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謝謝昭緯 是不是請我們這個部長請石部長"},{"start":15.973,"end":38.096,"text":"林委員好保庭你好上個禮拜三台中榮總神經外科爆出這個醫學上的醜聞科主任兩位還有網紅有5.6萬名粉絲的網紅醫師對外還主打脊椎手術是吃飯的技能原來是業配的"},{"start":39.497,"end":65.98,"text":"业务医材厂商业务的技能然后在进行脊椎内试镜微创手术对骨刺、坐骨神经痛、椎间盘突出脊椎滑脱等症状处理的主要的微创手术在未经病人同意下在病人麻醉不知道的状况下放任无照的医材厂商业务手术指导"},{"start":67.381,"end":91.269,"text":"那時間還長達三年那提供的手術畫面非法的證據這個有主任有2023年就開始的也有去年的那我們都知道說據了解那個無照的醫材廠商長臉幫醫師執刀的綽號叫做小老鼠"},{"start":92.78,"end":102.237,"text":"更是台中榮總的名醫小老鼠是名醫隱形的地下的指定的主刀業待醫師"},{"start":105.014,"end":123.904,"text":"但其實是醫材廠商而且主要是針對內視鏡器材的相關更換他的專業幫微創手術內視鏡器材的相關更換是小老鼠的專業專業就這樣做著做著然後就變成名醫了"},{"start":128.146,"end":141.195,"text":"那在這種狀況裡面我們知道每台內視鏡手術大約大概花費10萬元可以完成的但據知情人士表示這些醫師 網紅醫師 主任"},{"start":144.457,"end":169.506,"text":"然後他們開了內視鏡手術加上自費的等等加起來30萬到40萬經常的是每個月開5台到10台來計算三年算下來至少有一兩百位的患者在被麻醉不知情的狀況裡面然後被醫材廠商業代醫師假醫師操刀部長你是說怎麼樣"},{"start":174.64,"end":200.622,"text":"跟委員說明在過去醫療行為我們把它明確的定義為核心業務跟輔助業務那核心業務一定是醫師親自執行那麼手術麻醉我們都是把它定位為核心業務是要醫師親自執行的手術麻醉也是另一種專科也是醫師對 也是要醫師執行也是有另一種麻醉科"},{"start":201.443,"end":225.444,"text":"医师的执照的所以以这个脊椎手术或者是神经外科的手术这个如果是如同委员所提的这个涉及到是不是如同我所提的上个礼拜三你跟人家说一个礼拜以内你要提出调查报告到现在三四五六日今天第六天来说不是我提的"},{"start":226.084,"end":251.864,"text":"就是说我是要问你说你们调查的内容赵委员这个描述的内容那这个会涉及到医师法28条的密意罪那个是刑事责任的不是啊不对你都不知道你都不知道光是现在就可以伤害罪论处这一个小老鼠了那叫什么老鼠对小老鼠对吧不要讲医疗法伤害罪"},{"start":255.401,"end":270.312,"text":"傷害罪還有不要講醫療法醫師法不要講醫師法你知道現在這個醫師還有一起在密閉的手術房裡面的人共同涉及犯什麼罪嗎你不知道加重詐欺罪"},{"start":277.833,"end":294.825,"text":"加重詐欺罪 六個月以上不能緩刑 不能預科罰金這樣你聽得懂嗎 如果認真去調查不是這個醫生而已 你詐欺這個病人"},{"start":297.585,"end":311.541,"text":"當同伙三個人以上手術室不只三個人吧所以這個案子我們也請衛生局去調查但是沒錯 李鳳鑫因為我們知道這個裡面醫療糾紛不受理"},{"start":318.644,"end":336.13,"text":"沒關係 加重詐欺跟傷害罪這個不是依究法的範疇喔 這普通刑法喔可以的喔 可以辦的喔但是他如果再加一個依究法沒辦法 沒辦法 依究法停擺"},{"start":337.49,"end":363.369,"text":"我們當時醫療法鑑定 停擺醫療法鑑定我現在問你 無照的醫材廠商跟刀跟刀變開刀 行之很多年了冰凍三尺 非一日之寒你知道你以前也處理過 你也對外講過你記得多久以前嗎"},{"start":366.584,"end":392.318,"text":"委員講的是哪一件2019年4月媒體披露醫界人士透露業帶跟進手術房教學兼販售的情形然後傳出有人從跟刀變動刀儘管醫師法禁止非醫療人員去指導但對於進入手術室的人員身份"},{"start":393.238,"end":417.878,"text":"並沒有限制一定得是醫療人員所以法規規範不到的模糊地帶大家問你說醫病安全該怎麼把關那現行法規2019年的時候人家也有問你有沒有限制進入手術房的人員的身份你怎麼幫醫病安全把關你當時是怎麼說我當初不記得"},{"start":425.781,"end":446.405,"text":"你說當時是司長他說新興的一些或新購的一些儀器設備在這個使用的初期的確有需要業者的協助說明那當務之急在實務上它有必要性但是你說手術一定是醫師親自執行的那麼其他的輔助助手也好器械也好"},{"start":447.065,"end":466.426,"text":"因為這是一個團隊的過程他一定有其他醫事人員的協助這個也沒有問題但是對於這個完全不具有醫事人員身份者他是不能夠直接來進來執行手術的那人家問你說可不可以進去手術室完全沒有資格的人可不可以進去手術室"},{"start":468.174,"end":494.589,"text":"然後你沒有正面回答你說有分區作業的管理規定包含清潔區、無菌區以及動線的規劃這些在醫院評鑑裡面有詳細的要求了所以你沒有回答那今天再問你一下今天這個業帶它已經有做好全身消毒的清潔那依照現行的法規它可不可以進去"},{"start":495.816,"end":518.935,"text":"我聽委員剛剛念的我當時候講的好像也都正確啦到至今仍然適用啦但是當時候我沒有回答到的今天要補充好你來補充就是說我們現在的醫療科技的進步確實有一些設備他需要有這個技術人員也好或者是熟悉這個設備的廠商也好進去協助"},{"start":519.275,"end":531.064,"text":"你的意思是說醫生要開刀以前對這些設備都還不熟悉還不熟悉就要幫病人抄刀然後使用這些設備這樣東西比較容易碰到沒有不是這樣那些東西要組裝要組裝"},{"start":536.328,"end":553.962,"text":"已经要准备要组装要组装比如说我们达文西手术那整支要怎么倒不是组装好了不是组装好了我们才能起来不是他要组装然后医师才能操作所以他会进入到里面去协助现在很多"},{"start":555.463,"end":571.497,"text":"在现场所以你的意思是他们还是可以进入手术室但是必须要有规范比如说他要懂得这个手术室里面的无菌区跟这个那你们现在有规范吗"},{"start":574.798,"end":581.345,"text":"在這個正式上我們沒有規範是由醫院內進去規範純粹醫材的廠商的業務進去幫忙組裝這些醫材那現行有沒有規範"},{"start":589.392,"end":609.303,"text":"我想我们要做一个指引让医院内部所以你们还没有指引据我的了解很多医院是有他自己内部有规范我是在问你说但是我们现在由卫务部来做一个指引我们来做让所有的医院所以现在还没有指引那我问你他们这个"},{"start":610.624,"end":630.621,"text":"無照醫材業務代表代刀集中在哪些科別人家說集中在骨科脊髓外科神經外科甚至因為這是一個業務的這個區域所以甚至集中在哪些醫院還是特定哪些區域你有沒有了解了"},{"start":631.351,"end":649.859,"text":"这个我们要再进一步了解科别因为这三个科听起来就是他的那个用的这些设备现在特别是这些机器手背之类的比较多那所以医院都人力短缺然后你们现在就是要开放医材"},{"start":651.298,"end":673.87,"text":"廠商的助手可以進去手術的時候當助手你現在是要開放這個嗎我們要有一個指引來規範你是要開放這個嗎因為人力短缺嘛這個有它的必要性它有這個器械的熟悉度我現在找幾種視角有醫生曾經這樣講因為2019年人家就檢舉了然後就說了就問了"},{"start":674.73,"end":695.502,"text":"所以2019年江冠宇醫師也是蠻有名的聯合醫院中心院區的主治醫師他說他在臉書曾經說適用新醫材如骨科神經外科總會有一些新玩意兒出來但是操刀的醫師未必熟悉適當的角度這個時候有業代的協助操作空間"},{"start":698.069,"end":712.724,"text":"但是他說自己他將慣於跟過神經外科的刀大家都知道人力的關係那麼非技術性的如拉鉤這種刀柱等級都不到的根本是實習醫師等級的"},{"start":714.426,"end":724.995,"text":"人手不夠就會請業代醫師代勞這樣主治醫師才有辦法跳刀去接另外一台刀就把今天的報表的這個報滿的刀表給抄完所以這個是醫師"},{"start":730.92,"end":749.363,"text":"曾經這樣子說那江冠宇醫師這個講法就是連醫師同儕之間他也在證實醫材業務代表業帶帶刀確實有此事喔已經不是去協助組裝醫材是帶刀喔"},{"start":751.068,"end":774.513,"text":"有这种事我们在未来的指引里面会把它理清楚他们进去之后能够做什么事不能够做什么事情还要应该有基本的哪一些训练指引人家信叨指引指引可以有足够的约束力吗指引这个后面就是我们刚刚提到的医疗法 医师法就会有相关的法则"},{"start":776.443,"end":801.549,"text":"醫師法都講了因為侵入性行為你這無照的醫師你做這種侵入性的醫師的行為都有刑責了他就沒在信道理啊你現在只做指引夠好這查明的如果是執行的醫師法第28條就有刑責了那個就是移送檢調啦"},{"start":802.472,"end":818.064,"text":"沒有啦 現在就變成常態啊要移送就完嗎我現在要跟你說喔 我剛才說的不要供醫施法有刑者喔加重詐欺罪連交保 連一顆罰金都不可以喔"},{"start":819.625,"end":848.202,"text":"加重詐欺罪 藉由醫生就要抓奇怪非怪不可再來傷害罪這個業務業待醫師 假醫師也有傷害罪 也要抓奇怪如果沒有人在怕 繼續做因為這些人知道沒有人 如果沒有檢舉沒有本人會出事現在我剛才講江冠宇醫師講的是什麼江冠宇醫師講的是"},{"start":850.114,"end":877.625,"text":"他說其實是證實啊 證實就是都這樣啊你再收一個指引要怎麼講有法律就不怕 還怕指引嗎法律都不怕了還怕指引嗎指引的目的是讓醫院按照我們的指引去定他的規範指引 有法律就要有處分有法律有處分 這才是法律的作用有法律放者不敢處分"},{"start":878.745,"end":882.868,"text":"這個法律沒好企啊現在就是可以去管的也不敢用查明了 該移送檢調就移送檢調這個沒有模糊的空間"},{"start":891.054,"end":915.745,"text":"這就有爆料的 有沒爆料的沒人知道我現在跟護理師講法護理師在臉書粉專貼文外行人覺得驚訝 內行人早已見怪不怪各大醫院中很多外科手術都由廠商業代在刀房協助完成這個是醫療界普遍認為早就是公開的秘密了"},{"start":916.545,"end":940.448,"text":"而且廠商為了求推廣產品必須手把手的教導醫師使用畢竟對自家產品最了解的是廠商不是醫師然後從專業跟經驗累積角度來看廠商執刀後的成果比專業的醫師本人操刀更完美也很正常"},{"start":941.309,"end":955.256,"text":"所以衍生一些問題比如說膽子越來越大的醫生可能如同放風箏一樣手越抓越鬆風箏越飛越遠搞到最後一個主治醫師同時守好幾間房"},{"start":956.957,"end":963.72,"text":"仔細看全部都是業代跟住院醫師在開所以從指導醫師變成監軍來吊詭的事這護理人員第一線在臉書上貼的他說吊詭的是這樣的非法模式卻可以有效的擴張醫療量能"},{"start":979.201,"end":990.506,"text":"甚至維護醫療手術的品質說到底這其實是醫療崩壞下人力短缺所產生出來的另一片知秋知夜"},{"start":991.894,"end":1014.628,"text":"所以許多人包括我都認為應該趁機檢討現行法律跟制度無論是退場或是就地合法都應該給出明確的制度來保障各方權益然後不好聽的實話是事件的起源不是醫療疏失也不是因為他造成傷害然後去個個"},{"start":1015.929,"end":1041.923,"text":"讓大家盡量知道竟然事件的起源是來自於人們檢舉的不是那個病人去檢舉的還是去收購的都不是那中融最可能的處置方法就是懲處個別醫師對外宣稱將嚴格要求廠商遵守規定只能間接指導設備使用不可以接觸病人"},{"start":1043.462,"end":1050.268,"text":"也就是維持現狀而第一時間衛福部表明將個案處理大概也不會通盤檢討這是護理師這是護理師"},{"start":1061.018,"end":1082.05,"text":"那醫學中心怎麼講呢不具名的醫學中心高層表示醫療設備廠商進刀房幫忙是公開的秘密畢竟現在醫護人力嚴重不足把廠商當做人力使用很常見尤其是私立醫院凡事都要談成本廠商協助手術只要發揮"},{"start":1083.231,"end":1107.968,"text":"那個消毒手術的服裝口罩的費用幾乎零成本所以確實有聽說一些醫院讓業者協助開刀那這些醫材廠商的業務視角他們怎麼理解呢醫材廠商的業務說哎呦反正這個出問題了手術醫生一定會自己扛他們說他有一個叫小龍的這個是媒體報導的"},{"start":1110.302,"end":1125.413,"text":"他是大學傳播學系畢業的在朋友介紹下進入醫產公司擔任業務平常常跑醫院開發客戶沒有想到有一天竟然會被要求進開刀房協助醫師操作器械甚至參與手術關鍵步驟"},{"start":1127.515,"end":1150.048,"text":"然後他說 這個行業水很深醫材採購存在許多不成文的規則加上部分資深或有威望的醫師不願意花時間學習新器材的操作便把比較簡單的技術環節交給熟悉產品的業務處理久而久之就形成業務帶刀的灰色地帶"},{"start":1151.129,"end":1164.876,"text":"然後這個小龍爆料業務之所以敢盡手出事因為大家都心知肚明一旦出事了醫生他會說這是我帶刀的絕對不可能承認讓業務去直刀"},{"start":1166.637,"end":1181.914,"text":"所以只有誰不知道你知道嗎大家護理師也知道醫院也知道醫師也知道廠商的醫材廠商的業務也知道就只有誰不知道只有被麻醉躺在那裡的病人不知道還有衛福部不知道"},{"start":1183.447,"end":1209.613,"text":"所以在這種狀況裡面我們真的是希望說這個講出來問題很多 不對這要怎麼解決 要怎麼通盤檢討跟委員說明 我也問了幾位院長他們都跟我說沒有這回事但是既然委員提到說這個什麼網路上或媒體上這樣子的報導好像是一個蠻常見的現象那我們一定會正視這個問題"},{"start":1211.314,"end":1218.442,"text":"我現在要講說這個是房間裡面的大象大家都說沒有沒有"},{"start":1220.434,"end":1242.416,"text":"也不是只有台中中榮這個單一偶發事件那調查就局限在有提供證據的個案那我們講是你一定要從制度面通盤檢討你說的確立明確的指引或指原則甚至你應該要提的是吹哨者保護條款"},{"start":1244.481,"end":1266.595,"text":"對不對 你政府哪有這麼多的力量去監督然後呢在操刀手術的過程當中 我剛才講過這裏面參與到包括護理師 他知道他也已經會被控告 加重詐欺犯罪這裏面涉入到看到的"},{"start":1267.751,"end":1275.763,"text":"都加重詐欺犯罪他敢去敢去我問你你需不需要有一個吹哨者保護條款他如果出來檢舉了應該讓他免責啊不是嗎"},{"start":1287.388,"end":1305.914,"text":"這個跟委員說明第一個我們會重申會讓所有的醫院跟衛生局都了解這樣規範應該是怎麼規範那麼如果違反這個規範會涉及到的相關的罰則或者是法律的責任是什麼像如果大家都知道了醫師法第28條"},{"start":1308.855,"end":1315.917,"text":"我們要去重申他這個界線在哪裡那些人都結構性的犯罪如果出來檢舉的人自己也要有刑責是齁沒有人敢說如果說出來就有刑責會被告我覺得你更需要的可能是吹哨者保護條款免責出來檢舉的人免刑責是不是在這裡我告訴你"},{"start":1339.664,"end":1368.323,"text":"現在年紀到一個狀況以後追肩盤問題骨骼問題然後需要使用這些高單價的內視鏡微創醫療醫材的手術的人很多但是護理師出走刷手護理師流動率上升非教學醫院的骨科醫師沒有住院醫師也沒有經驗老道的刷手護理師要怎麼樣維持好的品質沒有辦法"},{"start":1369.224,"end":1382.937,"text":"人家沒去非教學型的醫院沒行李然後這個高收益的脊椎內視鏡微創手術成為骨科次專科當中的顯學行李最好"},{"start":1384.278,"end":1401.54,"text":"每項技術的成熟都跟學習曲線有關結果這種醫生要訓練好開這個刀至少要練20到100次才能獨立開好一台刀結果大家什麼要叫人做練習的大家也沒有人要做醫師練刀的對象"},{"start":1402.541,"end":1429.055,"text":"人力不足然後獲利壓力技術門檻三重狀況裡面專精於特定急隨內視鏡手術的廠商協助自然就進來了就成為醫療利益的共同默契換句話說啦這一種不法的行為已經固化到成為醫療產業鏈當中的共同默契還有生存的相互依賴"},{"start":1430.336,"end":1454.168,"text":"那你怎麼會抓得到 不可能抓得到所以你要如何去抓出揪出隱藏在手術燈下的不法行為你才能夠保障病患的權益啊我們現在說得難聽一點今天醫生的專業已經去受到挑戰了一個醫材商做操刀比你一個醫生還更賢熟這樣不就是醫生"},{"start":1457.745,"end":1486.074,"text":"對不對 做醫生的專業被挑戰耶然後你的管理和督導責任都沒了然後制度不嚴謹或明知或默許的不合規的情形發生然後醫院的行政責任只能說有檢舉這裡嗎沒有檢舉沒有如果檢舉下去呢大家都要行責事後你沒有吹哨者保護的條款所以這是常見的狀況但不合法也不合理啊"},{"start":1487.423,"end":1504.129,"text":"所以在這種狀況裡面當商業利益滲透到醫療決策醫療行為的時候醫師的專業的建立你看蕩然無存日本也是這樣啊有指引啊日本的指引2008年就有醫療機構等場所醫療設備配備的標準"},{"start":1508.793,"end":1529.984,"text":"結果在去年日本還是發現醫材商在有指引的狀況裡面在手術過程當中還是在協助醫師操作X光設備啊所以我在這裡我是要告訴你說制度性的全面性的以外我現在第一優先建議催少者保護條款"},{"start":1532.472,"end":1557.328,"text":"沒什麼人跟我說 你說你制度面建立好了但是 也是繼續來這樣做啊因為就沒夠人啊 因為已經沒夠選手啊因為還需要人來選啊就白人在這裡罵罪啊 不知道 對白人不公平啊所以檢舉的條款 吹哨者保護啊吹哨者保護條款第一重要 你可以認為嗎你可以認同嗎"},{"start":1560.222,"end":1577.851,"text":"我們來研究看看不過應該要加重的是醫院管理者的責任因為醫院不是多大的空間加重這個醫院管理者的責任是首先現在你開放業帶可以進入手術房你現在說要訂指引要讓他們可以進去"},{"start":1579.111,"end":1599.525,"text":"有進去就有操作的空間了以前沒有開放業帶進去偷偷摸摸現在業帶進去你開放了偷偷摸摸進去裡面不用偷偷摸摸但在裡面做什麼更沒有人知道只有在裡面的人知道在裡面的人講出去每個人都犯法"},{"start":1600.385,"end":1622.648,"text":"你沒有給他催哨者保護 這樣更不可能平衡啊醫院你看到這樣子而已 醫院的管理者也是很忙碌我們老實說 你說這件事真的是知識體大喔知識體大 所以我們在這個我們希望強化病人的知情權和參與喔"},{"start":1625.089,"end":1653.37,"text":"非醫療人員如果在場你不要忘了要以文件詳實記錄而且要取得受訴者知道吧我受訴者要知道誰參與我的醫療處置即便非醫療人員非醫事人員在場他是做什麼的也應該寫清楚我這一刀裡面有誰是非醫事人員他也會進來他要做什麼至少讓當事人知道吧"},{"start":1654.731,"end":1672.22,"text":"應不應該這個我會通盤來檢討那麼也因應這個技術跟能力的需要因為我們其他還有就是我們本來就有輔助人力在嘛那個就是醫事人員背景的輔助人力但是現在沒有公民政策"},{"start":1675.782,"end":1692.853,"text":"這個人力的協助的時候應該也要有一些訓練接受一些正規沒有啦你以前可以下去的都是麻醉科不是超大醫師啦相關需要的醫事人員護理師麻醉科醫師現在是要醫財商可以下去你現在要開放嘛要下去可以你給受訴者知情權啦"},{"start":1698.717,"end":1716.965,"text":"他不能接觸病人簡單的講就是我要知道有人在萬一有醫療糾紛發生了我就可以知道有誰在有沒有可能非醫療人員非醫師搞阿蟲他當然提出他權力保障的時候他要去調資料看對不對灰色地帶要補的規範很多"},{"start":1721.647,"end":1742.574,"text":"但是我在這裡要強調要以病人安全為優先的統一規範要以病人中心主義來去做相關的制度面的彌補才是最重要的啦好 謝謝我們來把您的意見把它納進來好 謝謝林淑芬委員發言"}]}},"supported_relations":[],"relations":[]}