CO₂ bubble stimulation (CO₂ bathing) can be applied to early rehabilitation programs. The subjects comprised two patients with hypertensive cerebral hemorrhage, two with aneurysmal subarachnoid hemorrhage, and two with cerebral infarction. CO₂ bubble stimulation was produced by dissolving 100g of commercially available CO₂ bubble forming tablets in 300L of warm water (41°C) and a course consisting of 10 minutes of CO₂ bathing was applied for seven days. Vital signs such as blood pressure, pulse rate, and body temperatures at the axilla and the external auditory canal adjacent to the ear drum were checked during each bathing. CBF measurements and routine laboratory examinations were made before and after the seven-day course of CO₂ bathing. Student-t test was used for statistical analysis.
No definite changes were shown in vital signs before and after CO₂ bathing. A significant decrease in WBC counts was observed after CO₂ bathing, but there were no changes in values of C-reactive protein. Although no significant changes in hemisphere CBF were identified, actual values of regional CBF in the unaffected hemisphere tended to increase in two patients.
These results suggest that CO₂ bathing produces no adverse effects on cerebral perfusion and can be applied safely to early rehabilitation programs.

  To evaluate the current state of the Onsen-Ryoho-Specialist (Broad Certified Fellow in Balneology, Climatology and Physical Medicine) training system, we surveyed the training facilities designated by the Japanese Society of Balneology, Climatology and Physical medicine (BCPM). Of the 24 facilities targeted by the survey, 21 responded (88%). Currently, the training curriculum for Onsen-Ryoho-Specialists consists of 8 units on diseases and 8 units on therapy methods. As shown in Figs. 1 and 2, it is difficult for a single facility on effectively cover all of these units. The most pressing need is to establish and implement a standardized curriculum across all facilities. Until now, each related academic society has selected training facilities based on its own criteria. Moving forwards, the review/accreditation body of the Japanese Medical Specialist Broad will make site visits to establish and review Onsen-Ryoho-Specialist training facilities. These efforts should lead to the development of fully qualified Onsen-Ryoho-Specialist training facilities.