38 Liters of Blood Transfusions Saved a Life; As Hospital Superintendent, He Started with Restrooms and Patient Meals — Lee Po-Chang: “True Reform Begins by Identifying the Real Source of Bleeding”
Recently, Netflix brought back the Japanese medical drama Iryu: Team Medical Dragon. Watching Ryutaro Asada repeatedly confront critically ill patients whose lives hung in the balance—making judgments, decisions, and performing surgery with incomplete information and no time for hesitation—suddenly brought back many memories that had long been buried deep within me.
Drama, after all, is drama. Real-life surgery does not come with so much heroic glory. More often, surgery is about pressure. A patient lies before you, blood pressure continues to fall, bleeding persists, and family members wait anxiously outside. Meanwhile, the surgeon must decide what to do next.
There is no script, and no one can tell you the answer in advance. A surgeon’s development is a continuous process of learning to make judgments amid uncertainty.
Courage has never meant acting recklessly or believing oneself capable of anything. True courage means understanding the risks, recognizing the possibility of failure, and knowing that one must ultimately take responsibility for the outcome—yet still making the most reasonable decision based on the information available at that moment.
Only many years later did I realize that this surgical training had never left me, even after I stepped away from the operating table. Whether serving as superintendent of Tainan Hospital or later entering public administration at the National Health Insurance Administration (NHIA), I was essentially confronting the same questions: Where does the real problem lie? What needs to be done most urgently? And who is willing to take responsibility?
That Day, I Wasn’t Even on Duty
There is one scene from 1990 that I have never forgotten.
That day, I was not the surgeon responsible for emergency consultations or operations. I happened to be passing through the emergency department when I noticed a patient lying on an observation bed, receiving bag after bag of blood transfusions.
I casually asked a resident, “What’s going on with this patient?”
The resident explained that the patient owned a cattle ranch. He had recently imported a bull from Wisconsin in the United States for breeding purposes. Although the bull’s horns had been removed, it may have been in its mating season. Suddenly, it charged at its owner with tremendous force, striking him directly in the abdomen. The injured man was subsequently brought to National Cheng Kung University Hospital.
The resident told me that the diagnosis was intra-abdominal hemorrhage. Because the patient’s blood pressure remained extremely low, they were administering transfusions first and planned to operate once his blood pressure stabilized.
After hearing this, only one simple question came to mind:
“If the source of bleeding hasn’t been stopped, how can continuously transfusing blood possibly solve the problem?”
This was not definitive treatment. It was merely replacing the blood that continued to be lost.
Some medical decisions can wait. We can wait for laboratory tests, imaging studies, consultations, or additional information. But in certain situations, waiting itself becomes a risk.
After explaining the patient’s condition to his family, I immediately arranged for him to be taken to the operating room.
The moment we opened his abdomen, blood came gushing out.
The left lobe of his liver had been almost completely shattered, and there was also a tear in his inferior vena cava.
The inferior vena cava is one of the body’s most important large veins, carrying substantial amounts of blood back to the heart. When such a major vessel ruptures, a patient can lose their life very quickly.
I had to press my hand directly against the tear in the inferior vena cava to control the bleeding. But to suture the vessel, I needed to move my hand slightly away.
The moment I lifted my hand and prepared to place a stitch, blood would surge out again. In the brief instant required to place a single suture, the patient could lose another 500 milliliters of blood.
Switching to Damage Control Surgery: The Strength of a Team
We repaired the bleeding sites that could be sutured, one by one.
However, after such massive blood loss, the patient’s clotting factors had become severely depleted despite continued transfusions.
Eventually, the problem was no longer bleeding from one major vessel. Instead, tiny blood vessels throughout the abdominal cavity were oozing blood. Bleeding was occurring everywhere.
If we had continued trying to stop each individual bleeding point using electrocautery, the patient might not have survived long enough for us to finish the operation.
We had no choice but to change our strategy.
We packed the entire abdominal cavity with large amounts of surgical gauze and temporarily closed the abdomen, using compression to control the bleeding.
This is the concept now widely known as damage control surgery.
When a patient’s physiological condition has deteriorated to the point that they cannot tolerate a prolonged operation, the priority is to address immediately life-threatening problems and keep the patient alive. Once coagulation, body temperature, and circulation have recovered, a second-stage operation can be performed.
Over the following three days, we continued administering blood transfusions and replacing clotting factors, gradually allowing the patient’s physiological condition to stabilize.
But three days later, we faced another unavoidable moment.
The large amount of gauze packed inside the abdomen could not remain there indefinitely. If left in place too long, infection could become another life-threatening complication.
We therefore had to reopen the abdomen and remove the packing.
But what if removing the gauze caused the entire abdominal cavity to start bleeding profusely again?
On the day of the second operation, Professor Yang Yu-Jen, then head of the Department of Surgery and a cardiovascular specialist, and Professor Lin Bing-Wen, head of General Surgery and a liver specialist, stood behind me.
Their presence conveyed a simple message:
“We are a team. You go ahead. We’re here. If bleeding starts again, we’ll handle it together.”
For a surgeon, the strength that comes from such support is difficult to put into words.
We began removing the gauze from the abdominal cavity layer by layer. Each time we removed a piece, we carefully checked whether bleeding had resumed underneath.
Fortunately, it had not.
Our treatment strategy had worked.
The bleeding stopped, and the patient survived.
Throughout the entire course of treatment, he received approximately 38,000 milliliters—38 liters—of blood transfusions.
Considering that an adult normally has approximately 5,000 milliliters of blood circulating in the body, this was equivalent to replacing his entire blood volume many times over.
Even today, I remain deeply grateful for the comprehensive resources available at National Cheng Kung University Hospital as a major national medical center, including its laboratory services, blood bank, anesthesiology, intensive care services, and multidisciplinary specialist teams.
I am also profoundly thankful to the Tainan Blood Center for its full support at the time.
Saving a severely injured patient from the brink of death is never the achievement of a single physician. It is the result of an entire healthcare system working together.
Saving a Life Does Not Mean the Story Will Always Have a Happy Ending
After the patient recovered, our medical team became good friends with him. We were even invited to his ranch for barbecues and roasted sweet potatoes.
Life can be remarkable.
A stranger whom I had happened to encounter in the emergency department became a friend in everyday life because of a single life-or-death experience.
There is an old Taiwanese saying: “A patient survives through the fortunate encounter between physician and patient.”
Sometimes, the relationship between a physician and a patient truly seems like a matter of fate.
What if I had not happened to walk through the emergency department that day?
What if I had not asked that additional question?
What if we had simply continued transfusing blood and waiting?
Life cannot be replayed, so no one will ever know the answers.
But I do know one thing.
What I saw in the emergency department that day was not simply a patient with low blood pressure.
The real problem was that he was still bleeding.
Unless the bleeding was stopped, every other intervention would only be temporary.
This understanding later influenced how I approached many other issues, whether in clinical medicine, hospital management, or National Health Insurance policy.
We cannot merely address the numbers on the surface. We must identify the true “source of bleeding.”
Yet life is never quite like a television drama.
Approximately 20 years after his successful rescue, the patient eventually passed away from liver cirrhosis caused by hepatitis C infection acquired through the massive blood transfusions he had received during his treatment.
At that time, the risks of acquiring hepatitis C through blood transfusions were very different from those today.
Medical technology, blood screening procedures, and antiviral treatments were not nearly as advanced as they are now.
That experience has remained in my memory ever since.
Medicine has never been omnipotent.
At a particular moment, we may succeed in bringing someone back from the brink of death. But medicine itself is also constrained by the technology and knowledge available in its time.
That is why I have never liked portraying surgeons as heroes.
Physicians are not gods.
We are simply professionals who, at some of the most critical moments in another person’s life, do our best to fulfill our responsibilities.
Sometimes we succeed. Sometimes we fail.
Regardless of the outcome, we must take responsibility.
As long as a patient still has a reasonable chance of survival, a physician must not begin by looking for an escape route.
Perhaps the most important lesson my surgical training gave me was not how to wield a scalpel, but how to face judgment and responsibility without retreating when another person’s life is in grave danger.
To be frank, the pressure of striving for perfection in matters of life and death is immense.
If Success Can Only Happen in One Place, It Is Not Yet a System
In 2004, I became head of the Department of Surgery at National Cheng Kung University Hospital.
By then, the challenge I faced was no longer the bleeding of an individual patient, but the broader problem of attracting and retaining surgical talent.
When I first assumed the position, only two residents joined the department that year.
Everyone knew that pursuing surgery was difficult. The working hours were long, the pressure was intense, and the responsibilities were enormous.
At the time, medical interns and residents not only had to learn clinical judgment, patient care, and surgical techniques, but also had to perform large amounts of routine work, including drawing blood, changing dressings, carrying out standard procedures, and handling administrative tasks.
Under such circumstances, simply telling young physicians that “surgery is a noble profession” or that “you must have a sense of mission” was meaningless.
What I really wanted to understand was why young doctors were unwilling to pursue surgery.
I also understood that not every medical graduate was drawn to the same kind of work. While some physicians were especially inclined toward the extensive academic study associated with internal medicine, others were attracted to surgery because they enjoyed hands-on, technically demanding work.
If the problem was the working environment, then we needed to improve that environment.
I began advocating for the hospital to assign surgical nurse practitioners to assist with clinical duties.
The objective was simple: redistribute routine tasks that did not necessarily require interns or residents to perform them personally.
That way, young physicians could devote their limited time to caring for patients, developing clinical judgment, and receiving proper surgical training.
National Cheng Kung University College of Medicine has its own medical graduates, and medical students are extremely perceptive observers.
Which specialties are worth pursuing?
Which attending physicians are willing to teach?
Are the residents doing well?
What is the working environment like?
There is no need for advertising. The experiences of senior students and residents are the most authentic advertisements.
Word spread quickly.
In my first year as department head, we recruited only two residents.
In the second year, 15 joined.
In the third year, another 13 arrived.
At the time, everyone genuinely felt that “spring had finally arrived for surgery.”
But that spring had come only to the Department of Surgery at National Cheng Kung University Hospital.
A dedicated department head can improve a department.
A dedicated hospital superintendent can improve a hospital.
However, if a successful model exists only in one hospital or one department and disappears when the person responsible leaves, it is not yet an institutionalized system.
It is merely the result of individual effort.
True reform should not depend forever on one person’s enthusiasm.
If a system is sound, it should be replicable and sustainable.
Later, as I moved from leading a surgical department to hospital management and eventually to the National Health Insurance Administration, I became increasingly concerned with one question:
How can an individual’s efforts be transformed into an enduring institution?
After Becoming a Hospital Superintendent, I Started with Restrooms and Boxed Meals
In 2012, Professor Lin Bing-Wen, then superintendent of National Cheng Kung University Hospital, arranged for me to be seconded to the Ministry of Health and Welfare’s Tainan Hospital as superintendent.
At the time, the hospital was experiencing serious financial difficulties. Medical professionals were leaving, and even the distribution of performance bonuses had become problematic.
Many people imagine that a newly appointed hospital superintendent should begin by announcing some grand strategy.
But what I noticed were much more basic problems.
The restrooms were in poor condition.
The patients’ boxed meals were unappetizing.
Employee morale was low.
Physicians were leaving.
Some people might ask, “Why would a hospital superintendent concern himself with restrooms and boxed meals?”
Because these are the things patients experience every day.
They are also the things employees experience every day.
Management cannot be conducted solely from an office by examining financial statements.
Just as a surgeon cannot rely only on laboratory results without actually examining the patient, hospital administrators must go to the front lines.
We began improving the physical environment, working conditions, and staffing arrangements.
We also expanded nursing support and strengthened cooperation with National Cheng Kung University Hospital.
Several years later, the hospital had moved from financial losses to profitability.
Nevertheless, I have always believed that making money should never be the ultimate purpose of a public hospital.
Financial stability is a prerequisite for a hospital to continue caring for patients.
If a hospital cannot sustain its own finances, it cannot retain good physicians and nurses, purchase necessary equipment, or improve its services.
In this sense, managing a hospital is remarkably similar to performing surgery.
You cannot simply observe that blood pressure is low. You must ask why it is low.
You cannot simply observe that a hospital is losing money. You must ask where the money is leaking away.
You cannot simply observe that healthcare professionals are leaving. You must ask why they are unwilling to stay.
True management means identifying the real source of bleeding.
True Digital Transformation Means Removing Unnecessary Obstacles
In 2016, I became Director-General of the National Health Insurance Administration.
At the time, the My Health Bank service already existed, but relatively few people used it—only about 220,000 users.
Naturally, I asked my colleagues to teach me how to use it.
They told me, “Director-General, you need a Citizen Digital Certificate.”
My immediate reaction was, “If it’s this complicated, who is going to use it?”
The real question we should have been asking was whether the services we developed were actually convenient for the public.
If accessing a government service requires people to locate their Citizen Digital Certificate, find a card reader, install software, and complete multiple authentication procedures, even the most useful service may attract only a small number of users.
I asked Huang Ming-Hui, then head of the Information Management Division, along with colleagues Tzu-Yu and Tzu-Fang, to find a solution.
Eventually, through identity verification mechanisms provided by Taiwan’s five major telecommunications operators, we enabled people to verify their identities directly using their mobile phones.
No more inserting cards.
No more searching for card readers.
On the surface, this appeared to eliminate only a few steps.
But true digital transformation is about removing unnecessary obstacles.
Later, when the COVID-19 pandemic broke out, people began using the NHI Express app and My Health Bank for a wide range of purposes, including purchasing masks under the real-name rationing system, checking vaccination information, reviewing medical records, and accessing laboratory test results.
What had initially seemed like a simple improvement to the login process became a critical piece of national digital infrastructure during a major public health crisis.
Today, My Health Bank has more than 12 million users.
As a surgeon, I have always had a personality that drives me to follow up actively and persistently on problems.
I acknowledge that this approach placed considerable pressure on my colleagues in the Information Management Division at the time.
Nevertheless, our collective efforts helped transform Taiwan’s healthcare landscape.
Policy reform does not always begin with grand slogans.
Sometimes, it begins simply because someone is willing to ask one more question:
“Why does it have to be done this way?”
National Health Insurance Governance: Directing Resources Where They Are Needed Most
Major hospitals have the strongest reputations, and naturally, many patients want to seek treatment there.
But when everyone chooses major medical centers, patients who genuinely require specialized care for severe or critical conditions may find themselves unable to obtain a hospital bed.
Therefore, NHI governance cannot focus solely on whether to increase or decrease payments.
The real question is:
How can limited healthcare resources be directed toward those who need them most?
This is why, during my tenure, I promoted a tiered healthcare system, two-way referral mechanisms, patient copayments, and the digitalization and cloud-based integration of medical information.
Reform inevitably encounters resistance.
Whenever institutional changes affect vested interests, payment arrangements, or established practices, some people will oppose them.
But my surgical training taught me very early that choosing not to make a decision is itself a decision.
When a patient is still bleeding, deciding to continue waiting is also a medical decision.
Likewise, when an institution clearly recognizes a problem but chooses not to address it, that is also a policy choice.
And such choices often carry consequences of their own.
Every Journey Leaves Its Mark
As a surgeon, you save an individual life.
As head of a surgical department, you build a team.
As a hospital superintendent, you ensure that a hospital can continue caring for patients.
At the National Health Insurance Administration, you face the healthcare system of an entire nation.
On the operating table, the results of a decision may become apparent within minutes or hours.
In public policy, the results may not emerge until five, ten, or even twenty years later.
Yet the fundamental principles remain unchanged.
Understand the problem clearly.
Identify its underlying causes.
Make choices within limited resources.
Someone must make the decision.
Someone must take responsibility.
When I was young, I tended to define achievement in terms of what I had personally accomplished.
As I have grown older, however, I have come to believe that what truly matters is what remains after you leave.
Some people leave behind a building.
Some leave behind an academic paper.
Others leave behind an institution.
Sometimes, what a surgeon leaves behind is simply a person who might otherwise have died but was able to live another ten or more years.
That alone is profoundly valuable.
Throughout my life, I have moved from the operating table to hospital management and then to the National Health Insurance system.
Yet the longer I have traveled this path, the more I have realized that the lesson I learned in the emergency department all those years ago has never changed.
When the real problem is still bleeding, simply continuing to transfuse blood is not enough.
We must identify the problem.
We must make decisions.
Someone must take responsibility.
We can be cautious.
We can question our assumptions.
We can recognize our own limitations.
But when human life, healthcare, and the public interest genuinely require someone to step forward, we must not allow the fear of failure to deprive us of the courage to act.
Looking back on my life, I would never claim that every decision I made was correct, nor could I say that I have lived without regrets.
But I am grateful that, at many moments when retreat was not an option, I did not choose to step aside.
Every journey leaves its mark.
And the marks truly worth leaving are not titles, applause, or entries on a résumé.
They are the things that remain many years later, when no one even remembers who first made them possible.
A person who was once saved.
A generation of young physicians who were given opportunities.
A hospital that continues serving patients.
A system that continues to function.
And people who continue to benefit from it.
For me, that is probably what a surgeon, after a lifetime of service, most hopes to leave behind.
Original Article Source:https://www.commonhealth.com.tw/blog/6518
