TAIWAN IS AN ISLAND OF APPROXIMATELY 36,000 square kilometers (almost twice the size of New Jersey) and 26 million people. The island’s National Fire Administration (NFA), established in 1995, oversees 23 local fire departments; within the NFA, an emergency medical service (EMS) section oversees the EMS operations of local fire departments. In the past, EMS in Taiwan focused on transporting patients to hospitals; providers would only pick up the patients and drive them to a hospital emergency room. The government then passed a law in 1998 that mandated the equipment to be carried in ambulances, which put EMS in Taiwan on the right track.
One of the NFA’s three core tasks is EMS. Although Taiwan had some EMS laws before 1995, a systematic and logical EMS system was developed only after the NFA came into existence. Since Taiwan had set up a cabinet-level department to oversee EMS, the government decided to provide free fire department-based EMS for its citizens. Taiwan’s Congress passed EMS laws in 1995 to regulate EMS providers’ licensing and also mandated that every local fire department set up emergency medical technician (EMT) teams in its jurisdiction. All local fire departments placed their EMT teams in the fire stations and trained firefighters as EMTs.
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Because of the ambiguous definition of EMS in the Emergency Medical Service Law, EMS becomes one of firefighters’ routine on-duty tasks. This fire-based EMS system aggravates staffing shortages-typically, on any given day, there are fewer than five firefighters on duty in a fire station. Thus, when a station receives fire and EMS calls in rapid succession, there may be fewer than three people available to respond to each emergency.
Taiwan modeled its EMS system on that of the United States. In 1983, before the establishment of the NFA, the government sent medical physicians (MPs) to the United States to learn emergency medicine. These MPs established the Taiwan Society of Emergency Medicine (TSEM) and encouraged every hospital to set up an EM division and train more MPs in emergency medicine. When the NFA was established, MPs from TSEM helped local fire departments train firefighters to become EMTs.
Taiwan divides EMT into three degrees: EMT-1, EMT-2, and EMT-P. Every firefighter goes through EMT-1 training, which requires 60 hours in academic and practical training at a fire academy. On completing the EMT-1 training, firefighters are encouraged to become an EMT-2, which requires 264 hours in academic and practical training. The first EMT-Paramedics (EMT-Ps) were trained in 1999; all trainees were firefighters who had passed the EMT-1 and EMT-2 previously. They completed 640 hours in academic and 640 hours in emergency room training in local hospitals. Since 1999, the NFA has held one or two training courses every year to enable experienced EMT-2s become EMT-Ps.
Hospitals are abundant in Taiwan’s cities. For example, Taipei City has 10 public hospitals, 31 private hospitals, and 2,794 clinics to serve more than 2.6 million people in an area of 270 square kilometers (smaller than Phoenix, Arizona). There are four levels of medical service in Taiwan: local clinics, local hospitals, regional hospitals, and medical centers. The dispatch center in every local fire station has a citywide radio communication system to direct ambulances to the proper medical services. Since National Health Insurance (NHI) was established in 1995, citizens receive health care at a reasonable price.
TYPE
In different areas of the United States, EMS may be fire department- or hospital-based, whereas EMS in Taiwan is exclusively fire department-based. Although there are some private ambulance companies in Taiwan, they mostly assist at nonemergencies and transport the dead. Many hospitals in Taiwan have their own ambulances, but they are used only for transporting patients to other hospitals.
STAFF
Career and volunteer personnel operate EMS stations in America, whereas only career firefighters provide EMS in Taiwan. Volunteers can join local fire departments and be trained as an EMT-1 or an EMT-2 but cannot respond to EMS calls alone. The volunteer’s role is to assist firefighters at the scene. There are no volunteer EMS stations in Taiwan.
COST
Depending on the local jurisdiction, in the United States, a fire department or an insurance company would charge fees for EMS transportation and supplies. In Taiwan, EMS is provided free to the public. The government pays for everything related to EMS; if the patient is poor, the local social welfare department would pay for that person’s medical fees. The free EMS system in Taiwan causes abuse problems. Some citizens regard ambulances as “free express taxis.” According to a 1995 survey, more than one-third of EMS calls are nonemergency, so many experts suggest charging patients EMS transportation fees. However, Taiwan’s citizens are used to the free EMS; it would be difficult to persuade people to start paying for it now.
NATIONAL STANDARDS
In the United States, many EMTs and paramedics must meet National Registry of Emergency Medical Technicians (NREMT) standards.
In Taiwan, all EMS providers are firefighters; the NFA’s division of EMS oversees national EMS affairs. Also, a Department of Health (DOH) committee develops EMS standards and provides medical advice to the NFA and local fire departments. The Emergency Medical Service Law and Regulations for Emergency Assistance are two fundamental national EMS codes in Taiwan. All EMS-related items such as clothes, licensing, and tasks are regulated in these two codes.
OVERSIGHT AND BUDGETING
EMS in the United States is typically regulated at the state level and administered at the local or regional level. Federal agencies establish training curricula, develop ambulance specifications, and establish rules to protect provider health and safety.
In Taiwan, the NFA and NOH, two cabinet-level departments, oversee national EMS. The NFA is in charge of personnel training and budgeting, and the DOH is responsible for providing professional instruction. The DOH assigns members to local medical committees to provide online instruction for EMT-Ps.
When the severe acute respiratory syndrome (SARS) swept Taiwan in 2004, the DOH instructed first responders to wear proper protective gear and created many guidelines and standard procedures for frontline EMS providers.
EDUCATIONAL BACKGROUND
In the United States, there is no national standard educational background requirement for EMS providers. However, an EMS applicant should be at least a high school graduate.
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In Taiwan, firefighters provide EMS. Since all firefighters are graduates of a fire academy, the Central Police University, or the Taiwan Police College, all EMS providers in Taiwan at least have an associate’s degree. Besides, the Key Points of First Aid Staff Management, a national regulation for managing EMTs and paramedics in Taiwan, requires that EMT-1 candidates graduate from junior high school and EMT-2s from senior high school.
TRAINING REQUIREMENTS
In the United States, EMS calls are divided into basic life support (BLS) and advanced life support (ALS). Dispatchers consider the emergency situation and assign EMTs or paramedics to the scene. EMS providers may pursue different levels of EMS qualification.
In Taiwan, EMS calls are divided by location. Dispatchers assign local fire stations to respond to EMS calls, so fire departments encourage firefighters to become qualified EMT-2s to respond to both ALS and BLS calls. Becoming an EMT-P benefits a firefighter by qualifying that person for a promotion, so more and more firefighters qualified as EMT-2s for four years are eager to take EMT-P training.
TRAINING HOURS
Required training hours vary in the United States. According to National Standard Curricula (NSC) developed by the U.S. Department of Transportation (DOT), BLS requires a minimum of 110 hours of instructional training, but states vary in their BLS training requirements-from less than 110 hours to more than 400 hours. ALS training for the paramedic level requires between 1,000 and 1,200 training hours beyond that of the EMT-Basic level, and the intermediate level (EMT-I) requires between 300 and 400 total training hours in addition to the EMT-Basic level.
In Taiwan, every EMT-1 must take 60 hours of training and pass both paper and practical examinations, while EMT-2s must take 164 hours and EMT-Ps 1,280 hours of training.
HIGHER EDUCATION
Many universities and colleges in the United States provide EMS degrees for the public, but there is no university or college that provides an EMS degree in Taiwan. The only way for EMS providers to update EMS skills and knowledge is through additional training.
PROMOTION
EMS providers in the United States are promoted through the EMS hierarchy. In Taiwan, because EMS providers are firefighters, they are promoted to fire officer. This system causes the experienced EMS providers to leave this field, because if they stay in the EMS field, there is no further promotional position for them in local fire departments. Thus, once an experienced paramedic becomes a fire commander, it means the fire department has lost an excellent frontline EMS provider.
LICENSE RENEWAL
In the United States, all states require that licensing be renewed typically every two or three years. Renewal usually entails completion of continuing education courses, verification of skills by a medical director, and current affiliation with an EMS provider.
In Taiwan, every applicant must complete continuing education every year to renew the EMT-1 or EMT-2 license. EMT-1 requires eight hours, and EMT-2 requires 24 hours of training. Both should include at least four hours of practical courses. EMT-Ps in Taiwan must complete at least 24 hours of training every year. Although EMT-Ps renew their licenses every three years, the Department of Health in Taiwan examines their continuing education record. If they do not take at least 24 hours of training annually, they cannot renew their licenses.
FIRST RESPONDERS
Because the first responders in Taiwan are at least EMT-1 or above, some tasks for first responders in the United States are done by EMT-1s in Taiwan, such as obtaining vital signs, taking the medical history, and controlling severe external bleeding with direct contact.
EMT-Basic (EMT-1 in Taiwan). The tasks of the EMT-Basic are similar in both countries.
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EMT-Intermediate (EMT-2 in Taiwan). The apparent difference between Taiwan and the United States in EMT-Intermediate tasks is in administering drugs. In Taiwan, only the EMT-P can administer drugs to patients (under the instruction from online medical doctors). Both countries allow EMT-Intermediates to administer IVs to patients.
Paramedics (EMT-P in Taiwan). American paramedics have more authorization for administering drugs on the scene. In Taiwan, EMT-Ps can use limited types of drugs on-scene, and they are administered under the instruction of online medical doctors. However, because administering drugs is a matter of life and death, not many medical doctors are willing to remotely diagnose patients, prescribe drugs, and direct paramedics in administering them.
In Taiwan, all experienced and senior EMTs or paramedics would be promoted to company officers; they are regarded as firefighters in Taiwanese fire departments after they get promoted from frontline EMS providers; these company officers have to spend a majority of their time in fire command and administration. Thus, rarely are people interested in the EMS field, and experienced EMS providers will not stay in this field. Taiwan needs to create further EMS career opportunities for the frontline EMS providers to enhance their morale and encourage them to stay in the EMS field.
The United States needs to mandate a national EMS standard. In a large-scale disaster or accident, different licensure personnel with different communication systems cannot work together. A unified EMS system can absolutely protect Americans’ lives.
References
Chou, C. C. “Decennial Review of EMS system in Taiwan.” Retrieved October 27, 2006, from http://www2.cch.org.tw/ebm/ebm/3100/em10.htm.
Department of Health, Executive Yuan. Retrieved October 28, 2006, from http://www.doh.gov.tw/cht/index.aspx.
Department of Health, Taipei City Government. Retrieved October 28, 2006, from http://www.health.gov.tw/Desktop.aspx.
Emergency Medical Service: At the Crossroad. Washington, DC: The National Academies Press, 2006.
Taiwan Society of Emergency Medicine. Retrieved October 27, 2006, from http://www.sem.org.tw.
HSIEN-HO CHANG, MS, EMT-2, is an administrator and EMT-2 (equivalent to the EMT-Intermediate in the U.S.) with Taipei County Fire Department (TPFD) in Taiwan, which he joined in 2001. He has a master’s degree in fire service administration from Arizona State University. Previously, he served as a company officer in the Banchiao City Fire Station, one of the busiest in Taipei County. Chang is an editor of The National Firefighters’ Handbook of Fire Tactics and Fire Ground Safety in Taiwan (2005 edition) and a fire educational speaker.
