This article was part of my year-long "International Mail" column for JEMS, and appeared in the November 1981 issue. Much has changed in EMS in 40 years, so this is an interesting look back to a different time, both for the world of EMS as well as what Hong Kong was like at the time. (Posted Feb.2021).

Within its relatively tiny toehold at the southern side of Mainland China, the British Crown Colony of Hong Kong displays an unbelievable hodge-podge of contrasts, presenting all the elements necessary to a superb EMS challenge.

The airport for example: On the final western approach to the one main runway, jumbo jets skim the high-rise rooftops of several million Kowloon area residents.

"Everyone lives in dread of the day a jumbo jet, fully loaded with passengers and fuel, doesn't take off safely and crashes into Kowloon," said Assistant Chief Ambulance Officer A.A.E. Milford. The predisaster estimate for that incident is 5,000 initially dead and 30,000 injured — if the fuel that would inevitably leak into the maze of underground waterways doesn't blow up.

Hong Kong harbor provides another arena of constant disaster potential; boats of every size, from sampans to superliners, criss-cross the water constantly. Recently, a huge hydrofoil moving at high speed struck a submerged object, resulting in 40 injured patients. Some of the six fireboats and 40 police patrol boats helped bring them to shore.

Then there are the traffic-choked streets. One overturned double-decker bus caused one death and 58 injuries. Industrial accidents are common in a city which seems to divide and grow like a malignant cell. Then there are the suicides (especially "falling from heights" in the maze of high-rises, many of which are as much as seven floor walk-ups). Of course there are also the full range of other situations encountered by EMS workers everywhere.

To top it off, Hong Kong also has some very rural problems, both in the sparsely populated New Territories (between the Kowloon Peninsula and China) and on the many outlying "islands" attached to the colony.

The ambulance service has access to three Dauphin helicopters from the Auxiliary Air Force for island and rural evacuation. The department also has an equipment van with extra stretchers, blankets, oxygen, and Antenox, splints, etc. for response to multi-casualty scenes.

Most calls in Hong Kong originate on the emergency 999 line, which is answered simultaneously by the fire and police control (or dispatch) centers. The most-needed service takes the information while the other monitors the call; thus an incident requiring multi-agency attention has simultaneous responses.

The Hong Kong ambulance service is a separate command of the Hong Kong Fire Department and hires its men (no women) directly for the ambulance service. It employs 1,400 men and places three on each ambulance. From 13 ambulance stations they respond to 800 calls per day for a population of about five million people. Only 50 calls a day are routine transfers.

The street personnel are all of ethnic Chinese origin, but the ambulance supervisor on each unit must know basic English. Hong Kong's general population is 98 percent Chinese.

The department, according to Mr. Milford, one of two non-Chinese in the ambulance command, holds a strict policy of discipline and control. According to him, the appropriate action for any possible situation is written in either the Fire Service's General Orders or the Ambulance Command Orders. (Of exotic interest is the section entitled "Anti-Cholera Precautions.")

Those found disobeying the rules are subject to a number of clearly stated penalties, even including paying half a paycheck for damaging equipment.

Thus, the new recruits spend two weeks in Discipline Training. In a society where most people work six days a week, this consists of 78 50-minute training periods, including squad drill where they learn words of command and parades.

Once the Discipline Training is complete, the ambulance men then have a six-week syllabus for Initial Training. This training regimen is of great interest when viewed for a balance of priorities. It consists of 234 50-minute lecture and practical sessions, for a total of 198 hours. Among them: two lectures, four practicals in resuscitation including training in the Sylvester method; three lectures, seven practicals in hemorrhage control; one lecture, three practicals in administration of oxygen, 12 practicals in physical training and games; and three lectures, 15 practicals in depot duties, including use of cleaning equipment and cleaning the premises.

The result is a basic life support system. The equipment used is standard to basic life support, plus Antenox (nitrous oxide, which is common throughout the British Commonwealth) and, according to Mr. Milford, "EOA's," or esophageal obturator airways. Upon inspection, these were actually oropharyngeal airways in two sizes. Hong Kong ambulances also routinely use Robinson resuscitators, and stretchers with wheels are a relatively new innovation.

The ambulance command generally has little contact with Hong Kong's medical establishment, including no direct training input. There is no medical advisor attached to the service. Hospital notification is relayed through the control center.

Major ambulance cases go to one of two main hospitals on Hong Kong island, one of two specific hospitals in Kowloon, or to one particular hospital in the New Territories. Minor cases are transported to one of a multitude of local clinics in each neighborhood.

According to Mr. Milford, a slow swing toward the advanced care concept is under way, but he cited the universal problem of resistance to change, both by the receiving medical establishment and by the ambulancemen. The outlined training plans for the future closely resemble the paramedic's syllabus familiar to American EMS workers.

One interesting aspect of EMS among the Chinese is that superstitions are an inherent part of life; people are constantly lighting "joss sticks" of incense for good luck. One ambulance command officer encountered a sample of Chinese superstition some years back when he decided the service needed new uniform shirts. Without consulting anyone, he ordered new light-blue shirts made for all the ambulancemen.

Unfortunately, light blue symbolizes death to the Chinese, and is the color worn by pall bearers and other funeral types. The ambulancemen adamantly refused to wear them, of course, and a new batch of shirts had to be ordered in another color.

Turnover in the Hong Kong Ambulance Service, according to Mr. Milford, is four percent per year. Most who leave, he said go back to school or into business.

The future of EMS in Hong Kong will depend mostly on the overall motivation for change and on the development of a rapport with the people in the hospitals. The seeds of change, as well as the various challenges, certainly exist, but time will have to answer the question of what pace and priorities emerge.