Taiwan Today

The scene is familiar to anyone who has ever watched a medical soap opera. A doctor cau­tiously inserts a tube into the mouth of an old man whose lungs are fill­ing with a mixture of mucus and blood, while a nurse hastily draws the curtain. Some of the medical staff are busy helping the doctor; some hurry from bed to bed, checking on other patients. A few minutes later, the doctor whisks the curtain aside and quickly moves on to the next patient. This emergency treatment room contains no fewer than eight elderly men hooked up to life-support equipment of one kind or another, but the doctor simply doesn’t have time to stay longer. With a harassed frown above his surgical mask, he hurries to the next ward.

This routine is typical for Wang Lee­-min (王立敏), who is an emergency room doctor at Taipei’s Veterans General Hospital, one of Taiwan’s leading medical centers. His day starts at seven o’clock, when he goes on emergency room rounds with a junior colleague. It usually takes him three hours to finish, but afterwards he has to stay on call. On average, this emer­gency room copes with 250 patients a day, and at times it resembles a street bazaar, with a hubbub of noise generated by pa­tients, relatives, friends, and the over­ worked medical staff.

“The rights of emergency room pa­tients have long been overlooked in Tai­wan,” says Hu Sheng-chuan (胡勝川), a doctor in the Department of Emergency Medicine at Buddhist Tzu Chi General Hospital. “Most patients are dissatisfied with the service they get from emergency rooms, as are their families.” According to him, patients suffer a number of significant inconveniences. They have to wait too long before they get to see a doctor, be­cause emergency rooms at large hospitals are invariably overcrowded. And once they have received some initial treatment, many patients then have to wait another lengthy period before being transferred to a standard ward, owing to the chronic shortage of beds.

“It’s nothing unusual for them to have to wait over a week,” Hu notes. “Some of them die while they’re waiting, because there aren’t enough beds, or because the doctor doesn’t like them—maybe he thinks they’re being difficult and uncoop­erative, or maybe he just feels the case is too complex and troublesome to be worth treating. And with cases involving more than one discipline, you get problems when none of them is willing to take responsibility.”

It is hardly surprising, then, that the quality of emergency medical care comes in for much criticism. In Taiwan, there is no concept of an emergency medical spe­cialist—a doctor who confines himself to offering expert emergency medical care. Such emergency care as exists is tradition­ally provided by doctors rotated from de­partments of internal medicine, surgery, and pediatrics. Most of them are young residents still undergoing training, who are assigned to emergency rooms for a couple of months.

Also conspicuously lacking is a rec­ognition of the importance of pre-admis­sion care, which often influences the outcome of an emergency. According to Hu Sheng-chuan, statistics show that the first moments of emergency care are criti­cal: the victim of a serious heart attack is much more likely to make it if basic life support measures are administered within four minutes and advanced cardiac life support within eight. But at present Tai­wan’s ambulances are equipped only to ferry patients to hospitals. They carry no emergency-care facilities.

As if all that was not bad enough, Tai­wan’s emergency rooms operate on an open-plan system, which means that pa­tients are not screened off from one an­other. It is common for relatives to gather around the bed to keep a close eye on eve­rything the doctor does. Given the serious overcrowding, at peak periods many pa­tients have to endure all this in a hospital corridor. There is virtually no concept of privacy.

Hu Sheng-chuan spent a year study­ing emergency medicine in the United States. On his return in 1988, he submit­ted a proposal that the Department of Health (DOH), the Executive Yuan, and Taipei City Government’s Bureau of Health should together devise a plan for the establishment of proper emergency medical services (EMS). In the following year, local governments responded by allocating funds to their various fire departments in an effort to build up a proper emergency medical care system.

Firefighters are at the heart of emer­gency medical services for historical reasons. Taipei’s first ambulance, a gift decades ago from the American army, was mainly used for transporting people who had been injured in fires to the hospital. Gradually the number of ambulances in­creased, and the range of services widened, but responsibility for the system remained with the fire department. Firefighters now receive sixty hours of training in basic emergency skills as part of the course which they take at the police academy. Once they get their job assignments, they receive a further 260-odd hours of interme­diate emergency skills training, after which they qualify as EMTs (emergency medical technicians).

As soon as the emergency services log a “119 call”—Taiwan’s equivalent of a 911 call in the United States—they dis­patch the ambulance nearest to the patient to transport him to a designated hospital. In addition to the driver, each ambulance carries two EMTs trained to provide cardiopulmonary resuscitation and other basic life support treatment. This has gone only part of the way to alleviate problems, how­ever. A study conducted by the Society of Emergency and Critical Care Medicine shows that about 30 percent of call-outs result in “empty runs,” when an ambulance is called but for one reason or another the patient declines to ride in it to the hospital. And only 13 percent of the emergency patients who do make it to a medical center travel there by ambulance. This is because many patients and their relatives are reluc­tant to wait for an ambulance to come, and they don’t trust EMTs anyway. The result? A lot of injured or seriously ill people travel to hospitals by taxi.

Lack of public trust is a serious problem. Fang Chen-feng (方禎鋒.), a doctor in theTrauma Department of Chang Gung Memorial Hospital, has experience of emergency medicine in both Taiwan and the United States. Asked to highlight the differences between the two systems, he points out that in America the regula­tions vary between states, but that most US firefighters receive about a hundred hours of basic life-support training and must un­dergo refresher training every year. Fire­fighters with three years of experience and a good performance record may then be selected to receive a further 2,500 hours of advanced life support training—nearly ten times more than the 260 hours of the com­parable course in Taiwan—after which they become paramedics. “The percentage of people using ambulances is pretty high in those areas of the United States where the emergency services work well,” Fang says. “But here, people don’t have confi­dence in the system. We need to create a corps of paramedics, as well as strengthen the existing training of EMTs.”

Hu Sheng-chuan admits that the tech­nicians are part of the problem. “Most of them don’t regard it as their responsibility to offer medical care for emergency patients,” he says. “Their job is to fight fires, not provide medical services. There’s nothing in it for them—they don’t get anything for administering care, and they don’t expect to be disciplined for not giving it.”

Prompted by such considerations, the Society of Emergency and Critical Care Medicine and the DOH started working on a draft EMS law. The intention was to create a proper structure for emergency medical services and at the same time offer incen­tives for EMTs to provide medical care. The first draft was ready in 1990, and after lengthy revision it was sent to the Legis­lative Yuan for screening in 1993. The law was finally promulgated on August 9, 1995. Basically, it obliges fire departments to establish emergency medical service communications centers and provide teams equipped with not less than one ambulance and seven EMTs, at least two of whom must be aboard the ambulance on every trip. It also provides for a new type of ambulance equipped with emergency care facilities.

The law is obviously a good thing, but no amount of legislation can solve a problem like this without a corresponding change in the attitudes of those who have to implement it. Un­der the present arrangements, friction and disputes occur all too often. Doctors working in this field are dissatisfied with the existing degree of coopera­tion between EMTs and hospitals, and they often complain about it. But EMTs have a case, too.

“Basically, I think that provision of medical care should be the responsibility of doctors and nurses,” says Shieh Jiing-shiuh (謝景旭), director of the Taipei Fire Department’s Operations Communication Center. “Hospitals say they can’t equip ambulance with medical personnel, because of staff shortages. Well, we’re in the same boat, because our primary work keeps us extremely busy. At present we offer these medical services free of charge, and it’s very convenient for people—they just dial 119 and they don’t need to waste time filling out forms.” (The new EMS Law empowers the fire department to charge certain kinds of patients, particularly those not suffering from emergency conditions, for the services it provides.)

The Taipei Fire Department maintains sixty-nine ambulances, and in 1995 they were dispatched more than 50,000 times. “As firefighters, we’re very pleased to be of service to the public,” Shieh says. “But the difficulties involved in our offering emer­gency medical care are huge.” Apart from reluctance on the part of many patients to ac­cept treatment from EMTs, Taipei’s serious traffic jams make it hard for ambulance driv­ers to get to hospitals in a hurry. “We do our utmost to get there quickly,” Shieh main­tains. “We aim to get to the patient in 3.95 minutes.” And, according to Yang Han-chuan (楊漢湶), director of the DOH’s Bu­reau of Medical Affairs, “The time it takes to get a patient to hospital isn’t bad, com­pared with other countries. Our major problem is that there aren’t the facilities to provide care for patients at the scene of an accident and while in the ambulance.”

The fire department has also experi­enced problems with certain troublesome categories of patients, such as alcoholics and vagrants, who sometimes attack emer­gency medical technicians. There is a re­luctance on the part of some EMTs to deal with AIDS carriers, or persons suffering from serious infectious diseases. Some­times patients arrive at the hospitals aim­ing to have lost valuables or money, and they often blame EMTs. “The most depressing thing,” Shieh says, “is that sometimes the patients and their relatives don’t even bother to say thank you. So I ask you, should we be doing this, or not?”

Consumer attitudes have also had an influence on the development of emer­gency medical services. “People who won’t allow EMTs to administer medical care have got the wrong idea,” says Wang Lee-min of Veterans General. “Also, in many cases, patients who can walk will still call an ambulance to take them to the hospital. It’s a waste of resources.”

Another problem is the innate prefer­ence of many Taiwan citizens for large hospitals. Few people choose to attend a par­ticular medical center simply because it hap­pens to be near their homes, and the resulting influx of patients has become a serious burden for many of the island’s bigger hospitals. Wang Shih-ming (王世名) is president of the Society of Emergency and Criti­cal Care Medicine, and chairman of the Depart­ment of Emergency Medicine at National Taiwan University Hos­pital (NTUH), one of Tai­wan’s foremost medical centers. “Everybody wants to come to our hospital,” he says. “Even when we point out that they ought to transfer to another facility that specializes in their illness, they often turn us down. Even though there’s no bed available, they’d rather lie in a corridor here.”

Statistics highlight the size of the problem. The number of patients who passed through NTUH’s emergency room in 1995 was estimated at 63,943, well above the 60,000 who came the year before. In December 1995, for example, the number of patients “temporarily” staying in the emergency room while waiting for admission to a ward was 1,800. “This is peculiar to Taiwan,” Wang Shih-ming laments. “No Western countries have this problem. But it’s hardly surprising, because there really is a huge gap in quality between what’s on offer at large hospitals and at the smaller ones.”

What most concerns emergency room staff, however, is the possibility of disputes. “Sometimes relatives will even interrupt doctors while they’re checking other patients,” says Wang Lee-min of Veterans General Hos­pital. “They assume that they can speak to doctors anytime they want. If doctors don’t answer them, sometimes they lose their tempers and pick a fight. It doesn’t matter to them that the doctor has already examined their relatives. I think it’s better to keep the family out of the emergency room. There, it’s not like the normal doctor-patient relationship. These patients have never met the doctor before, and they won’t see him again. That’s why I always tell young doctors that they shouldn’t pay any attention to what the family says or does, but just act as they see fit.”

Medicine is traditionally seen as a highly respected, well-paid profession, but emergency room doctors have to handle more pressures and dangers than their col­leagues. “For example, emergency doctors often have to examine their patients while family members keep a suspicious eye on them,” Hu Sheng-chuan says. “Chinese people are curious by nature, so sometimes a whole group of people will gather round to monitor what the doctor’s doing. Even complete strangers come and have a look. Emergency doctors don’t get the respect they’re entitled to. Then there’s the prob­lem of ‘underworld’ patients—drug ad­dicts, people carrying firearms—and that’s worse in small private hospitals, because they tend not to have security guards.”

There are other reasons that cause young doctors to hesitate before choosing to work in emergency medicine. “The hours are unreasonable,” says Wang Lee-min of Veterans General. Doctors in pub­lic hospitals work a forty-four-hour week, just like any other civil servants. “But emergency doctors are on the go the whole time they’re on duty,” Wang emphasizes. “They’re always in a race against time. They should be allowed to work more flex­ible hours, like American emergency doc­tors. I think that ideally they should only have to work three days a week, leaving time for research and teaching. If that hap­pened, I think more young doctors would show interest in this field.”

One factor that almost certainly would entice more doctors into emergency medicine is fair remuneration for the job. “At the moment, the national health insur­ance program doesn’t pay enough for emergency medicine, even though it’s tougher than other fields,” Hu says. “A doctor is paid the same amount for curing someone of a cold as he is for treating critically ill patients. Night shift staff are paid the same as the day shift. Pay depends sim­ply on the number of patients, not the nature of the illness. And emergency specialists get the same as resident doctors. It’s unreasonable.”

Hu’s opinion is echoed by NTUH’s Wang Shih-ming. “Some of the really tough departments, such as surgery and gynecology, also find it hard to recruit,” he says. “It’s worse in public hospitals, be­cause there the pay is lower than in the pri­vate sector.” Even NTUH has had trouble recruiting enough surgeons this year. “Our surgical department has advertised for new doctors three times, and still can’t fill the vacancies,” Wang comments. “In the old days, only top-class NTU graduates were allowed to enter our surgical department. Now, any medical graduates can apply, no matter what school they’ve graduated from. Why the shortage? Because, despite the tough training surgeons have to un­dergo, they only earn the same as or even less than doctors in other departments.”

At present, emergency medicine in Taiwan is classed as a sub-specialty. The refusal to upgrade it to major specialty is another cause of concern to doctors. “Young doctors, worried about their career paths, are reluctant to devote themselves to emergency medicine,” Hu says. He notes that before emergency medicine can become a full specialty, the move will have to be approved by a committee consisting of DOH officials, academics, and specialists in other fields of medicine. “Perhaps spe­cialists in other fields are worried about the competition,” Hu says bluntly. “That’s why they won’t agree to our being upgraded.” But Yang Han-chuan of the DOH disagreed with him, pointing out that many doctors who practice emergency medicine have qualified as specialists in their individual fields. “Emergency medicine is just as important as internal medicine and surgery,” he says. “The procedures for issuing certificates are different, but I don’t regard that as important.”

One way of encouraging hospitals to develop emergency medicine is through the system of accreditation. This ranks hospitals and is a factor in determining how big a subsidy each one gets from the national health insurance program. Proce­dures do now include a review of the qual­ity of emergency-room services. “This shows that the authorities really have be­gun to pay attention to the development of EMS,” Hu says. “But the accreditation cri­teria don’t do much to encourage hospitals to employ specialists in emergency medi­cine. It’s left up to them. That’s under­standable, though, because the fact is that if every hospital were forced to hire emer­gency specialists, most of them would shut down [because there aren’t nearly enough specialists, islandwide]. New rules will have to be brought in gradually.”

Despite all the difficulties facing Tai­wan’s emergency medical services, many of the doctors who practice in this field express optimism. “I believe the future of emergency medicine is promising,” says NTUH’s Wang Shih-ming. “Specialists in this field are likely to become ‘hot.’ That’s because they tend to gain a lot of experi­ence in surgery, internal medicine, pediatrics, and gynecology, so one emergency specialist can cover everything, and hospitals save money by hiring them.”

Moreover, the DOH clearly recognizes the need for action. “Development of emergency medical care will be one of our priorities over the next few years,” Yang Han-chuan says. “And recently we’ve been cooperating with hospitals in promot­ing public CPR classes, which is going to be very helpful in developing Taiwan’s EMS.”

Wang Lee-min of Veterans General Hospital certainly has no doubts. “I confi­dently expect to see EMS put on a proper footing,” he says. “As long as everyone­ and that includes doctors, patients, EMTs, and the authorities—has the right ideas, proper emergency medical services will be here before we know it.”