CHINA - For Li Minghua, the sound of a phone ringing sends his heart racing and causes him to break into a sweat.
"That's why I don't have a fixed landline at home," he said, joking that it is a side effect of years working as an ambulance medic in Shanghai.
The 35-year-old doctor has been a first responder for eight years and now works as a trainer for the Shanghai Medical Emergency Center, which has more than 110 ambulances covering the large downtown area.
Li is among only a handful of doctors who have stuck with the job for so long. Most leave after a year due to the low salary and high-stress environment.
According to Shanghai Health and Family Planning Commission, the city has about 2,275 ambulance workers. Yet most are drivers and nurses, less than 30 per cent are trained doctors and the number has been steadily dwindling.
Last year, for example, the emergency centre recruited 31 doctors, while at the same time 55 quit.
Shanghai has more than 240 ambulances, which are on day and night shift by turns, Li said, estimating that on an ordinary day they can be dispatched 1,000 times.
"It's higher at peak times," he said. "An ambulance doctor will be sent out at least 12 times during a 12-hour shift. The work leaves us totally stressed out, and many develop back or knee injuries from lifting and carrying patients.
"And almost every doctor has faced abuse from patients or their relatives. Some have even been beaten up," he said.
The decrease in resources goes some way to explaining why complaints about the city's emergency response service have been so common in recent years. The latest to make headlines came in mid-April after an ambulance failed to show up to help a British boy with head injuries, despite two calls being made to the 120 hotline.
The 3-year-old was hurt when a large, wooden folding screen fell onto him as he played at Kervan Orient Express. According to Sun Ying, owner of the Turkish restaurant in the central business district, a 120 call centre worker said all ambulances were busy and suggested she call a taxi to take him to hospital.
The child's parents opted to take him by cab to Shuguang Hospital, the nearest medical clinic. However, they arrived to discover it did not have an emergency room and had to then travel to a second hospital, where the boy was pronounced dead.
"I don't understand," Sun said in late April, still clearly traumatized by the incident. "An ambulance never came, even after we'd sent the boy's body to the funeral home."
Shanghai authorities have no target time for ambulances responding to emergency calls. According to authorities, in more than 75 per cent of cases a paramedic will be on the scene within 12 minutes, but it can take longer due to road traffic.
Wang Bing, a Beijing lawyer who specializes in medical disputes, said that although firetrucks and police cars can force their way through traffic, ambulances do not have that right and must wait for other vehicles to make way.
"When demand for ambulances is intense, our operators will suggest a patient take a taxi if his or her condition is not serious, such as a sprained ankle," said Zhang Yu, an official at Shanghai Medical Emergency Center. "If they are in a serious condition, such as bleeding profusely, we suggest they wait for the ambulance."
However, as health professionals point out, not every resident is aware of what each hospital is equipped to handle. In the case of the British boy, Sun said she did not know Shuguang Hospital specialised in traditional Chinese medicine and would be unlikely to have an emergency room.
"Most people will naturally think of just heading to the nearest hospital," said nurse Shu Hua at Zhongshan Hospital. "For example, Huashan Hospital doesn't have obstetrics or gynecology units ... so rushing a pregnant woman in labour there would be extremely dangerous."
To make matters worse, the demand for what authorities term "pre-hospital care" - first-aid doctors and ambulances - is rising at a rate of 10 to 15 per cent. This is due to the fact the city's population continues to increase and grow older.
Health authorities say they have been looking at ways to boost their limited resources and efficiency.
"We plan to build more ambulance stations, hopefully so each community will have one," said Zhang at the emergency centre, without elaborating on a time frame for the project. On average, one in every two communities has a station.
The service will also introduce a classification system, which will see patients in serious condition or who need emergency surgery sent to designated hospitals to avoid wasting time on transfers, he added.
The biggest hurdle to improving services, however, remains staffing.
Zhang conceded the decreasing number of trained doctors willing to work as ambulance crew is hampering daily operations, but insisted his centre has not eased off on recruitment.
"Over the years we've been attempting to hire more medical students from neighbouring cities," he said, but now even medical graduates are turning down offers due to the meager pay and vast workload.
Unlike Western paramedics, who are highly trained but do not need medical degrees, ambulance medics in China have usually spent five years in medical school and one year as a resident at a clinic, the same as any doctor.
The salary is about 4,000 yuan (S$800) a month, roughly the same as an entry-level doctor at a hospital, but unlike their counterparts on the wards, ambulance doctors have little or no opportunity for career progression.
"Seeing this, many people leave the job in the end," said Li, the veteran first-responder. "Fewer stay loyal to the cause."
To produce more medics faster, the Shanghai Institute of Health Science said this year it will launch a three-year programme to train people in pre-hospital care. Students who apply will be exempt from paying tuition fees, said Shen Yuefen, vice-president of the institute.
Li welcomed the move and added: "Three years of training is enough to meet the demand. A medical student with five years of experience is probably a bit overqualified."
Shi Yingying contributed to this story.