The recent water park tragedy brought to light some of the strengths and weaknesses of Taiwan’s emergency medical system.

In what New Taipei City Mayor Eric Chu described as the “worst incident of mass injury [ever] in New Taipei,” a dust explosion at the Formosa Fun Coast water park on June 27 flooded emergency rooms in northern Taiwan with over 500 burn victims. Remembered as a hellish inferno by those who experienced the explosion, the tragedy has already claimed nine lives, with many more patients still in intensive care.

The scale of the disaster strained Taiwan’s already overstretched medical system. The New Taipei City fire department sent 53 ambulances and 490 emergency medical technicians (EMTs), and fire departments from as far away as Taoyuan, Hsinchu, and Keelung also dispatched vehicles and personnel. In total, 144 ambulances and 1,235 EMTs were mobilized to attend to the crisis, and patients were sent for treatment to 43 hospitals around northern Taiwan.

The magnitude of the disaster forced many attending hospitals to call on off-duty or even retired physicians and nurses for assistance, and other medical professionals volunteered to put in extra shifts to help relieve the suffering of the hundreds of victims. The added manpower proved vital to the overall successful handling the crisis, says Dr. C. J. Huang, director of the emergency room at Chang Gung Memorial Hospital in Linkou, which received 48 of the victims.

At the same time, the incident prompted various suggestions for how the efficiency of Taiwan’s emergency response system could be improved. Taipei City Mayor Ko Wen-je, for example, himself a former emergency room surgeon, called for the integration of the response systems of New Taipei and Taipei to allow for better coordination in the event of future disasters.

In total, 144 ambulances and 1,235 EMTs were mobilized to attend to the crisis, and patients were sent for treatment to 43 hospitals around northern Taiwan.

The need for improved organization at the trauma site itself was also cited. “The onsite command system is not very strong,” says Chang Gung’s Huang. “Because of this, everyone could see ambulances coming and going at the site without much of a control mechanism.”

This mix of successes and stumbles has been characteristic of emergency care in Taiwan, a typhoon and earthquake-plagued area that is no stranger to large-scale disasters. Hopefully, lessons are learned from each episode, and from the Formosa Fun Coast explosion, the major problems requiring attention would appear to be ambulance coordination and ER overcrowding.

Standardized pre-hospital care is a relatively new concept for Taiwan, having developed in the latter half of the 1990s following enactment of the Emergency Medical Services Act in 1995. Under the new system, fire departments were designated as the control centers responsible for dispatching ambulances. In addition, more sophisticated EMT care, such as the widespread use of automatic external defibrillators (AEDs), was introduced.

When a major disaster occurs, information about available hospital beds is coordinated among six regional emergency operations centers (EOCs) around the country, which pass the data on to local fire stations. The EOCs, which constitute the first line of response in mass-casualty emergency situations requiring the services of fire department from multiple areas, are a relatively new addition to Taiwan’s emergency medical system. Established in 1999, they were set up following that year’s devastating “921” earthquake. The magnitude 7.7 quake killed over 2,400 people and injured over 11,000, and the sheer scale of the crisis prompted a massive centralization of Taiwan’s emergency medicine.

Damage caused by the 921 earthquake was concentrated in rural and mountainous Nantou County, where emergency resources are scant and coordination among local fire departments is difficult. “This disaster challenged our remote-area management,” says Dr. Shih Chung-Liang, Secretary General of the Ministry of Health and Welfare (MOHW), explaining the rationale for development of the EOCs. In the case of the water park crisis, it was the Taipei City EOC that had responsibility for passing information about vacant hospital beds to a commander on the ground at the trauma site.

Everyday emergencies

For a standard call to “119” where the coordinating services of the EOCs are not needed, local fire departments handle the EMT dispatch. In a system modeled after that of the United States, EMTs in Taiwan are trained to three levels of capability, with the highest classification earning the title of paramedic.

According to expert observers, efforts to standardize pre-hospital care throughout Taiwan in terms of accessibility and efficiency have not yet been fully successful. Rural areas, especially in central and southern Taiwan, face a serious shortage of paramedics. While Taipei and New Taipei City each has over 100 paramedics, in every other county and city in Taiwan there are very few such well-trained professionals. The 2014 MOHW annual report noted that funding continues to be allocated to improve emergency care in “areas with insufficient resources.”

Taiwan has a three-level classification system for hospitals. A level-one hospital has the lowest level of capability, while a level-two hospital is capable of delivering time-sensitive treatments for ailments such as heart attack and stroke. The top tier – level three – comprises largescale medical centers such as National Taiwan University Hospital (NTUH), Veterans General Hospital, and Chang Gung Memorial Hospital, institutions capable of providing advanced medical care when faced with severe trauma situations.

In Taipei, there are 21 level-one hospitals, 19 in level two, and 12 level-three medical centers, totaling 52 across the city. Patients from the recent waterpark disaster were sent to level-two and level-three emergency rooms, both of which were fully equipped to handle burn victims.

Dr. Yen’s suggestion is to affiliate each medical center with several medium-sized hospitals. Patients could first go to a medical center to be diagnosed, but would be expected to accept the doctor’s recommendation if he proposes transfer to a local hospital.

But even when not faced with major disasters, Taiwan’s top-ranked emergency rooms tend to suffer from a shortage of resources. “Overcrowding in emergency departments is the situation we are most concerned about,” says MOHW Secretary General Shih. A major source of the problem appears to be the unrestricted access to precious medical center ER care for patients with non-critical conditions. Because the National Health Insurance (NHI) system allows free choice of medical provider, many patients choose to go to a medical center ER instead of a local hospital or clinic. “The crowding problem, I have to emphasize, is a problem of medical centers dealing with non-life-threatening cases,” says Dr. Eric Zui-shen Yen, a member of the NTUH staff and Secretary General of the Taiwan Society of Emergency Medicine.

Dr. Yen advocates lightening the burden on medical center ERs by transferring more non-critical patients to lower-level hospitals. Under the current NHI system, patients must consent to a transfer, and many reject the idea for fear they will receive inferior care. Dr. Yen’s suggestion is to affiliate each medical center with several medium-sized hospitals. Patients could first go to a medical center to be diagnosed, but would be expected to accept the doctor’s recommendation if he proposes transfer to a local hospital.

In Dr. Yen’s view, “there is an opportunity for reform” by both streamlining the transfer process and educating the public about the adequacy of level-two hospitals. He makes the case that such reform is in the patient’s own interest. “Actually, from a patient’s perspective, an overcrowded ER is a big problem for patient safety,” he explains, noting that hospital-acquired nosocomial infections increase with overcrowding.

Although the handling of the water park incident revealed some areas in need of improvement, it also reflected some strengths in Taiwan’s emergency medical care, particularly in terms of preparedness. “Every year we ask the hospitals to do practice drills and prepare mass-casualty incident response plans,” says Secretary General Shih explains. “Every hospital has to have a plan to call back physician staff and to do it in a very short time to receive the incident patients.”

Chang Gung’s Dr. Huang says that when the water park tragedy occurred, “our hospital had just conducted a practice drill, so we were very prepared.”