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Improving Surge Capacity for Biothreats:

Experience from Taiwan

Fuh-Yuan Shih, MD, Kristi L. Koenig, MD

This article discusses Taiwan’s experience in managing surge needs based on recent events, including the
1999 earthquake, severe acute respiratory syndrome in 2003, airliner crashes in 1998 and 2001, and yearly
typhoons and floods. Management techniques are compared and contrasted with U.S. approaches. The
authors discuss Taiwan’s practices of sending doctors to the scene of an event and immediately recalling
off-duty hospital personnel, managing volunteers, designating specialty hospitals, and use of incident man-
agement systems. The key differences in bioevents, including the mathematical myths regarding individual
versus population care, division of stockpiles, the Maginot line, and multi-jurisdictional responses, are
highlighted. Several recent initiatives aimed at mitigating biothreats have begun in Taiwan, but their effi-
cacy has not yet been tested. These include the integration of the emergency medical services and health-
facility medical systems with other response systems; the use of the hospital emergency incident command
system; crisis risk-communications approaches; and the use of practical, hands-on training programs.
Other countries may gain valuable insights for mitigating and managing biothreats by studying Taiwan’s
experiences in augmenting surge capacity.
ACADEMIC EMERGENCY MEDICINE 2006; 13:1114–1117 ª 2006 by the Society for Academic Emergency
Keywords: surge, surge capacity, biothreat, bioevent, Taiwan

aiwan has experienced a multitude of disasters in 1. The plans require immediate dispatch of hospital-
recent times, including yearly typhoons and floods, based physicians to incident sites without first
a huge earthquake in 1999,1 airplane crashes in assessing whether the scene has been secured
1998 and 2001,2 and severe acute respiratory syndrome or whether physician care on the scene would
(SARS) in 2003.3 These mass casualty or complex inci- improve patient outcomes.4,5 The emergency medi-
dents created demands that challenged the medical and cal services (EMS) system of Taiwan was established
public health infrastructure. Emergency medical pre- in 1995, and the responding firefighters were trained
paredness programs evolved in response to medical to be emergency medical technicians (EMTs).6 Nearly
surge needs for these disasters. half of the EMTs are EMT-I trained (60 hours training),
Several approaches have been adopted to expand and the remainder are EMT-II trained (264 hours
medical-care delivery systems aimed at managing increased training). Despite this, people believe that physicians
volumes of patients with unusual medical needs. Medical at the scene can provide better medical care than
response plans in Taiwan and many other Asian countries can firefighter–EMTs. There is an expectation from
(because of their similar cultural backgrounds and social both the public and the politicians that physicians
norms) have several characteristics that differ from plans will report to the scene of an incident after a media
in the United States. These include the following: call for help. Although some physicians may possess
the experience and training to improve scene triage
and provide definitive medical care when indicated
at an event scene, many hospital physicians lack the
From the Emergency Department of National Taiwan University requisite skills in scene safety and austere trauma
Hospital (F-YS), Taipei, Taiwan; and the University of California care. In addition, when personnel from the emergency
at Irvine, School of Medicine (KLK), Orange, CA. department (ED) of a smaller hospital are deployed to
Received June 19, 2006; revision received June 27, 2006; ac- the scene, the hospital then may lack adequate capac-
cepted June 30, 2006. ity to receive patients. Requests for physician assis-
Presented at the Academic Emergency Medicine Consensus tance at the scene also can be confusing when the
Conference, ‘‘Establishing the Science of Surge,’’ San Francisco, frontline of an event is obscure, as for example in
CA, May 17, 2006. the case of a biothreat.
Address for correspondence and reprints: Kristi L. Koenig, MD. 2. The plans tend to call for all off-duty personnel to
E-mail: report immediately to the hospital.7 Although this

ISSN 1069-6563 ª 2006 by the Society for Academic Emergency Medicine

1114 PII ISSN 1069-6563583 doi: 10.1197/j.aem.2006.06.044
ACAD EMERG MED  November 2006, Vol. 13, No. 11 1115

procedure can generate adequate human resources for

the first few hours, it can prematurely deplete person-
nel resources in a prolonged emergency, because there
is no backfill to relieve the first wave of staff. The time
curve of casualty numbers found and treated after the
Chi-Chi earthquake in 1999 (Figure 1) is available be-
cause of a requirement that health care workers report
casualty encounters to the central government. The
curve illustrates the effects of a procedure that calls
for all available personnel to report to work immedi-
ately after a disaster. The data show that patient treat-
ment dips precipitously 24 hours after the event. It is Figure 1. Casualty flow after 1999 Taiwan earthquake.
probable that this occurred because most of the rescue
workers and medical personnel were exhausted after A biothreat is different from other disasters in several
working continuously for a prolonged period, so oper- ways: it is usually insidious in onset with a covert origin;
ations were temporarily shut down. it is relatively slow at first but progressively escalating;
3. The plans rely on a substantial number of volunteers and victims require unique laboratory and epidemiologic
responding to the surge demand. There is a belief investigations and may not be easily recognized. Coun-
that there will be many volunteers during disasters, and termeasures that successfully augment medical capacity
it is socially inappropriate to refuse their participation.2 and capability in other hazards may not be effective
Functions filled by volunteers include provision of against this threat.
psychological support, transportation, and supplies There are several mathematical myths inherent in
needed for activities of daily living. For disasters that many response plans:
are familiar to civilians such as earthquakes, typhoons,
or multivehicle traffic collisions, a simple call from the 1. The myth of simple multiplication of individual
media can activate thousands of volunteers. The situa- care. Mathematically, one times one thousand equals
tion changes when the hazards are exotic and sub- one thousand times one, but separate care for one
stantial perceived risk exists for the responders.8 For thousand individual victims is not equivalent to popu-
example, in the SARS outbreak in Taiwan in 2003, lation care for one thousand people at a time. We tend
when a community hospital was isolated because of to manage multiple-casualty incidents with the same
the internal spread of disease, only dozens of people model used for a single trauma patient by simply pro-
volunteered despite a vigorous countrywide govern- viding an extraordinary number of responders. In fact,
ment-run campaign.8 Some surveys predict that the the mainstay of many emergency plans is to summon
same phenomenon will happen in radiation and hazard- as many responders as possible. This may be effective
ous material (hazmat) incidents in Taiwan.9 in some limited-scale events, but in more complicated
4. The plans usually designate specialty receiving situations such as SARS, the logistics for individual
centers.3 Because it is easier and more cost-effective care escalate exponentially when casualty numbers in-
to provide equipment and personnel training to a lim- crease, and the system collapses if we fail to adapt and
ited number of hospitals, specialty hospitals are desig- provide a population-care model.12,13
nated in some cities for natural disasters, multiple- 2. The myth of simple division of a stockpile. If there
casualty incidents, hazmat incidents, radiation acci- are one thousand apples for one hundred people,
dents, and biohazard events. Medical societies em- mathematically, each person will have ten apples.
brace this policy because these designated hospitals However, in reality, the efficiency of dispatch deter-
are the only ones required to maintain training and mines who gets the apples and how many. Resource
equipment. This approach is problematic, however, management is more than simple division. Too often
because it does not account for self-presentation of we focus on how many resources we have in a phar-
victims after a disaster or emergency to a nearby facil- maceutical stockpile, coupled with the number of vic-
ity, rather than a designated one. This is especially tims who require medications, but we forget that the
true for an emerging infectious-disease scenario.10 supply management is the determinant factor.12,13
5. The plans tend to lack the necessary functional- 3. The myth of the Maginot Line. In the wake of World
area expertise for a robust incident command War I, the French constructed the Maginot Line, a line
structure and overemphasize clinical skills, espe- of concrete fortifications, tank obstacles, machine-gun
cially for chemical- biological- radiological-nuclear- posts, and other defenses along its borders with Ger-
explosive (CBRNE) events. Medical and health many and Italy. They believed that this fortification
infrastructures are poorly organized for an emergency would provide time for their army to mobilize and
situation. Most of the command structures are staf- would compensate for their relatively small numbers,
fed by experts from the medical profession, whereas but this plan failed. Likewise, despite lack of a compre-
the logistics, administration and finance, and plan- hensive strategy, we believed that a fortification line of
ning personnel are not activated.11 For a familiar specialty receiving centers, experts, and specialized
and short-lasting hazard, such a command structure laboratories would provide time for responders to
has been shown to be effective; however, for an mobilize in the event of an attack and would also com-
unfamiliar and long-lasting event, logistics support pensate for numerical weakness. For example, during
within such a command structure usually is insufficient. the SARS epidemic in Taiwan, a failure in a single

hospital resulted in community-wide spread of the dis- an all-hazards approach that focuses on the opera-
ease to the entire metropolitan area. The infrastruc- tional skills that health care providers are asked to
ture of the health system should be fortified and perform after an incident.
adequate training and equipment provided, especially
for general care, casualty transportation systems, sur- Through these efforts, Taiwan plans to build a robust
veillance, sanitation, public education, crisis risk com- and efficient framework for health authorities that max-
munication, and information technology.14 imizes their ability to provide adequate medical eval-
4. The myth of multi-jurisdictions. In a cage, there are uation and care for all kinds of mass-casualty and
birds, rabbits, and monsters. In total, there are 12 complex incidents that exceed the normal medical capac-
heads and 41 legs. Can we determine the numbers of ity and capability. This will be a critical component of the
birds, rabbits, and monsters? We cannot, because community safety network.
we do not know how many heads and legs one
monster has. When a complex event occurs, multiple CONCLUSIONS
disciplines may be called into action, including public
safety, public health, human resources, and emer- Taiwan is a country with vast experience in managing di-
gency management. Because these communities do sasters and that has much knowledge to share regarding
not routinely work together, they are unfamiliar with how to enhance surge capacity for a bioevent. Although
each other’s procedures. In emergency response, the new initiatives remain untested, other systems can gain
monsters, which are the untrained, uncontrolled, and valuable insights by studying the pros and cons of vari-
unreliable responders, will cause the system to be- ous approaches to increasing surge capacity, the mathe-
come paralyzed. Other hazards include the self-pro- matical myths for a biothreat, and the actions initiated by
claimed experts and the omnipotent media, which Taiwan after the SARS outbreak and in the face of the
can be more destructive than well-meaning people looming threat of avian influenza.
who simply are ignorant.15
Facing the potential challenges from avian influenza,
some actions have been adopted based on the experience 1. Liang NJ, Shih YT, Shih FY, et al. Disaster epidemiol-
of SARS. In comparison to other Asian countries, the ogy and medical response in the Chi-Chi earthquake
medical resources in Taiwan are luxurious. In Taipei in Taiwan. Ann Emerg Med. 2001; 38:549–55.
City, population 2.6 million, there are 13,000 hospital 2. Lee WH, Chiu TF, Ng CJ, Chen JC. Emergency
beds, and 30% of them are typically unoccupied. Despite medical preparedness and response to a Singapore
these abundant resources, coordination between sys- airliner crash. Acad Emerg Med. 2002; 9:194–8.
tems needs improvement. To augment the surge capacity 3. Twu SJ, Chen TJ, Chen CJ, et al. Control measures for
and capability of the medical system, several projects severe acute respiratory syndrome (SARS) in Taiwan.
have recently been implemented: Emerg Infect Dis. 2003; 9:718–20.
4. Hsu EB, Ma M, Lin FY, VanRooyen MJ, Burkle FM Jr.
1. The out-of-hospital and health care facility medical Emergency medical assistance team response follow-
systems are being integrated with other emergency ing Taiwan Chi-Chi earthquake. Prehospital Disaster
response systems, including hazmat and nuclear Med. 2002; 17:17–22.
accident and bioterrorism medical care systems. 5. Chen KT, Chen WJ, Malilay J, Twu SJ. The public
Medical resources can be shared by different hospitals health response to the Chi-Chi earthquake in Taiwan,
to optimize care of patients received from the field. 1999. Public Health Rep. 2003; 118:493–9.
2. Hospitals are required to adopt an emergency inci- 6. Bullard JM, Liaw SJ, Chen JC. Emergency medicine
dent command system that balances command, op- development in Taiwan. Ann Emerg Med. 1996; 28:
erations, and logistics in emergencies. No hospital 542–8.
is immune to disasters, so basic medical preparedness 7. Chen WK, Cheng YC, Ng KC, Hung JJ, Chuang CM.
for all hospitals is mandatory per new hospital-accred- Were there enough physicians in an emergency
itation criteria. department in the affected area after a major earth-
3. Crisis and risk communication training is provided quake? An analysis of the Taiwan Chi-Chi earthquake
for appropriate personnel. CBRNE is exotic for this in 1999. Ann Emerg Med. 2001; 38:556–61.
community, so public concern and confusion can 8. Editorial board, Taipei Times. Time for Sense and
paralyze the health care system. A robust and honest Conscience. Available at:
risk-communications program that directs people to News/editorials/archives/2003/04/30/204097. Accessed
medically appropriate care can ease the risk to the Jun 27, 2006.
public and preserve the health care system for those 9. Shih FY. Radiation emergency medical care pre-
who truly need medical attention. paredness in Taiwan. Proceedings of International
4. Practical, hands-on training is provided for medi- Radiation Emergency Medical Care Workshop. Na-
cal and health responders. The objective of the train- tional Association of Radiation Protection. Taipei,
ing is to ensure that responders will be able to Taiwan, July 29–30, 2005.
competently and efficiently perform their jobs accord- 10. Wu D. Hospital is closed over SARS fears. Taipei
ing to the plan and is not to convert health care pro- Times. 2003; Apr 30:1. Available at: http://www.
viders into instant experts. The training programs
have shifted their focus from biological incidents to Accessed Jun 27, 2006.
ACAD EMERG MED  November 2006, Vol. 13, No. 11 1117

11. Chiang WC, Shih FY, Chang KJ, Chen WJ. Prob- 13. Centers for Disease Control and Prevention. Severe
lems of immediate medical care at community acute respiratory syndrome—Taiwan. MMWR Morb
hospitals of Taipei during Typhoon Nari, 2001. Mortal Wkly Rep. 2003; 52:461–6.
6th Asia-Pacific Conference on Disaster Medicine. 14. Shih FY. SARS—a global threat, Taiwan experience.
Fukuoka, Japan, 2002. Prehospital Disaster Med. Annual Conference of National Disaster Medical Sys-
2002; 17:S21. tems, Dallas, TX, Apr 17–21, 2004.
12. Ko S. Experts warns of health-care hole. Taipei Times. 15. Editorial board, Taipei Times. We Need to Close the
2003; May 7:3. Available at: http://www.taipeitimes. Loopholes. Available at:
com/News/taiwan/archives/2003/05/07/204989. Ac- News/editorials/archives/2003/05/11/205544. Accessed
cessed Jun 27, 2006. Jun 27, 2006.