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A guide for kidney transplant patients A new book by SGH’s renal transplant team aims to help transplant patients extend the life of their kidney transplants Don’t visit the Bird Park or any bird exhibition, and avoid exotic animals.

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This piece of advice comes from My LifeBook, a publication for kidney transplant patients by physicians and transplant coordinators of Singapore General Hospital’s (SGH) Department of Renal Medicine. The authors wrote that rejection of the new organ, drug toxicity, infections, heart disease and cancer are long-term concerns for these patients. Learning how to prevent them from happening can help

extend the life of a kidney transplant, hence the warning by the renal transplant specialists to avoid contact with exotic or wild animals. It is fine to have pets, but they should be kept clean and healthy, and have regular checkups and vaccinations. This and other information and practical advice are aimed at helping transplant patients live well with their transplanted kidneys. “If you have been on dialysis before, a working kidney transplant should offer you a better quality of life. When

The editorial team, headed by Dr Terence Kee (third from left), Director of SGH’s Renal Transplantation programme, put together information, tips and advice to help transplant patients take care of their health and extend the life of their transplanted kidneys.

Overseas ministers study local healthcare Ministers from several countries, who were in Singapore for the 15th World Conference on Tobacco or Health – organised by the Ministry of Health and the Health Promotion Board – took the opportunity to study Singapore’s healthcare landscape. The Singapore National Heart Centre (NHCS) hosted a ministerial delegation from Fiji, Laos, Myanmar and Turkey. Associate Professor, Koh Tian Hai, Medical Director, NHCS, told the delegation about the transcatheter heart valve, which is used in a minimally invasive procedure to correct severe aortic stenosis. This is a condition where the heart’s aortic valve becomes narrowed or obstructed, preventing it from opening properly and

The delegation witnessing how the Patient Lifter System works.

free of dialysis, you will have greater independence to do the things you have always wanted to do,” the authors said in the book’s introduction. “However, a kidney transplant can only be successful if you take good care of yourself.” Information and tips include preparation for the procedure, what the procedure involves, what to expect before and after surgery, the risks and benefits of an organ taken from a living versus deceased donor; taking care of the surgical wound, clinic consultations, possible complications, the medication to be taken after a transplant, diet and hygiene; as well as how a patient might show his gratitude to the family of the kidney donor. Just as importantly, the patient is taught to recognise the signs of organ rejection as he is never free from this possibility, and it is important that he knows what to do if he has symptoms or signs of rejection. SGH’s renal transplant patients are given a free copy. It is also available for sale at $17 a copy, with the proceeds going to TRUEfund – a fund managed by SingHealth Foundation for needy transplant patients. Copies of the book are also available for reading at SGH’s Patient Education Resource, Peritoneal Dialysis Centre and T Clinic. It is published in English, Chinese and Malay. For more information about My LifeBook, call 6326-5195 or send an email to singhealth.transplant@singhealth.com.sg.

After a kidney transplant... The risk of infection is highest in the first six months after transplant because the doses of immunosuppressant drugs are highest to prevent rejection. A wide variety of bacteria, viruses and fungi can cause infections in kidney transplant patients, with some types of infection occurring more frequently as a result of an immune system weakened by the consumption of immunosuppressive drugs. When the kidney donor is a deceased person, the donated organ may not work immediately after an operation, and the transplant patient may need dialysis for several days to weeks before the transplanted kidney starts producing enough urine to clear toxins from the body. Rejection can happen any time, but is most common in the first few months after an operation. The patient’s appetite improves after a kidney transplant, and weight gain is common – a result of the new organ’s ability to remove toxins more efficiently as well as the effect of the steroids taken to prevent organ rejection.

A milestone for The Academia Mr Gan Kim Yong, Minister for Health, and SingHealth’s senior management donned robes and broke open a sake barrel during the Topping Out ceremony at The Academia on April 2, 2012. When completed in 2013, The Academia will house Singapore General Hospital’s (SGH) Department of Pathology

and SingHealth’s research and education facilities. The modern facility will boost interconnectivity with the healthcare institutions located within SGH Campus and Duke-NUS Graduate Medical School. It will facilitate the pursuit of Academic Medicine with new knowledge, discoveries and innovations to transform healthcare for patients.

Prof Koh Tian Hai showing members of the delegation the transcatheter heart valve.

blocking the flow of blood from the heart’s left lower chamber to the aorta. At a separate event, an eight-member Brunei delegation toured Singapore General Hospital (SGH) and were shown the A&E department, major operating theatres, intensive care units and wards by Professor Ng Han Seong, Chairman, Medical Board, SGH. They were also given a demonstration of the Patient Lifter System, which allows nurses to lift and move immobile patients in wards without physically carrying them. With it, nurses can move a patient from the bed to a chair or bathroom, in a safe and dignified manner. SGH is the first Singapore hospital to use this system in wards and common areas.

Health Minister Gan Kim Yong (third from left) was joined on stage by (from left) Prof Ranga Krishnan, Dean, Duke-NUS Graduate Medical School; Prof Ivy Tan, Group CEO, SingHealth; Mr Peter Seah, Chairman, SingHealth; and Mr Koizumi Hiroyoshi, Managing Director, Kajima Overseas Asia Pte Ltd.


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Meet your Health Buddy By Rachel Chan

The other day I had a runny nose and watery eyes. I wondered if it was sinusitis or the flu, so I checked with Health Buddy – SingHealth’s free mobile application that delivers medical information to your smartphone. According to its A to Z glossary of medical conditions and treatments that you can scroll through, it appeared that I had allergic rhinitis. I found out that allergic rhinitis is a perennial condition, occurring throughout the year, and is typically triggered by indoor allergens. Its symptoms include continual sneezing and postnasal drip. Remedies include antihistamines, corticosteroids and decongestants. I learnt all this without venturing out of my house, but simply by referring to the Health Buddy app. Information on the go Developed with busy, working adults in mind, the user-friendly app by SingHealth can be accessed using the iPhone, Android

or Blackberry smartphones. The app empowers users to be more proactive about managing their health. Although written by medical professionals, the helpful information is not meant to replace a doctor’s advice. Its aim is to improve patient outcomes and, thus, reduce unnecessary hospitalisation and healthcare costs. To create the app, SingHealth identified the most relevant and popular searches by users of its multiple health websites, and customised the information. It is viable because of the growing wave of tech-savvy smartphone users, who are accustomed to accessing information on the go.

PHOTO: Vernon WONG

SingHealth’s free medical app provides smartphone users with a wealth of health information

find answers such as “Are antioxidants helpful in preventing cancer?” or “What are the 12 dental tips for achieving a lovely smile?” Health Tips: Users can also access the “Health Tips” feature for insights, or browse through a repository of articles from the interactive Health Xchange portal and the bimonthly health publication Singapore Health. Specialties: The app lists all 40 clinical specialties and sub-specialty services available at SingHealth hospitals, centres and polyclinics. Users can read about the services offered before booking their appointments via the app. Selecting a doctor: Patients who want to select their doctor can use the “Find A Specialist” feature. They can view doctors’ profiles, consisting of their expertise, resumes and photographs. Such transparency goes a long way in assuring patients of the quality medical care available at SingHealth’s hospitals, centres and polyclinics. Events: Stay up to date with the events

How it works The app was downloaded 4,000 times in the first week after its launch, and was one of the top five free apps in the App Store’s Health and Fitness category. Access a wealth of information through the following features: Medical questions: Those with burning medical questions can go to the “Ask The Specialist/Doctor Q&A” feature. They will

Other free health apps Developed by:

KK Women’s and Children’s Hospital What it does:

Pregnant women can calculate their estimated date of delivery and get weekly updates on the foetal development milestones. There are useful tips on the best foods to eat and whether to believe old wives’ tales. A comprehensive list of hospital services and in-house experts, as well as a hospital map, are also available. Download from: The Apple App Store and the Google Play Store Rheumatoid Arthritis Health Diary Developed by: Singapore General Hospital What it does: People with rheumatoid arthritis can enter data into a questionnaire about their daily activities and general health, so pain levels can be monitored. The app

also tracks the effects of medication and the progression of the disease. Charts generated from the data collected can be printed out, so users can take them along to their next doctor’s appointment. Download from: https://mobilecare. sgh.com.sg. Users have to sign up for a password-protected account.

and talks organised by SingHealth, ranging from dental care to eating disorders and surviving a cardiac attack. The talks address health concerns and educate the public on medical advances. Find a GP: If you are feeling under the weather and looking for a clinic in your neighbourhood, just use the app’s “Find a GP/Family Doctor” service for a detailed list of GP clinics in Singapore. With this feature, you are three taps away from locating and contacting your desired clinic. The clinics are classified based on their locations in the central, north, northeast, east and west regions. Download the Health Buddy app from the Apple App Store, www.singhealth.com.sg/healthbuddy and the Google Play Store.

In focus

Interactive Diet and Activity Tracker (IDAT) Developed by:

Health Promotion Board What it does:

Users enter information on their food intake and physical activity. The app calculates the calorie intake using a database of more than 3,000 local dishes. It also works out how many calories were burnt, taking into consideration Asian body types and local working lifestyles. Users can then figure out how much to eat or exercise daily, to attain a healthy weight. IDAT has its own online community, so users can motivate one another and organise group activities. Download from: The Apple App Store and the Google Play Store. Users have to sign up for a passwordprotected account.

PHOTO: alecia neo

Women and Child HealthPedia

Get health and medical tips on the go with SingHealth’s Health Buddy app.

Can you guess what this is? See page 26 for the answer.


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Here’s to you! The Singapore Health Quality Service Awards honoured 2,700 healthcare professionals this year. Meet four of the deserving recipients who work at community hospitals

Dr Gilbert Er Registrar Ang Mo Kio-Thye Hua Kwan Hospital SILVER AWARD

We don’t think of doctors doing mundane tasks like pouring water for a thirsty patient, but that is exactly what Dr Gilbert Er, a Registrar at Ang Mo Kio-Thye Hua Kwan Hospital does. Dr Er, 43, sees a constant stream of patients each day, each with his own medical, functional, psychological and social problems. “But I see each person as an individual and not just a face in the crowd,” he said. Dr Er joined the Intermediate and Long Term Care sector because he realised the pressing need to provide Singapore’s rapidly ageing population with quality medical care. He is encouraged by his patients’ smiles and spurred on by the challenge of “making a difference, no matter how small it may be”. Among the thank-you notes he gets from grateful patients is one from a stroke patient who was bedbound, had bedsores, was tube-fed and severely depressed when admitted. When discharged, her bedsores had healed, she could eat and her mood had improved considerably. On the award, Dr Er said: “It is always nice to have your efforts recognised. It was never on my mind that there was an award for good service. I just did what I knew was right for my patients.”

Mr Lam Kwok Kheong Customer Service Officer Ren Ci Hospital Silver Award

Driven to serve

Mr Lam Kwok Kheong, 63, made a career switch in his 50s which turned out to be fulfilling. After a decade driving ambulances for Ren Ci Hospital, he became a customer service officer, working at the community hospital’s information counter.

PHOTOS: ALECIA NEO, Alvinn lim and Vernon wong

Doctor with a heart

Ms Celis Zeng Qi Zhi Physiotherapist St Luke’s Hospital Silver Award “Driving an ambulance is very different from handling customers, but it’s always very satisfying to help people. Some patients find it difficult to walk on their own, so I help them in and out of vehicles,” said the father of two. He even takes patients to clinics personally to ensure they get there safely. Affectionately known as “Uncle Lam”, he was nominated for the Quality Service Award only a year after the job switch, for going beyond the call of duty. His superiors noticed his love of helping others, his ready smiles, easy camaraderie with patients and staff, and dedication to his job – all while adapting to a new environment and acquiring new skills. The award has affirmed his belief in putting his heart in his work. “I’m doing a job I truly enjoy. It makes me happy to make patients happy,” he said.

Still fascinated with the job Ms Celis Zeng decided she wanted to be a physiotherapist right after her A levels. Fascinated by the job description and eager to join the healthcare industry, she enrolled in Nanyang Polytechnic’s Physiotherapy course. Six years on, her job still holds the same fascination for her. Ms Zeng, 28, who is with St Luke’s Hospital in Bukit Batok, works mostly with elderly patients and, occasionally, adults who have post-surgery or post-treatment disabilities. The most common conditions she sees in the elderly are hip fractures, knee replacements and strokes. She helps them regain mobility and functionality, and also teaches family members and caregivers how to help them at home. Making a difference spurs her on. She recalled one stroke patient in her 70s, who could not sit up by herself and was depressed at the thought of never walking again. Ms Zeng said: “We gave her lots of training, building strength in her limbs and trunk. After a month or so, she was able to walk several metres with a quad stick. She was so happy!” The award – her first – surprised and pleased her. She said: “I’m also motivated as it’s not just staff from big hospitals who win awards. We, the staff from community hospitals, are also recognised. This is encouraging.”

Madam Magheshwari Sabapathy Assistant Director of Nursing Bright Vision Hospital Gold Award

A childhood ambition realised When Madam Magheshwari Sabapathy was 11, her father discovered a growth on her head. She was immediately admitted to hospital and scheduled for surgery. While in hospital, Mdm Maghesh, as she prefers to be known, was moved by how caring the nurses were to her and the other patients. “I decided to become a nurse when I grew up, so that I could do something meaningful for others as well,” she said. Mdm Maghesh, 46, has realised her childhood ambition. She is now Assistant Director of Nursing at Bright Vision Hospital, where she has worked for nine years. She decided to work in a community hospital because patients there are warded for 30 to 40 days on average. “We have a longer period of contact with them and get to know them well,” she said. To her, every patient is family and she serves with love. Even when patients lose their temper, she keeps her cool because she understands where their frustration stems from. Her boss nominated her for the Gold Award after noticing the profound effect she has had on patients’ lives and how she gives more of herself than is required by the job. She often listens to patients’ problems and accommodates individual requests where possible. On the award, she said: “I never expected to win but I’m happy my work has been recognised. I plan to continue doing what I’ve always done.”


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Spiral enteroscopy drastically shortens procedural time

Gastroenterology and Hepatology, Singapore General Hospital (SGH), who pioneered the spiral enteroscopy technique at SGH. Dr Kong has performed 10 of these procedures to date. His first patient was Mr Ong Hua Kok, 72, who suffers from anaemia. In early 2010, Mr Ong agreed to undergo the procedure in a bid to pin down the source of the anaemia. Anaemia is often due to intestinal bleeding. Dr Kong had explained to his patient what he wanted to try, the risks and advantages. Dr Kong found nothing abnormal. But months later, Mr Ong’s anaemia recurred and his red blood count fell to dangerously low levels. He was urged to go for another investigation of his small intestine. Cancerous tumour detected In July 2011, he underwent his second spiral endoscopy. This time, a 4cm cancerous tumour was detected. A sample of the tissue was taken for examination and the site of the tumour marked. When it was found to be malignant, he was immediately operated on. Dr Kong’s early investigation and marking of the tumour site provided a clear map for surgeons. Both times, Mr Ong underwent spiral endoscopy as it was faster than the alternative, conventional balloon enteroscopy. “I knew the risk… but we had to move on. It’s like crossing the road. There is a three per cent risk (of getting into an accident), but you assess the risks against the

benefits and you cross the road,” he said. The shorter procedure, said Dr Kong, is possible because of the spiral enteroscope’s design, which uses the concept of a screw in its over-sleeve design. The doctor rotates the endoscope, or flexible telescope, into the small bowel or intestine for a snug fit, and keeps the device steady amid the constant movement of the bowel walls. “We want a technique that is fast and reliable,” said Dr Kong. “We don’t want to take out a polyp, then have the scope slip back and have to tell the patient, ‘Sorry, our scope slipped back so we couldn’t go back down again.’”

The longer a patient is on the table, the greater the chance of a complication, so we try to keep our procedural time as short as possible. dr chris kong san choon, consultant, department of gastroenterology and hepatology, Singapore general hospital

A slippage can happen during the conventional single and double balloon enteroscopy procedure. Depending on whether a suspected bleeding or abnormal mass is near the beginning or end of the small intestine, the snake-like endoscope is guided through the patient’s mouth or anus to reach the affected site, which then allows the doctor to repair or remove the problem. The length of the small bowel can be around 6m in all, making insertion of the endoscope all the way through difficult. In the balloon method, the long tube moves through the organ and a balloon is inflated via an external pump to hold the endoscope in one place. The balloon is deflated when the endoscope is pushed or pulled to a new location in the small

bowel. The balloon method can take two to three hours to perform and a key problem is that there is a chance that the endoscope will slip backwards or lose its place in the small bowel, particularly when the balloon deflates, because the bowel wall is always moving. With spiral enteroscopy, there is no pump because the physician rotates the endoscope in the small bowel, the key being to catch the inner lining of the intestine with the threads of the screw. The aim is to pleat the organ’s inner lining back, which allows the endoscope to inch forward. But it is also the screwing effect that holds the endoscope firmly in place – no slippage. Outside studies have shown spiral enteroscopy to be a faster procedure than its balloon counterpart and relatively safe. Last year, the Journal of Gastroenterology and Hepatology reported that, among an Asian subset of patients, the average depth of insertion of the spiral endoscope was 249cm past the ligament of Treitz – the section near the start of the small intestine that connects the organ to the diaphragm.

Duodenum

Jejunum

Ileum

Anatomy of the small bowel The small bowel’s main function is to absorb the nutrients in food. Its inner wall is lined with millions of tiny finger-like projections called villi and microvilli, which greatly increase the surface area of the small intestine, allowing nutrients to be absorbed. The small bowel is anatomically divided into three parts:

Procedural time less than an hour Dr Kong estimated the shortest procedural time he has encountered so far with using the spiral endoscope to be about 40 minutes. Once the doctor locates the problem area, it may take another five minutes to prepare the minuscule tools needed to repair a bleeder or cut out a polyp. With the balloon method, the flexible telescope might slip back from the right location during this waiting time as it is not firmly anchored to the small bowel walls, thus lengthening the time of the procedure and increasing the risk to the patient if the doctor has to reprobe the area. As with any scope procedure, perforation, bleeding and pancreatitis remain risks in spiral enteroscopy. But, skilfully done, spiral enteroscopy can be an outpatient procedure. Because it is relatively new at SGH, spiral enteroscopy is done under inpatient care. However, the patient is sedated and not put under anaesthesia during the procedure. Complications have been negligible.

Duodenum – This is the beginning and shortest section of the small bowel and is mostly involved in digestion. It is also the opening to the pancreas where pancreatic juices enter the small bowel to aid in absorption. In endoscopic procedures, this area is vulnerable to irritation of the pancreas, which can lead to pancreatitis. Jejunum – This coiled section accounts for about 40 per cent of the length of the small bowel. The circular folds of the organ can best be seen here. The folds increase the surface area inside the intestinal walls for enhanced absorption.

From top: Dr Chris Kong shares a lighthearted moment to put the patient at ease before the procedure. Mr Ong Hua Kok (foreground, with his wife) was the first patient to undergo spiral enteroscopy in Singapore. A tiny, highresolution video camera attached to the endoscope relays images to large monitors, helping Dr Kong see the inside of the small intestine in great detail.

PHOTOS: ALECIA NEO AND ALVINN LIM

Ileum – This section accounts for about 60 per cent of the small bowel and runs from its midsection to the entrance of the large intestine. It is a rare feat for a physician, even one who is very experienced and skilled, to manoeuvre any endoscope through the entire small bowel from one end. This is why, depending on the location of a polyp or bleed, an endoscope will be inserted from the patient’s front end (the mouth) or his back (the anus).

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When all else fails Catheter Nerve Heart RF probe RF energy emitted Renal artery Above: A catheter guided into the renal artery delivers low power radiofrequency (RF) energy, generating heat of up to 60°C to disable the nerves in the renal artery without destroying them.

Incision

renal denervation helps to decrease these excessive signals, which in turn decreases blood pressure,” said Dr Tan.

Mdm Yusminah (left) takes her mother Mdm Malia’s blood pressure at home.

What is resistant blood pressure? Normal blood pressure should be below 140/90 mmHg (the first figure is the systolic blood pressure, while the second is the diastolic blood pressure). With each increase of 20 mmHg in systolic blood pressure above the normal level, a person’s risk of cardiovascular disease is doubled. For patients with diabetes, kidney or heart problems, the target blood pressure level is below 130/80 mmHg. For patients with hypertension but no other medical conditions, the

target blood pressure level should be below 140/90 mmHg. Resistant hypertension is when blood pressure cannot be brought down to the target blood pressure level with three types of drugs or more, inclusive of a diuretic at optimum doses. The diagnosis of resistant blood pressure needs care as uncontrolled hypertension may be due to poor compliance in taking medication, or white-coat hypertension (anxiety of being in a clinic).

Kidney

Femoral artery

PHOTO: ALECIA NEO

Resistant to medication Dr Jack Tan Wei Chieh, Consultant, Department of Cardiology, National Heart Centre Singapore (NHCS) said that in the resistant variety, although patients take their medication as instructed, their blood pressure remains high. “About a fifth of the adult population above the age of 60 currently has hypertension and, among them, three to five per cent are likely to have the resistant form. With the nation’s rapidly ageing population, the proportion of adults with hypertension will increase, bringing with it a rising trend of resistant cases,” he added. In some patients, resistant hypertension may be caused by some identifiable condition such as hormone imbalance, kidney failure or blocked kidney arteries. In others, like Mdm Malia, there is no

known cause. What is known is that it is aggravated in individuals who are older, obese or diabetic. Previously, these patients had no other option. Despite changes in diet, lifestyle and medication, they were unable to lower their blood pressure. For them, renal denervation is a breakthrough. The renal sympathetic nerves contain both afferent and efferent nerves that send signals to the brain, which responds accordingly. For instance, the brain may send signals back to the kidney (through the renal nerves) for the arteries to constrict and retain more salt and water, hence, increasing blood pressure. The kidney also sends signals back to the brain which, in turn, signals the heart to beat faster when stressed, thus affecting blood pressure. “This channel runs amok in disease states such as resistant hypertension. The brain and kidney perpetually send excessive amounts of signals to each other, not just during stress or dehydration, but even in restful states. So, by selectively disabling certain sections of these sympathetic nerves that surround the renal arteries,

ILLUSTRATIONS: HEYMANS THO

Hypertension, known as “the silent killer”, can remain unnoticed for many years, and is sometimes only discovered when the disease progresses and patients develop potentially fatal complications, such as strokes or heart attacks. However, some patients may have symptoms like headaches, shortness of breath and dizziness.

A safer procedure The concept of disrupting the brain’s signals is not new. Since the 1930s, surgeons have removed the nerves surrounding the kidney arteries, but that involved very invasive open surgery. Although it was effective in controlling hypertension, too many patients suffered other complications such as urinary incontinence and sexual dysfunction. The surgical method was subsequently abandoned when effective anti-hypertensive drugs became available. Today, the minimally invasive technology has made the procedure much safer. Furthermore, it has been carried out overseas for two years, and has shown to be effective and durable. Although renal denervation will not cure high blood pressure, it is able to reduce the blood pressure by an average of 32/12 mmHg. All three patients, who have had the procedure done at NHCS since September last year, have achieved more than 20 mmHg reductions in their blood pressure. Even a small 5 mmHg reduction in blood pressure can bring down the risk of stroke by 14 per cent, heart disease by nine per cent and death by seven per cent. How is she doing now? Mdm Malia’s blood pressure is now at an acceptable level of 140/90 mmHg, and she now takes a smaller dosage of medicines. With further monitoring, doctors will probably reduce the number of drugs too. “She hasn’t started going to the exercise park, but is definitely happier. All my mother’s siblings had high blood pressure and have passed away, some even before they reached 50. None of them had the option of this new procedure. I’m just glad my mother did,” said Mdm Yusminah.

Catheter

How renal denervation is done The illustrations above provide overall and closeup views of the procedure The patient is awake but lightly sedated. A catheter (less than 2mm in diameter) is guided through the femoral artery (blood vessel in the thigh) to the renal artery via a small puncture site at the groin. It is done under fluoroscopy (real time x-ray) guidance. When the tip of the catheter is in contact with the renal artery wall, low power radiofrequency energy is applied for two minutes, which generates heat up to 60°C. This disables the nerves without damaging the renal artery. “Burning” is carried out at different spots along the artery, usually at five to six locations in one artery. The procedure is repeated for the nerves in the renal artery of the other kidney. When done, the catheter is removed. The whole procedure takes about 40 minutes to one hour.


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Close to the real thing Getting the perfect smile without dentures has made dental implants an increasingly popular choice

If you have lost a tooth, a dental implant is as close to the real thing as you will get. There is a growing demand for them in Singapore from a spectrum of people – teens, young professionals, the middle-aged and the elderly. The National Dental Centre of Singapore (NDC) has seen a steady increase in the number of implant patients, with the number of implants placed tripling between 2005 and 2010. Improvements in technology and techniques plus rising awareness have fuelled demand, said Dr See Toh Yoong Liang, Senior Registrar, Prosthodontic Unit, Department of Restorative Dentistry. He said: “In the last decade, demand grew as science improved. We can now predict with greater accuracy the success rate of implants. Lower jaw implants, for example, have a success rate of 95 per cent while it’s 90 per cent for the upper jaw.” An option for missing teeth Dr See Toh explained that a dental implant, as an option for replacing a missing tooth, has several advantages compared to other alternatives. Implants do not affect other teeth, unlike dental bridges, where the adjacent teeth have to be filed down. Compared to dentures, implants are more comfortable, less obtrusive in the mouth and do not trap food. Elderly people who have lost most of their teeth may opt for implants that function as clips for securing overdentures. For this, two implants are placed in the jaw. But instead of adding prosthetic teeth onto them, dentures with corresponding inserts on their undersides are fitted onto the implants.

“This is a relatively cheap option, easy to maintain and not as complicated compared to a regular implant,” said Dr See Toh. But dental implants do have associated risks and are not for everyone. For instance, patients with low bone density in the jaw or medical problems that limit wound healing may not be suitable for such implants. Proper investigation before surgery Dr See Toh said, due to these risks, it is important that dentists conduct examinations and use diagnostic procedures, such as x-rays and conebeam scans, to assess the width and density of the jaw bone before surgery can take place. Such images allow them to check if there is enough bone to support an implant and determine the length of the implant. Only then can the operation take place. “The standard process, without any complications, takes about three to four months,” said Dr See Toh. “In complicated cases, where there is insufficient bone and bone grafting is required, the process can take six to eight months.” Bone grafting is a procedure to “grow” more bone. This may seem like a long time, but the process is important to help the dentist identify structures to avoid, such as nerves and bones, and use an implant of the right size. A proper healing period also allows the bone to heal and fuse well with the implant – a process known as osseointegration. “You don’t want to load the implant (with a permanent crown) too soon. We usually allow at least two months before attaching a crown,” said Dr See Toh. “There have been cases where immediate loading of a crown onto the implant root resulted in higher risks of failure. This is because the crown puts pressure on the

implant before it is stable. However, a temporary crown or prosthesis may be fitted in a way that does not add pressure on the new implant.”

The cover screw is removed in readiness for the next stage.

The photo above shows models of parts of a dental implant

Are mini implants safe? New to the market are mini implants, which use much smaller screws – and several of them – to secure a crown to the jawbone. They are being marketed as a cheaper and faster alternative to regular implants, but people should exercise caution if they are considering them for longterm use.

The abutment is attached to the implant.

A The screw is first fixed to the jawbone. It can be made of titanium, titanium alloy, ceramic or zirconia.

B The abutment fits on top of the implant.

C The crown goes on the tip of the abutment. It can be made of zirconia, gold alloy or ceramic. The typical cost of a dental implant procedure starts from $3,500.

Dr See Toh carries out a dental implant for a patient.

Steps in dental implant surgery A hole is drilled for the implant. A cover screw is put in and left till the bone fuses and is ready for the implant.

About dental implants

PHOTOS: ALECIA NEO

BY Sheralyn Tay

The final stage where the crown (prosthetic tooth) is attached.

“Typically, mini implants are used at NDC as anchorage in orthodontic treatments,” said Dr See Toh. “There is not a lot of evidence to support using mini implants as a permanent tooth replacement solution. This is because they have a very narrow diameter and, therefore, a higher risk of breakage or fracture over the long term.” NDC has treated a number of problems resulting from the improper use of mini implants, said Dr See Toh. “We generally see more complications arising from mini implants used as a permanent measure, compared with conventional implants with wider diameters.” Knowing the options, undergoing comprehensive checks and choosing the right type of dental implant will help to improve the success rate of replacing a missing tooth. “Implants are subject to considerable wear and tear from chewing and biting, so it is very important to choose the right type,” added Dr See Toh. After surgery, people should care for their implants by brushing and flossing, and going for a regular dental exam once a year. People who smoke should quit and those with diabetes should control their sugar levels, as both can affect bone healing and the success of implants.


MAY⁄ JUN 2012

singapore he alth

11

News

It’s true

As Singapore’s oldest and largest hospital, SGH has a rich store of stories from its 191-year history. For this year’s Heritage Day, staff dredged their memories to recall the quirkier ones Dry iron The day I joined the famous MUIII Unit (SGH medical unit headed in the 1970s by the late Professor Seah Cheng Siang, who is widely recognised as the founder of gastroenterology in Singapore), I saw a dry iron which was used to iron case notes, so they would be all neat and flat with no dog ears; and a paper cutter, so all the notes of varying sizes can be trimmed neatly to the same size. Prof Seah made it very clear that the dots in the temperature charts had to be even and right in the middle of the squares. It may sound all petty, but it was all about maintaining standards and discipline. Professor Ng Han Seong, Chairman, Medical Board

Beef hor fun piping hot (The renowned late surgeon) Professor Yahya Cohen loved the beef hor fun cooked by a particular ah jie (amah or ward helper). Every Friday, he would instruct the ah jie to cook a big pot of beef hor fun, which he would share with all the radiographers and radiologists. Ms Yeo Joo Geok, Senior Radiogr apher

Eggs galore Staff were given two eggs for each night that they were on night duty. Most saved the eggs until they had collected 14 eggs after seven consecutive nights. They then gave the eggs to their parents or the amahs (ward helpers) to make scrambled eggs or French toast. Ms Nagalingam Saraswathi, Senior Nurse Clinician

Some nurses carried their raw eggs in their pockets, but forgot about them when rushing to the wards to attend to the patients. When you bent over a patient or leaned over the nurses station, you would suddenly find yourself covered in egg! Ms susan loh, Senior nurse manager

Thick felt pen

All radiography students had to use a felt (marker) pen with a broad nip when doing their assignments. Failure to do so would get them a big zero for the assignment. Later, the students found out it was because he (the late Professor Khoo Fun Yong) could not see properly! Ms Anne Wong, principal radiogr apher

Colour picture above: Three luminaries of the healthcare sector planted tree saplings to commemorate SGH Heritage Day this year. The trees will be a reminder of their legacy. From left: Associate Professor Lim Swee Hia, who recently stepped down as Nursing Director of SingHealth and SGH; Professor Tan Ser Kiat, who stepped down as SingHealth Group CEO; and SGH Medical Board Chairman, Professor Ng Han Seong. Prof Ng was the trailblazer behind the advancement of SingHealth and SGH Campus into a formidable medical powerhouse, while Assoc Prof Lim was key in raising the stature of the nursing profession in Singapore.

Dipstick During one of our ward rounds with the late Professor Gordon Arthur Ransome, a pioneer of modern medicine in Singapore in the 1960s, we stopped in front of a diabetic patient. “How do you tell if someone has diabetes?” Prof Ransome asked. “You taste their pee,” he replied, then dipped his hand into the urine bag and licked a finger in front of the horrified students. The students mirrored his action only to be told that he had put one finger into the liquid, but a different one into his mouth. Prof Ransome was teaching us the importance of observation, one of the most important lessons in medicine. Professor Tan Ser Kiat, former group Ceo, SingHealth, and Emeritus Consultant, Orthopaedic Surgery, Singapore General Hospital

Chick! Chick!

On Chinese New Year’s eve in the ’60s, the nurses on afternoon shift duties inevitably had to do a fair amount of stitching and suturing of fingers at the C theatre (the present Blood Bank Building). Many Chinese patients would be seeking treatment for their chopped fingers! They had accidentally cut off their fingers instead of the chicken for the reunion dinner!

Missing dentures We had a patient who accidentally dropped his dentures into the bag he was vomiting into. By the time we realised what had happened, the garbage from our centre had been cleared and dumped into the central bin. With our colleagues and two others from Housekeeping Department, we managed to retrieve the bag from the central bin. Luckily, the bags were numbered, indicating where they were from. Still, it took us almost two hours to find the bag containing the dentures. Ms Chong Hwei Chi, Principal Physiotherapist

Ms Nagalingam Saraswathi, Senior Nurse Clinician

A pair of oranges for a pair of listening ears During my MO (medical officer) days, I saw an old lady for her aches and pains and spent quite a bit of time with her to explain her condition. A few months later, she walked into my clinic and presented me with a pair of oranges for Chinese New Year. She told me later that she had walked all the way from Chinatown to give me the oranges. She said she was just grateful that someone had offered her a listening ear. That was an assurance that I had entered the correct profession. Professor Fong Kok Yong, Chairman, Division of Medicine


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singapore health

MAY⁄ JUN 2012

Tell us

Healthier food choices

NDC, not polyclinic please

I would like to see all hospitals, including SGH, offer healthier foods at their eateries. I think about 80 to 90 per cent of the stalls in your food court should use less oil, sugar and salt in their dishes, and no stall should sell any fried food. All the dishes should be priced cheaper – maybe a discount of 30 to 50 cents can be offered – to motivate people not to eat unhealthy food.

I am a 65-year-old and had a set of dentures made at the National Dental Centre of Singapore (NDC). The dentist who treated me was very good. However, now that the problem is fixed, I have been discharged and told to go to the dentist at the polyclinic for any followup treatment. I find that it makes no sense for me to travel a long distance to the polyclinic when the NDC is very near my home. How can I continue to be treated at the NDC?

– Yap Soon Chia

We agree with you. All the eateries at SGH offer healthier food choices, like wholegrain

noodles, brown rice and vermicelli, as well as light cooking oil. If you choose the healthier options, you will get a discount. Did you know that whole grains are an important source of antioxidants, like vitamin E and phytochemicals, which are beneficial plant substances. These work together to help lower your risk of heart disease, diabetes and some cancers, and may even help with weight management. This winning letter wins two pieces of Backjoy worth $129.80. Backjoy is a device that aims to improve back pain and posture.

AND WIN A PRIZE FOR BEST LETTER Letters must include your full name, address and phone number. Singapore Health reserves the right to edit letters and not all letters will be published. Write to editor@sgh.com.sg or The Editor, Singapore Health, Singapore General Hospital, Communications Department, Outram Road, Singapore 169608, or talk to us on Facebook. The winner will receive a bottle each of Odour Controlled Garlic 300mg, Glucosamine Gel 100ml, Cod Liver Oil with Multi Vitamins Capsules and Maximum Strength Triple Omega 3-6-9 (1,200mg) (worth $111.60 in total) from our sponsor, Holland & Barrett.

Facebook us!

Singapore General Hospital Bautista Rowell James I was visiting SGH earlier today and read from a wall that this week is Eating Disorders Awareness Week with the theme “Let’s celebrate our natural SIZES!” I have a naturally bulky body and the wall is so encouraging for me. I always believed that beauty, talent, skill and others come in all human SIZES. Like · Unlike · Feb 13 at 8.50am 5 people like this

Singapore General Hospital @Bautista, we also believe in embracing each other’s culture, gender, shortcomings and human size too! Feb 14 at 11.01am · Like · Unlike

Bess Low Do you have any seminar on caregiving for the elderly at home coming up soon? Like · Unlike · Feb 13 at 4.48pm 2 people like this

Singapore General Hospital Hi Bess, you can contact our nurse educators at 6221-1240 for more information. Feb 13 at 6.48pm · Like · Unlike

Bess Low Thanks. Feb 12 at 10.16am · Like · Unlike

We are glad you are happy with the care given by your NDC doctor. Many patients come to us for specialist treatment and we try our best to attend to every one of them in a timely manner. In the current situation where resources are limited, right-siting care helps to ensure that specialist resources go to patients who need these most. Right-siting means matching the complexity of the health condition to the level of expertise needed. When appointment slots are used appropriately, waiting time for specialist appointments may then be reduced. If followup is uncomplicated, a dental GP will be able to attend to your needs. This can be right-sited at a polyclinic’s dental clinic or dental GP clinic* at a lower cost to you. Your specialist would have reviewed your oral condition and found it stable and fit for followup in a primary setting, before discharging you from specialist treatment. At any point in time, if you need to see a specialist again, the dental GP will be able to refer you to NDC. We wish you good health. *Subsidised dental treatment is now available at more than 200 dental GP clinics islandwide, under the Ministry of Health’s Community Health Assist Scheme (www.chas. org). Many of the participating clinics are located in the HDB heartlands.

Donating used crutches and leg brace Now that my broken leg has healed, I would like to give away my crutches and leg brace to anyone who might need them. They are still quite new and would be a waste to throw away. Who can I contact at SGH to donate these? Thank you for your offer but, unfortunately, SGH doesn’t have the resources to manage used crutches and other aids. Instead, you can donate walking aids and other items to Pass It On – a programme run by the Central Singapore Community Development Council. Visit www.passiton.org.sg for details.

Tributes I want to commend Ms Kelly Chng Bee Ling, Senior Pharmacist, National Heart Centre Singapore (NHCS), for going out of her way to help me. I asked her if my blood test results were normal, as the normal range was not indicated on the report. She explained each of the results, checked the computer and wrote down the normal range for each test on my results slip. She was attentive and full of smiles throughout. She is an asset to NHCS and an example of your high standards. - A grateful patient

I am grateful to Dr Tan Shi Ming, Medical Officer, Department of Orthopaedic Surgery, Singapore General Hospital (SGH), who was on duty at the A&E department when I slipped, fell and fractured my hand on Jan 20. He and his colleague had to have a “tug of war” with my hand before putting it in a cast, but he did a very good job of realigning the twisted bones. My hand is healing nicely and I do not need surgery. - Ms Lorraine Wee

I was diagnosed with diabetes before my pregnancy by a private gynaecologist and given a calorie chart to manage my own diet. There was no followup. I was at a loss and losing my appetite. I went to KKH’s O&G 24-Hour Clinic where I broke down. KKH assigned a dietitian and gynaecologist who worked together to help me. I broke down again when the insulin injections started, but was comforted and helped by the nurse on duty. At home, I found I could access the hospital’s services using the KKH iPhone application and the Ask-A-Nurse hotline. I also had direct access to my specialists, something I would not have had if I had stayed with the private gynaecologist.   The quality service didn’t stop there. In the delivery suite, Dr Jasmine Mohd, Consultant, Department of Obstetrics and Gynaecology, immediately checked on me. She showed genuine concern for my welfare and even personally updated my husband on my condition.   I have been singing the praises of KKH to friends and introducing them to the iPhone application for them to benefit from the boundless information there. My experience at KKH has changed my view of restructured hospitals and reaffirmed my belief that Singapore can truly be the medical hub it aims to be. - Mdm Faith Leong


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May/Jun 2012

Wellness p16-17 Nutrition Courses help carers of dementia patients cope

Eat well without feeling guilty with golden rules, healthy pork recipe

p17 Health

Fix various eye conditions while having cataract surgery

Photo: getty images

Tips on treatment

Gastroenteritis is distressing enough for adults. In children, there is also the risk of dehydration caused by vomiting and diarrhoea. By Sheralyn Tay

accompanied by tummy pains and fever. More significantly – though infrequently – it can have a detrimental effect on babies and young children. At KK Women’s and Children’s Hospital (KKH), some 11,700 children were seen at the Children’s Emergency department in the first 10 months of 2011 for gastroenteritis, making up some 8.5 per cent of total emergency cases. Stomach flu or gastroenteritis refers to an infection of the intestines, explained Dr Tham Lai Peng, Senior Consultant, Emergency Medicine, KKH. “It can be caused by exposure to a virus through person-to-person contact, or contact with a contaminated surface.” Eating contaminated food or drinking sullied water can also cause gastroenteritis. Children can come into contact with virus-contaminated surfaces (by putting infected toys in their mouths), or be exposed to the vomit or faeces of an infected person (because of unclean hands and food). Food contaminated with bacteria or toxins, or those that were poorly refrigerated or washed, can also cause it. Dr Tham noted that good food hygiene practices can lower the rate of disease caused by contaminated food.

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Tackling the tummy bug What is commonly known as stomach flu causes discomfort due to the ensuing vomiting and diarrhoea, which are often

singapore he alth

The most common cause of gastroenteritis is exposure to viruses. Rotavirus, which causes infections in the intestinal tract, results in a large proportion of hospitalisations due to gastroenteritis.

The rotavirus threat According to a local hospital-based study led by Professor Phua Kong Boo, Senior Consultant, Gastroenterology Service, KKH, nearly 40 per cent of children under five years old, who were hospitalised at KKH for gastroenteritis between September 2005 and April 2008, were infected by rotavirus. “The most number of children hospitalised for rotavirus gastroenteritis were aged between 13 and 24 months, followed by those aged zero to 12 months. The average hospital stay lasted three to four days,” said Prof Phua. He said about 95 per cent of children will suffer from rotavirus gastroenteritis by the time they are five years old. “In the Asia-Pacific region, rotavirus is the most common cause of diarrhoea and dehydration in young children. An Asia-based study found that vaccination is the most effective strategy to protect children against this infection.”

Dangers of dehydration Gastroenteritis can have severe symptoms and result in serious dehydration in babies and young children if left unchecked. Vomiting, one of the first signs, usually occurs in the first eight to 24 hours, while diarrhoea may last for two to four days, and even up to 14 days. “The risk of dehydration increases if these symptoms are severe and

Use different chopping blocks for meat and vegetables. Food that comes into contact with contaminated surfaces can cause gastroenteritis.

Seek medical attention if: There are signs of dehydration Stools or vomit are bloody The vomit is greenish, which may indicate a blockage of the bowels There is persistent abdominal pain The child is under six months old The child is lethargic or irritable

happen together,” said Dr Tham. “As children, particularly babies, have a weaker immune system, they have a higher risk of getting the disease. They also may develop symptoms faster than adults. More crucially, they are more at risk of dehydration as they have lower blood volume and, so, less of a ‘reserve’.” Severe dehydration can cause shock and decrease blood circulation, while the loss of essential salts and electrolytes due to vomiting and diarrhoea can lead to seizures. In rare cases, acute kidney failure can result. To prevent dehydration, parents should increase the frequency of milk and liquid feeds, but give these in smaller volumes, using a small spoon or dropper if needed (see sidebar). Some common signs of dehydration include having a dry tongue and/or lips, said Dr Tham. “There may be lethargy and decreased or no passing of urine for six hours or more. The eyes, as well as the fontanelle – the soft spot in a baby’s head – may also be sunken and the skin may lose elasticity.” She advised parents to look out for these signs and, if present, to seek emergency treatment.

Dr Tham Lai Peng said most children do not need medicine or antibiotics to treat gastroenteritis, although doctors may prescribe medication to relieve symptoms of vomiting or severe tummy pains. While the bug runs its course, it is important to replenish lost fluids and prevent dehydration. “There is no need to change the diet intentionally, but do give more fluids.”

If your child has diarrhoea, but is not vomiting For breastfed babies, continue breastfeeding and feed more often. For formula-fed babies, continue with the usual formula. If the diarrhoea lasts for more than 10 days, an option to change to a soy- or lactose-free formula may be considered. Do not feed your baby with only water. For every bout of loose stools, add 60 to 100ml of fluids, such as rice water, barley water or rehydration solution, to replenish lost electrolytes and sodium. If a child cannot hold down any fluid at all, seek emergency care. For older children, there is no need for dietary restrictions, but increase the intake of rice water, barley water or rehydration solution. Fruit juice should be diluted four times. If your child is under three years old and vomiting, but not dehydrated Give 15ml of fluid (rice water, barley water, rehydration solution, milk or diluted juice) every 15 minutes for the first three to four hours. Double the fluid volume and increase the feeding interval if your child does not vomit (i.e. 30ml/30min for one hour, then 60ml/ hour for two to three hours). For breastfed babies, feed more frequently but in smaller amounts. Seek medical advice if vomiting persists. After eight hours without vomiting Start milk feeds for babies and give about one to two ounces less per feed. For breastfed babies, return to normal nursing. For older children, offer a soft diet of porridge, bread, biscuits, soup or mashed potatoes. Usually, your child can be back on solids within 24 hours after recovery from vomiting.


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MAy⁄ Jun 2012

Health

Carers get a helping hand Looking after patients who can no longer recognise family members or remember life’s daily activities can take a heavy toll on caregivers

He wakes up at 2am every night and demands breakfast. After eating, he asks for food again,

Course for caregivers Many people don’t realise how difficult it is caring for a dementia patient and dealing with behavioural problems. To help carers look after dementia patients, the Department of Geriatric Medicine (Memory Clinic) started a course for caregivers in July last year. Running over six weeks, the course helps caregivers understand the disease, how it changes over time, how the changes affect the patients, and how to handle difficult behaviour such as not wanting to bathe or eat, or when the patient becomes delusional. The course also looked at the legal and social aspects associated with the illness, including wills and community resources that are available to the families of dementia patients. “When someone is diagnosed as demented, there are lots of personal, ethical, social, occupational and legal implications,” said Dr Seow. Caregivers are given practical tips on

Mahjong is a social activity that draws people out of their homes to interact with others.

PHOTO: ALECIA NEO

shouting at his maid and accusing her of trying to starve him. He also showers several times a day because he forgets that he has already done so. The man is in his 90s and has dementia – a debilitating illness that is marked by progressive memory loss, particularly in recalling more recent events. Because of the personality and behavioural changes that accompany the disease, caring for a person with dementia can physically and mentally drain the caregiver, who is often the spouse or the maid. “Dementia is devastating because it robs the family of a family member. He may not be able to recognise his family members, which adds to their pain and burden. He may get delusions, or make repetitive motor actions that lead to increased friction between him and his caregiver,” said Dr Dennis Seow, Consultant, Department of Geriatric Medicine (Memory Clinic), Singapore General Hospital (SGH). “In illnesses like hypertension, the caregiver can just give the patient his

medication and wait for it to take effect. But in dementia, the disease affects so many areas of the patient’s life, and good care has shown to have as great or greater impact as medication.”

PHOTO: Roger chua

BY Stacey Chia

Ms Julian Lee and Dr Dennis Seow teach caregivers to understand dementia and manage the patients they look after.

looking after dementia patients, such as fall prevention. During the course, they can also air their views and share information and their experiences with other caregivers, said Dr Seow. Ms Julian Lee, a Nurse Clinician specialising in dementia care at SGH, said caregivers she sees at the hospital’s geriatric clinic sessions are stressed to the point where they can no longer cope with the 24/7 pace of caring for the patient. They may also be clueless about how to deal with the patient’s aggressive or unreasonable behaviour. Giving them pamphlets and brochures can provide them with a basic understanding of the patient’s condition but, often, they aren’t enough to help a full-time carer deal with the various issues that can emerge, she added. Feedback from people who attended the course has been largely positive, with many finding the sessions useful in helping them gain a deeper understanding of the disease and the behaviour of the patients. “This helped them care for their loved ones better,” said Ms Lee. The department has run a few caregiver courses, including English and Chinese sessions in 2011, and another English one earlier this year.

> Continued on page 17

It may not be dementia A 60-year-old brain may not function as well as a 20-year-old one. It may not be as quick to react and may not remember things as well as the younger mind. But that is a normal part of ageing, said Dr Dennis Seow, Consultant, Department of Geriatric Medicine (Memory Clinic), Singapore General Hospital. “With ageing, the mind does slow down a bit in terms of our ability to process information, recollect things or do organisational tasks. “This slowdown only becomes a problem when it affects our daily living.” People shouldn’t jump the gun and automatically assume they have dementia once that happens, as memory loss and other forms of deterioration can be due to other causes, such as diabetes, uncontrolled hypertension or thyroid disorders. Also, older people who don’t eat much meat and fibrous vegetables because of poor teeth may have weakened memory function due to low intake of vitamins such as B12 and folate.


Celebrating Allied Health Professionals Psychologists talk to and observe people to assess their mental state and emotional wellbeing. They use therapy – not medication – to help people cope with their psychiatric conditions to improve their general condition and psychological wellbeing.

Optometrists

test vision, ensure the prescription and fit are correct for contact lenses and spectacles, assess refraction in eyes (eg. myopia and astigmatism) and check eyes for diseases and abnormal movements.

Orthoptists

assess misalignment of the eyes (squints), eye movement disorders and amblyopia (lazy eyes), and treat with patching, eye exercises, glasses and prisms or recommend surgery by the ophthalmologists (eye surgeons).

Audiologists

deal with hearing problems. They select and programme the most suitable hearing device, and give advice on its proper care and maintenance.

Speech Therapists assess and manage communication and swallowing disorders, and offer therapy programmes to improve speech and swallowing functions.

Clinical Care from Head to Toe We all know what a doctor or nurse does, but do you know there is another group of healthcare professionals collectively known as Allied Health Professionals (AHPs) who play a vital role in caring for patients? Armed with specialised expertise in various disciplines, AHPs work closely with doctors and nurses. Some operate high-tech machinery for diagnostic purposes, while others offer holistic rehabilitation or therapeutic programmes. There are also AHPs who conduct research to improve clinical outcomes and patient care. Find out more about SingHealth’s AHPs in this four-page supplement. Our cover gives you a snapshot of their disciplines and work. Inside, four of them share their work experiences and candid stories. Turn to the back page for interesting facts and figures about AHPs.

Other Key Allied Health Professionals Diagnostic Radiographers provide safe and accurate imaging examinations through a variety of imaging modalities and interventional procedures with radiation, ultrasound and magnetic fields. Medical/Laboratory Technologists conduct a wide array of diagnostic laboratory tests to analyse and detect problems at the cellular and molecular levels to help in the diagnosis of patient conditions and diseases. Medical Social Workers provide psychosocial and emotional care to patients and their families through counselling, access to financial assistance and by harnessing community support. Music Therapists help patients with eating disorders, depression, learning disabilities and other conditions by encouraging positive change through music. Occupational Therapists use goal-specific activities to help patients overcome their physical conditions and mental health issues to independently perform tasks required for daily living. Pharmacists dispense medicines and educate patients on their use, dosage, possible side effects as well as allergies and the concurrent use of other medicines. Physiotherapists help patients optimise their mobility after an injury, surgery or illness by increasing their tolerance of exercise, building muscle strength, improving joint mobility and pain relief. Radiation Therapists are integral members of the cancer care team who treat and manage cancer patients, providing care and support throughout their radiation treatment.

Respiratory Therapists help patients breathe better using ventilators, monitor their breathing and provide relief to those with cardiopulmonary or lung disorders.

Dietitians

manage patients’ nutritional needs to ensure optimal health and promote recovery from illness. They also manage patients who have specific medical problems like eating disorders, kidney diseases or diabetes, or those who are critically ill.

Podiatrists diagnose and treat problems in the legs and feet, including ingrown toenails, corns, deformities, and development problems in children’s feet.

www.singhealth.com.sg


Celebrating Allied Health Professionals

A second chance

Mr Lim Fang Keang

Saved from life in a wheelchair, she now wants to help others

Principal Radiogr apher Depar tment of Oncologic Imaging National Cancer Centre Singapore

Tracking down tumours Playing “detective” is part of his everyday work Mr Lim Fang Keang is a bit of a private eye on the job. The Principal Radiographer in the Department of Oncologic Imaging, National Cancer Centre Singapore (NCCS), uses sophisticated machines to detect tumours in a patient’s body. “It’s more than just pressing buttons. Before doing a scan, I’m like a detective. I must understand the patient’s condition and plan how to go about tracking the tumour,” said Mr Lim, 44. When doctors ask for a scan, he has to decide what technique to use to get the best image, as it helps the radiologist (a doctor who interprets the images) make an accurate diagnosis. However, getting good images can sometimes be challenging when a patient is in pain, unable to cooperate or keep still. The procedure takes 30 to 45 minutes, with breaks in between each scan. If a tumour is not readily detected in a suspected location, Mr Lim discusses with the radiologist whether to zoom in on a different area. This is usually encountered when doing magnetic resonance imaging (MRI) of the spine. Nothing to do with radios Mr Lim, who has been a radiographer for 20 years, became one by chance. Previously an aviation technician, he saw a recruitment advertisement by the former School of Radiography and checked the dictionary to find out what the job was about. “I realised that radiography had nothing to do with radios,” he said with a laugh. Being a tech enthusiast, he was excited at the prospect of doing such a job, and after graduating, he joined Singapore General Hospital, where he did x-rays for the first three years.

Later, he was trained to perform MRIs and computed tomography (CT) scans. He keeps up to date with the latest technology by attending seminars and reading books. The final gatekeeper Mr Lim said a good radiographer needs to be meticulous and mindful of patient safety. When doing an MRI, for instance, because of the powerful magnetic field, it is important to thoroughly screen patients for any implants they might have in their body. If an implant in the body is not secured to a bone, it could get dislodged, causing harm to the patient. Other implants could heat up during a scan, resulting in burns. “Even though there are several levels of screening before the patient comes to us, we are the final gatekeepers,” he said. Mr Lim likes working with patients, many of whom ask for him at followup visits. One of them is a patient with severe neck pain who can only lie down for two minutes at a time. To ease her discomfort, Mr Lim always moves the bed out from the machine in between scans to let her sit up, even though it prolongs the procedure. His work also involves training younger colleagues and students on attachment, as well as research. He is currently working with radiologists on using MRI-guided highintensity ultrasound to identify and destroy cancer tissue in the prostate. “Research is crucial as it can provide new treatment options for patients in the future.” Although his job is varied, what gives him the most satisfaction is “when a patient returns for a followup scan after treatment and there is no more cancer”.

Sixteen years ago, Ms Shamsunnisah Mohamed Khan thought she would never walk again. A blood clot in her spine left her unable to walk, and she was eventually bedridden. But she recovered after an emergency operation and was so grateful to the doctors and nurses who gave her a second chance that she wanted to help others in return. “I felt so relieved to be standing on my own two feet again. I wanted to give someone else a chance to go on in life and thought the best place to do this would be in a hospital,” said Ms Shamsunnisah, 38, who graduated with a polytechnic diploma in chemical process technology and joined Singapore General Hospital as a medical technologist. A crucial role Now a Senior Medical Technologist at the National Heart Centre Singapore (NHCS), she works in the Cardiovascular Laboratory where invasive cardiac procedures, such as angiograms and pacemaker implantations, are done. She leads a team of medical

Ms Shamsunnisah Mohamed Khan

Senior Medical Technologist Cardiovascular Laborator y National Hear t Centre Singapore

technologists, whose main task is to monitor patients’ blood pressure and heart rates during procedures. Along with doctors, nurses and radiographers, a medical technologist plays a crucial role during procedures, which can last from 10 minutes to five hours. “We look out for any drastic changes which are dangerous. We act as eyes for the doctor. He is busy doing the procedure and entrusts the monitoring to us.” As there has to be at least one medical technologist present during a procedure, they work in teams, and have to be alert and ready for unexpected developments. “Although there’s an adrenaline rush, we have to be calm and let the doctors and nurses know if anything is wrong, and help them with any additional equipment needed,” she said. The rest of her time is spent at the Cardiac Laboratory, attending to patients with pacemaker implants who regularly return to ensure their devices are working well. Enjoys working with people Ms Shamsunnisah also trains junior colleagues and conducts lessons biannually for Singapore Polytechnic’s cardiac technology students on attachment at the centre. When she joined the profession, there were 16 medical technologists at NHCS. Now, there are 50 and more are needed. It takes two years of onthe-job training to become competent in invasive and non-invasive cardiac procedures using different machines. But learning never stops and medical technologists must be willing to keep learning and adapt to changes. Ms Shamsunnisah, who has won several service quality awards, enjoys interacting with patients. The satisfaction of seeing patients resume normal activities is one of the best parts of her job. “I love my job because I’m constantly on the move and always learning. And even though I operate many machines, I still get to work with people,” she said.


Dr Dawn Tan

Principal Physiother apist Depar tment of Physiotherapy Singapore General Hospital

A dual passion She is not just passionate about helping children, she wants to see the profession reach new heights too

A mother was at her wits’ end when her little boy with autism took to dipping the toilet brush in the bowl and sucking it. She went to KK Women’s and Children’s Hospital (KKH) for help and was referred to Ms Tan Peng Chian, Principal Occupational Therapist from the Department of Child Development. Ms Tan knew the two-year-old wanted the oral sensation of sucking the bristles. She suggested that the child be given special equipment to chew on and crunchy food like cornflakes to eat. She also suggested locking the toilet door and providing other forms of stimulation through play. “It was wonderful that the methods worked,” recalled Ms Tan.

The sky’s the limit Dr Dawn Tan’s career path is proof that opportunities abound for physiotherapists to go far in their careers Dr Dawn Tan, 36, Principal Physiotherapist, Department of Physiotherapy, Singapore General Hospital (SGH), worked her way to a doctorate by taking opportunities which presented themselves to her along the way. The first was getting a scholarship to study physiotherapy in London after her A levels. Seven years later, while a practising physiotherapist at SGH, she decided to do her Masters in neurological physiotherapy in Australia. She continued pursuing a doctorate in clinical physiotherapy at the same university and received a scholarship to do that too. “There’s a wide range of clinical specialties to pursue, depending on your interest, and physiotherapists can potentially go far in any one of them.” Practising physiotherapists here can also hone their skills through courses, including advanced certification courses, conducted by the SGHPostgraduate Allied Health Institute. This continual pursuit of knowledge means better care for patients as physiotherapists keep up with the latest developments in their field. Opportunities for research Dr Tan works with patients with neurological disorders, such as stroke and Parkinson’s disease, who need rehabilitation to improve their mobility. She teaches patients with dizziness or balance problems (resulting from inner ear disorders) customised exercises. In addition, she is involved in research and education. “Research intrigues me, while I enjoy interacting with patients and their families in clinical work. I feel satisfied when I see them recover and go back to normal activities, and when they learn to manage the condition themselves.” She is currently part of a team,

with neurologists at SGH and the National Stroke Research Institute in Australia, conducting an international trial. The trial is to find out if early and intensive rehabilitation of post-stroke patients reduces their disability and improves their quality of life in the short and long term. “Research has shown that stroke patients spend a lot of time lying in bed and not engaging in activities that can contribute to their recovery. But bed rest has many negative effects including pulmonary complications and reduced endurance,” said Dr Tan, who also mentors other physiotherapists and teaches advanced certificate courses in physiotherapy. Improving patient care Dr Tan has been active in improving patient care. She helped set up a multidisciplinary vertigo clinic at the Ear, Nose & Throat (ENT) Centre, where patients with dizziness and inner ear disorders have early access to physiotherapy. She also initiated monthly meetings between members of the multidisciplinary team – neurologists, nurses, physiotherapists, occupational therapists, speech therapists and medical social workers – to improve communication and collaboration within the team. Dr Tan advises that to excel as a physiotherapist, a person needs dedication, patience and the motivation to want to do their best for patients. That is why she cherishes The Courage Fund Healthcare Humanity Award, which she received in 2006. “It’s what the award stands for. It recognises healthcare workers for their courage, dedication, compassion and humanity. It’s important to not just treat our work as a job, but to be committed to improving patient outcomes”.

On the job This is only one example of what an occupational therapist does. The job entails using strategies to help people who have difficulties cope with everyday activities and function as independently as possible. Ms Tan, 40, heads the department’s satellite clinic in Sengkang, overseeing a 20-strong team. The centre helps KKH doctors assess a child’s development in speech, language, motor skills and cognition. In her previous work in child rehabilitation, she helped children with trauma injuries and neurodevelopmental issues such as Down’s syndrome and cerebral palsy. Her current job allows her to pursue her passion of working with preschoolers with developmental delays and disorders, such as autism. Ms Tan gets a lot of satisfaction from helping the children’s parents too. “I love it when parents go home to try my different strategies and they work. Some even come back and share other strategies that they’ve discovered. I get a lot of satisfaction when I help a family restore their regular pattern of life,” she said.

Taking the profession higher Ms Tan, who has a degree in occupational therapy and a Master’s in occupational therapy and occupational science, has seen much progress in child development services here in the past 16 years. But she thinks more can be done. “It would help to have full degree courses in Singapore for occupational therapists. That will build up the academic environment and allow more research and papers to be published.” Her other passion is research. She believes Singapore, with its unique multiracial population, and educational and social-economic system, will benefit from research. Her own research attests to this. Her team looked into the visual-motor performance of Singapore preschoolers using a standard test to assess their ability to copy shapes. Their findings were different from data collected from studies on American children. “We found that our general population did much better than the general US population, and there were also differences among the races,” she said. The results of this study have helped local occupational therapists identify and help children who had done well when compared to the US population, but who were unable to write as well as their peers could in school. Ms Tan Peng Chian

Principal Occupational Therapist Depar tment of Child Development KK Women’s and Children’s Hospital

www.singhealth.com.sg


Celebrating Allied Health Professionals

key Figures

Learn more about SingHealth’s Allied Health Professionals (AHPs)

SingHealth has close to 2,600 AHPs from 16 different professions.

The decade when Dietetics, Physiotherapy, Occupational Therapy and Medical Social Work were introduced in SingHealth.

The year SGH-Postgraduate Allied Health Institute – the first postgraduate school for AHPs – was officially opened. It offers a comprehensive range of courses, certification and clinical programmes for AHPs from Singapore and the region.

8,363

AHPs have been trained at the SGH-Postgraduate Allied Health Institute since 2006.

SingHealth AHPs have post-graduate qualifications. 80 per cent have a Masters degree and 20 per cent have PhDs.

www.singhealth.com.sg

The year the Allied Health Professions Act was passed. It recognises the integral role trained and qualified AHPs play in healthcare. Under the Act, Physiotherapists, Occupational Therapists and Speech Therapists are registered under a single national regulatory body. The Act will be progressively expanded to include the others.

The year Music Therapy was introduced in SingHealth, making Music Therapists the youngest allied health group there.

The number of Medical/ Laboratory Technologists in SingHealth, constituting its largest allied health group.

The age of SingHealth’s most senior AHP, Mr Ng Hon Wing, Principal Radiographer, Singapore General Hospital. Mr Ng has chalked up an impressive 57.7 years (and still counting) in the profession.

If you are interested in joining SingHealth as an AHP, more information is available at www.singhealth.com.sg/careers.


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singapore h e alth

Nutrition

Yummy, healthy recipes

Recipe

Roast Pork

Try this delicious recipe from Where is the Fat? Cookbook

Sauce: 50g onion, chopped 1 gherkin (about 20g), chopped 2 tbsp margarine 100ml white wine 360ml demi-glace Pinch of pepper Pinch of salt

Singaporeans love their food, and it’s possible to eat well without feeling guilty with these eight golden rules from Singapore General Hospital’s dietitians Variety – the spice of life No single food can provide all the nutrients your body requires every day. Select a variety of foods from the different food groups. Eat more rice and foods that provide carbohydrates and dietary fibre, a moderate portion of fruits and vegetables, a small amount of meat and protein-rich foods, and minimal fats, oils, sugars and salt. Forget extremes Eat sensibly. Do not go to extremes if you want to achieve and maintain a body weight that falls within the normal range. Food provides us with the energy to perform a full range of daily activities. To help us stay trim and fit, our energy input (what we eat) should be balanced by our energy output (what we do). Grains Enjoy foods that are rich in carbohydrates or starch, dietary fibre, vitamins and minerals. Grains and grain products make up some of Singapore’s

HEALTH TIP Pork loin, depending on which part of the animal it comes from, can contain varying amounts of fat. Tenderloin is a better option as it contains less fat.

favourite foods, including noodles, pasta, chapati, lontong and porridge. Remember fruits and vegetables Most vegetables and fruits are low in calories and high in dietary fibre, vitamins and minerals. Eat two portions of fruits and two portions of vegetables every day. Add colour, taste and health to your meals with bright green, leafy vegetables, red chillies and tomatoes, as well as fruits like papaya, banana, watermelon, starfruit and longan.

Cut down on fats Go easy on the fats, especially saturated fats. Choose and prepare dishes that are low in fat. Weight for weight, all types of fat have more than double the caloric value of carbohydrates and proteins. Cut down on your fat intake CHEF’S TIP to significantly reduce your Use a fork to prick total caloric consumption. the pork several times before marinatGo natural Use less ing to allow the sauce salt and sauces. Salt or to seep into the meat sodium occurs naturally for better flavour. in all foods as well as in table salt, seasonings, ready-made sauces, as well as preserved and processed foods. Reduce your salt intake gradually and you will soon begin to appreciate new tastes and subtle flavours that would otherwise have been overwhelmed by salt. Sugar…less A good way to reduce calories is to cut out sugar by taking less sweet drinks. A can of soft drink

Saute onion and gherkin with margarine. Add white wine and cook till it is reduced to half, then add demi-glace. Season with pepper and salt. Serves 4 Ingredients: 500g lean pork loin ½ tsp paprika ¾ tsp rosemary ½ tsp pepper Pinch of salt Method: 1 Marinate pork with paprika, rosemary, pepper and salt 2 Tie pork with butcher string 3 Roast for 30 minutes at 180°C in a preheated oven 4 Remove from the oven and slice into medallions 5 Prepare the sauce and serve pork hot with sauce

ESTIMATED NUTRITIONAL CONTENT (PER SERVING) Energy 233kcal* Carbohydrate 4g Protein 19g Fat 14g Sodium 389mg Cholesterol 80mg *Alcohol contributes 16kcal to the energy content TYPES OF PORK LOIN (LEAN) Centre cut Rib end Tenderloin

FAT CONTENT PER 100G RAW, EDIBLE PORTION 5g 9g 3g

consumed twice a day adds to your sugar intake by about 15 teaspoons of sugar or 280kcal a day! Alcohol in moderation Alcohol contains calories and excessive drinking can lead to weight gain, heart problems and alcohol dependency. If you must, take no more than two standard drinks for women and no more than three for men.

Adapted from Where is the Fat? Cookbook, which is available at SGH Pharmacy, Block 4.

> Continued from page 16

Playing games to keep the brain healthy Being able to feel the character carved on a mahjong tile isn’t just a skill that experts pick up from years of playing the Chinese game. Feeling the tile, “seeing” its shape in the mind, then understanding or remembering what it means keep the brain nimble and healthy, and help to slow the decline in its many functions as a person ages.

“Successful brain ageing is based on almost the same tenets as successful ageing,” said Dr Dennis Seow, Consultant, Department of Geriatric Medicine (Memory Clinic), Singapore General Hospital. “Successful agers often are people who look after their physical health, keep any illness such as hypertension or diabetes under control and lead an active social life. By the same reckoning, these factors also apply to successful brain ageing.” Helpful games Brain health embraces many aspects of life and living. According to one approach to treating memory loss, biological, psychological and social factors all play

a significant role in human function and the treatment of disease. “In a biopsychosocial model, mahjong is a very good game because it feeds into all these factors,” Dr Seow said. The latest available data, from the 1990s, show that about three per cent of people under the age of 60 develop some form of memory impairment, including dementia and Alzheimer’s disease. The figure rises to five per cent for people aged 65, and doubles every five years till it’s 40 to 45 per cent for people who are 80 and older, he added. It’s not just mahjong that can help keep the brain healthy. Other games such as sudoku, chess, crossword puzzles and, increasingly, games played on the computer that stimulate memory,

speed, attention, recall and organisation can also help slow the decline in the brain’s functions. Not all are appropriate, however, and the lack of governance and medically approved standards means it’s anyone’s guess how useful a game can be. Mahjong is a social activity between a group of friends or relatives. The game draws people out of their homes to interact with others. “Social interaction is not the most vital (factor for a healthy brain), but it is very important. People who are reclusive can become depressed. When they are out with friends or family, they find their spirits uplifted. They come out of their shell and are nourished emotionally and spiritually,” said Dr Seow. “Depression is a risk factor for dementia.”


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Health

All-in-one cataract surgery With today’s lenses, patients undergoing cataract operations can have other eye conditions “fixed” at the same time BY Tan May Ping

For almost three years, Mr Roger Kang, a real estate agent, lived with worsening eyesight due to cataracts. But despite his blurred vision, he carried on with his daily activities and did not see the need for an operation. “Although it was uncomfortable – like seeing smoke in front of you all the time – I could live with it,” he said. Finally, having no other choice, he underwent surgery last year and was pleasantly surprised to learn that not only could he have his cataracts removed, he could also correct his astigmatism, longsightedness (hyperopia) and near vision (presbyopia) in one fell swoop. No need for spectacles Mr Kang had premium multifocal lenses inserted into his eyes, one at a time, two weeks apart. After the procedure, he was able to do away with his multifocal spectacles, which he had worn for 10 years. “My eyesight is almost perfect now. The best part is that I don’t need to wear specs anymore,” he said.

He does, however, see halos around lights at night, but is not bothered by it. “I’ve no regrets and have recommended it to quite a few friends,” he said. Mr Kang is among a growing number of cataract patients at Singapore National Eye Centre (SNEC) who have opted for premium intraocular lens implants. In cataract surgery, the cloudy film that blurs vision is removed and a lens implanted. Those who needed spectacles previously may be able to give them up after getting the lenses. Lenses that multitask In recent years, cataract operations have become not just about removing cataracts. Premium lenses allow other conditions such as Mr Kang’s, as well as myopia (short-sightedness), to be fixed at the same time during these operations. Premium lenses are the result of the convergence of both cataract and refractive surgery technologies. This worldwide trend has made these procedures more convenient, and provides opportunities for patients to improve their vision and become spectacle-free. According to Associate Professor Chee Soon Phaik, Senior Consultant Ophthalmologist, SNEC, 11 per cent of the 10,500

Premium lenses such as the above may enhance visual outcomes of cataract surgery by correcting astigmatism, long-sightedness (hyperopia) and near vision (presbyopia).

cataract procedures performed each year at SNEC involve the use of premium intraocular lens implants. About 50 to 70 per cent of her patients – from young professionals to older housewives – opt for premium lenses. “Premium lenses enable a surgeon to offer patients the option of not just targeting good distance vision, but also correcting astigmatism to give very sharp vision,” said Assoc Prof Chee. What the lenses do “In addition, they can correct visual aberrations, sharpening the vision further when the pupils dilate at night.”

Premium lenses enable a surgeon to offer patients the option of not just targeting good distance vision, but also correcting astigmatism to give very sharp vision. Associate professor chee soon phaik, senior consultant ophthalmologist, singapore national eye centre

Associate Professor Chee Soon Phaik checking a patient’s eyes for visual abnormalities.

Some boutique, premium intraocular lenses can also enhance vision, but need to be customised to the individual and may not be suitable for all.  But concurrent eye conditions may limit the achievable visual success. Surgeons can guide and advise what lens would be most suitable for patients’ eyes, and address their needs and desires regarding visual performance. Assoc Prof Chee said standard monofocal lenses in cataract surgery target clear distance vision and can correct myopia or hyperopia. Monofocal lenses target the master eye to see distance well and the fellow eye for intermediate or near vision.

When both eyes are used together, it increases the range of vision so the patient is not that dependent on spectacles. But patients often have residual astigmatism and presbyopia, and typically have to use spectacles for near vision. Very small incisions To implant premium lenses, surgeons use the phacoemulsification technique, where a small incision of 1.8mm is made in the eye, through which the cataract is removed and the lens put in. The incision allows surgeons to better control post-operation astigmatism and centre the lens more precisely, enhancing its performance. Using ultrasound energy, they use the phaco needle to break down the nucleus into smaller fragments. These become emulsified and are sucked out of the eye through the incision. Lens materials have also improved, resulting in lenses that can now be scrolled up and slid through very small incisions, before opening to full size in the eyes. This ability to remove cataracts through increasingly small incisions has made cataract surgery safer for patients. Not for everyone Assoc Prof Chee cautioned that not everyone will benefit from these premium lenses and that total spectacle independence will not be possible for some patients, as the outcome depends on individual eye conditions. For instance, monofocal and toric intraocular lenses can be used for any eye condition, including those with astigmatism. However, implants with multifocal components are reserved for eyes which are perfectly healthy except for cataracts. “The decision is based on the patient’s eye condition, visual needs, lifestyle and cost,” said Assoc Prof Chee. Premium lenses are also generally priced higher, depending on the type of lens. The cost of cataract operations can be claimed from Medisave and, depending on the particular policy one subscribes to, health insurance may cover this procedure for any type of lens.


May⁄ Jun 2012

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19

Viewpoint

Where are you from, Doctor?

A locally trained Singaporean doctor reflects on the influx of local and international doctors who were trained overseas and are now part of our healthcare system

I asked after my spiel of risks versus benefits of cataract surgery. “No… Thank you hor, doctor. I think I do op lah.” “Okay Auntie, no problem. Wait ah… I arrange op for you.” “Okay. Where you from ah, doctor?” Now, where did that question come from? How was it relevant to our discussion? And Auntie, didn’t I just help you understand what you had was bai nei zhang (cataract) not qing guang yan (glaucoma), and tell you that ji guang (laser) was not the solution, but dong shou shu (undergoing an operation) was, along with a peppering of Singlish like hor, meh and lor? I answered: “Marine Parade,” before trying to get the cataract listing forms sorted. “No lah, but from India which part? Your Chinese quite good hor.” I admired her perseverance, but failed to see the connection. But why should it bug me so much? After all, over the last decade, we have received quite a large number of foreign healthcare workers – nurses, doctors and other paramedical staff – from various countries. The statistics To alleviate the critical shortage of doctors here, more than half of the doctors employed since 2005 have been overseas trained. An article in The Straits Times (March 26, 2011), entitled Easier to Bring in Foreign-trained Docs, reported that the number of new doctors more than doubled – from 639 for the three years from 2004 to 2006, to 1,392 from 2007 to 2009. And of the 1,392 new doctors, half were trained overseas. The 2011 Singapore Medical Council’s Annual Report notes that of the 1,527 new medical registrations, 919 were “foreigntrained foreigners” and 161 were “foreigntrained locals”. So, fair enough, Auntie was confused. But seriously, does this matter? From the patient’s perspective Based on letters to The Straits Times’ forum page, it apparently matters. Most letters wondered whether the foreign doctor (FD) is attuned to the local cultural context and lingo, and is as competent as his locally trained counterpart. From the layman’s perspective, it

Since 2005, more than half of the doctors here have been trained overseas.

might be a little frustrating for the patient if the healthcare professional is unable to understand the local context, whether it is the language, nursing home issues or even the patient’s unwillingness to go for surgery. In the wider context, the local populace appears to be generally frustrated with foreign-sounding service providers. In my opinion, it really shouldn’t matter whether or not your service provider is a foreigner or local, as long as the service rendered is competent. The local doctors’ perspective Most local doctors (LDs), at least in the public healthcare setting, have many FD friends and most are happy working alongside FDs.

The best way forward might be to acknowledge that foreign doctors are an important component of our healthcare system and are here to stay.

On the positive side, many have unique skill sets and experience. I remember one very experienced and skilled foreign-trained doctor who, while here as a medical officer, was regularly consulted by on-call registrars for difficult cases throughout the night. The flip side is that not all FDs come well trained, and not all find it easy to adapt to the local system and way of doing things. Some LDs privately acknowledge that, having been admitted to local medical schools with difficulty, they are now

being nudged aside by FDs when competing for residency spots or places in specialist training programmes. While the FD has a way out – back in his home country – the local doctor has nowhere else to pursue his interest should he be denied such an opportunity. The foreign doctors’ perspective There are two types of FDs: 1. Foreign-trained local doctors 2. Foreign-trained foreign doctors Most FDs I know, of either category, have acclimatised well to the local setup. However, some find it difficult to get accustomed to the long work hours and high patient load in certain specialties. Many FDs of the first category already have a good idea of the LD’s work schedule. Despite this, some have a difficult time with the working system. Some perceive our local culture to be more hierarchical, stern and, perhaps, more punishing than what they were used to overseas. Most, however, appear happy enough to stay on. Many in the second category may have difficulties with local cultural and linguistic intricacies, and have to grapple with large patient loads and a new system of working. The challenges which less experienced doctors in this category face may be especially difficult to surmount. For the more experienced ones, having to work under the supervision of less experienced local doctors and “study again” for local postgraduate exams may not be the most enviable option. The way forward It is important not to let xenophobia creep in, as our society owes a fair amount to foreign-born residents, whether they are construction workers, domestic helpers, high-level foreign talents or FDs. There appears to be many measures to boost the number of healthcare professionals to match the growing needs of

illustration: heymans tho

“Got any more questions, auntie?”

our ageing (and increasing) population, including plans to increase the medical student intake in our existing medical schools and start a third medical school. In the short term, the actions include attracting foreign-trained doctors and recognising more medical schools from abroad. The situation is apparently so dire that even doctors not trained in the English medium are being employed. Such measures, while not necessarily desired by local doctors or the population, may well be necessary. The best way forward might be to acknowledge that FDs are an important component of our healthcare system and are here to stay. Current supervisory systems to ensure clinical competence of these conditionally registered doctors serve as useful checks in ensuring clinical proficiency. To further instil public confidence in our FDs, perhaps a United States Medical Licensing Examinationstyle assessment for entry into our medical system could be considered, both to ascertain basic clinical proficiency and English proficiency for those not trained in the English medium. Local doctors should be consulted and updated on a regular basis regarding current patient load patterns and where we fit into the scheme of things, prior to implementing measures, so that we have an active role to play in shaping the healthcare of our nation. As for Auntie, she was subsequently operated on by an experienced FD colleague of mine and is now delighted with her 6/6 vision. Dr Jayant V Iyer is a locally trained LD based at Singapore National Eye Centre. This article has been adapted, with permission, from the original piece in SMA News (January 2012 issue), which he wrote in his capacity as an editorial board member.


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MAY⁄ JUN 2012

Spotlight

You do not walk alone The NCCS nose cancer support group provides what no amount of medicine can – a listening ear, a helping hand and, when needed, a shoulder to cry on

“I was worried and uncertain, but he went through the whole treatment process and shared his own journey with me. That night, I had my first good night’s sleep since the diagnosis. This group is not only useful but, here, I don’t feel alone,” said Mr Chang, who is a patient from another hospital.

PHOTOS: ALECIA NEO

A true blue support group The group, which started in 2005 with 20 participants, now has about 300 – mostly survivors and a few caregivers. It also gets queries from other hospitals and even overseas.

Ms Sim and her parents. The tips on nutrition helped her father through the gruelling seven weeks of treatment.

In March last year, Ms Winnie Sim, 39, quit her marketing job when her 71-year-old father, Mr Sim Teng Juay, a retired senior clerk, got Stage 4 nasopharyngeal (nose) cancer. She knew it would be hard on her mother Mdm Ho Mew Wan, 70, a diabetic, to care for him alone and accompany him to his daily radiation and chemotherapy treatments. So she pitched in to help. “It was tough but he’s my dad,” she said. “I thought to myself that it might be the only battle we have to fight, so I wanted to give it my all.” She plunged into the task trying to find out as much as she could about the cancer. Then she did something which really helped – joining NCCS’ Nose Cancer Support Group. Others in the same boat Initially, she went to the meetings alone, as her father was too ill to attend. But she would go home and share everything with him. It made her realise that her family was not suffering alone – there were others, including many who recovered after treatment. “I learnt how they coped and survived. Before this, we didn’t know much about nose cancer, except that a distant relative had it.” She picked up tips on nutrition to reduce the side effects of treatment. “I learnt that lemongrass could help protect cells, so my Dad took a lemongrass drink every day before chemo. I heard that manuka honey soothes throats affected by radiation, so we gave that to him too.” She combined recipes to get the best effect, and went shopping for ingredients every day. “It was tiring but it helped, because he didn’t suffer much from chemo and so could continue with the treatment.” Recently, she learnt that, in eight or 10

years’ time, her father might experience some hardening of the muscles, so he now sees a speech therapist and is learning simple exercises to delay its onset. “I wouldn’t have known about this if they hadn’t told me about it.” Her efforts have paid off. Mr Sim, who attended his first group support meeting almost a year after his diagnosis, is in the clear after treatment, with only his hearing and taste buds affected. “This group has made our battle with cancer and the journey to recovery easier, brighter and warmer. Without them, we’d be journeying alone in the darkness,” said Ms Sim. Learning and sharing Others have similar experiences. Mr James Chang, 44, a tax officer, was reeling from the diagnosis when Mr Teo Thiam Chye, 58 – the group’s leader and a nose cancer survivor himself – visited and reassured him.

> Continued on page 22

Here are a few of the many groups within SingHealth National Heart Centre Singapore (NHCS) (Open to patients of NHCS)

Cardiovascular Rehabilitation Patient Support Group Tel: Nurse Manager in charge at 6436-7603 Heart/Lung Transplant Patient Support Group Tel: Transplant Coordinator at 6436-7635, email: transplant.office@nhcs.com.sg Pacemaker/ICD Patient Support Group Tel: Ms Chiong Siau Chien Manager, Cardiac Lab at 6436-7867, email: chiong.siau.chien@nhcs. com.sg

National Cancer Centre Singapore (NCCS) (Open to all cancer patients in Singapore) The Revival Connection (for patients with advanced and recurrent cancers)

The Nasopharyngeal (Nose) Cancer Support Group The Mandarin Support Group (for Mandarin-speaking cancer patients) cancer patients)

The Lung Support Care Programme The Grief in Recovery Programme (for surviving spouses of cancer patients)

To contact the various support groups, call 6436-8126/6436-8117 or email mss@nccs.com.sg.

KK Women’s and Children’s Hospital (KKH) (Open to members of the public)

Perinatal Depression Support Group Tel: 6394-2205 (8am to 5.30pm, Mon to Fri). Patients must be assessed for suitability before joining. Cleft and Craniofacial Support Group Tel: Josephine Tan, coordinator, at 6394-5034/91003978, email: Josephine.Tan.CH@ kkh.com.sg; tel: Aini Dahlan, Nurse

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“We welcome everybody. This group has gone beyond nose cancer. We’ve got people with colon cancer, lymphoma, as well as head and neck cancer. They come because of the bonding,” said Mr Teo, affectionately known as TC – a name he prefers to use. Having walked the rocky road to recovery, TC sees it as a calling to help new patients, especially during the seven gruelling weeks of radiation and chemotherapy. “Our group’s motto is that nobody should journey alone with cancer.” He said: “This is a true blue support group. There is warmth, closeness, commitment, information, support and friendship. Many people contribute to it. After our sessions end, people will hang around outside talking, sharing, laughing and making arrangements to meet up either individually or in smaller groups.

Some patient support groups

The Malay Support Group (for Malay

TC and his wife Mrs Margaret Teo-Lee, whom he said has been “a pillar of strength” during his trials.

singapore health

Clinician, at 9180-0186, email: Aini. Dahlan@kkh.com.sg KK Alpine Blossoms Breast Cancer Support Group Tel: Doris at 6394-5816; Breast Care Nurse at 8121-7943

Singapore General Hospital (SGH) Breast Cancer Support Group (open to patients from SGH and NCCS) Tel: Mdm N Saraswathi at

6321-4474 Haematology Support Group There are separate support groups for patients with chronic myeloid leukaemia, multiple myeloma, thalassemia, haemophilia and myelodysplastic syndrome. Call Senior Nurse Manager or Nurse Clinician at the Haematology Centre at 6321-4722, who will link callers to the groups. Amputee Support Group (open to patients from SGH) Tel: Sister Sivagame at 9842-8932; Sister Chew at 8119-0398 Stroke Club and SGH Dementia Support Group (focusing on early dementia) Tel: Nurse Diane at 9239-5907, email: theng.li.ping@ sgh.com.sg Parkinsons Disease Support Group Tel: Tan Siok Bee at 8125-3543, email: tan.siok.bee@sgh.com.sg The Colorectal Cancer Support Group (for all patients with colorectal cancer in Singapore) Tel: Ms Carol Loi at 6321-3615, email: carol.loi@sgh.com.sg or ong.choo.eng@sgh.com.sg Oncology Support Group (for cancer patients from SGH and NCCS) Tel: Aw Fung Chee at 6321-4480, email: aw.fung.chee@sgh.com.sg; tel: Lee Teng Teng at 6321-4482, email: lee. teng.teng@sgh.com.sg


It’s smarter to monitor your blood pressure before you fall sick.

Blood Pressure Monitor

Hi h bl High blood d pressure (BP) iis called ll d th the ‘‘silent il t killer’ because there are often no symptoms. Even though you feel well, you could have had it for years without knowing. And untreated high B BP can cause damage to your ar arteries, leaving you more sus susceptible to heart attacks and heart failure. For better heart health, you should have good eating habits, exercise regularly and practise BP home monitoring. pract Knowing your BP status helps Know you seek your doctor’s help when necessary. Visit www.omron-healthcare.com.sg to learn how the leader in BP home monitoring devices, Omron, makes it easier for you to do so.

Check out in store for Omron Blood Pressure Monitor promotions! Available at leading retail pharmacies including major hospitals.

For more information, please contact Kingston Medical Supplies, 6745 3922

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People

The good old family doctor From working at a private clinic to a polyclinic and to a hospital, Dr Matthew Ng displays the versatility of a doctor trained in family medicine

By Jamie Ee

PHOTO: ALECIA NEO

I chose to specialise in family medicine because… I get to attend to patients with a variety of conditions. Family medicine is about providing holistic, continuing care to patients of all ages across the entire healthcare

As a consultant at the Department of Family Medicine and Continuing Care… My doctor colleagues and I are rostered to provide a wide range of services for patients at SGH and SingHealth. I work closely with a team of social workers and therapists to help patients reintegrate into the community. Besides treating their medical conditions, we look at where the patients can live after being discharged, and whether anyone in the community can take care of them. We think of ways to coordinate their care by working with doctors from other specialist departments. We also provide home-care service for patients who are bedridden or have difficulties coming to the hospital. These patients have very complicated medical conditions that cannot be easily managed in the community, so our doctors are rostered to visit them at home. When their conditions stabilise, we hand over their care to doctors who work in the community. For a month each year, I lead a team of doctors to help take care of patients who are admitted to SGH. When Bright Vision Hospital joined the SingHealth cluster in 2010, our department was tasked to oversee the medical care of patients at the community hospital. Doctors were needed at Bright Vision, so I took up the opportunity and now head

system. I’m trained in all aspects of care, from adult medicine to paediatrics. I started out as a private general practitioner before moving to a polyclinic in 2001. When Singapore General Hospital (SGH) set up the Department of Family Medicine and Continuing Care in 2006, I saw an opportunity to use my training to help even more patients who are in need of holistic care.

Dr Matthew Ng treats patients and helps them reintegrate into the community.

Turning a frown into a smile By Sheralyn Tay

It was troublesome enough having to go to the hospital to fill his prescription after seeing the doctor at the polyclinic. But the elderly patient also had to make an out-of-pocket payment for the medicine because his Medisave claim could be made only at the place where he received treatment – the polyclinic. To top off his grouse of having to multiple trips, his medicine cost more than $200, which was an amount he didn’t have on hand. Mr Thomas Kwan, Manager, Service Quality Department, Singapore General Hospital, listened quietly as the patient fumed and ranted. While he could understand the patient’s anger and frustration, he also realised that the problem wasn’t something he could resolve easily as it stemmed from a combination of Central Provident Fund and hospital procedures. Just then, the elderly man’s wife called and the expression on his face changed from anger to worry.

“Suddenly, he didn’t look like a difficult patient I had to deal with, but an old man with a big worry on his shoulders. I patted him on the shoulder and said, ‘Uncle, please don’t worry.’ He blinked back tears and calmed down,” said Mr Kwan. The patient, who accepted Mr Kwan’s explanation, said he felt angry partly because he was worried about his wife, who was ill with cancer and alone at home. Having to go back and forth took too much of his time, and he needed to hurry home, he said. A complaint that could have escalated into something bigger was quickly resolved. Putting himself in the other person’s shoes, and understanding that the other party had other concerns and wasn’t just being unreasonable, has helped Mr Kwan settle many disputes. He always tries to keep a cool head and connect with the other person. “That simple pat was just a small gesture on my part, but it made a difference,” he said. Mr Kwan also saw an opportunity for improvement, and asked if the polyclinic would consider carrying the medicine.

PHOTO: ALVINN LIM

When it comes to dealing with complaints, a listening ear, a sympathetic approach and a little patience go a long way

Mr Thomas Kwan keeps a cool head while listening to complaints.

the Department of Medical Services there. I spend nine months a year at Bright Vision and the other three months at SGH. Working at Bright Vision Hospital is different because… Most of the patients aren’t in critical condition, having been discharged from acute care hospitals like SGH. They still need care but tend to be more stable. Our goal is to improve their ability to perform normal daily activities or provide wound care. Many Bright Vision patients live alone, so we make sure they learn to care for themselves or they might end up at the hospital again after their discharge. My greatest challenge is… Reintegrating the patients into the community after rehabilitation. Some have been at Bright Vision for as long as nine months and still cannot be discharged as they can’t get proper care at home. I get most satisfaction from… Seeing patients get well and smiling when they come for their reviews at the clinic. As Associate Director of SingHealth’s Family Medicine Residency Programme... I want to see more doctors specialise in family medicine as the training will let them treat more complex medical problems at their own clinics, leaving very severe cases for the hospital. That way, we won’t overload the hospitals with cases that can be seen at the clinics, thus helping to reduce the load for hospitals.

The polyclinic did a review but found that too few patients used the drug. This was explained to the patient, who said that he appreciated the polyclinic’s efforts. Although the case didn’t end as well as Mr Kwan would have liked, he said he approaches each case with the same hope – that “everyone wins”. “Once, I felt quite frustrated because I could not – however hard I tried – resolve a case,” said Mr Kwan. When that happens, he sweats it out, either by exercising in the gym or baking in the kitchen. “Once, I just baked and baked, and I ended up with more than 100 muffins!” he chuckled. In his six years of handling complaints and contentious issues at SGH’s Patient Relations Centre, Mr Kwan has seen it all: patients struggling with financial difficulties, family members unable to come to terms with a loved one’s death and people who complain about the services provided. But he is always ready to lend a listening ear and reach out to help. Mr Kwan and another manager oversee a team in which officers deal with a whole range of cases, from the more straightforward ones such as explaining a situation or policies, to rectifying mistakes and the more complex complaints that involve several people or departments. “My job can be challenging, but I’m a people person. I enjoy serving people and love seeing them leave happy,” he said.


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May⁄ Jun 2012

FYI

Scientists find clue to male balding US scientists have identified a protein that triggers hair loss in their studies of bald men and laboratory mice. Their findings might lead to a cream to treat baldness. Researchers at the University of Pennsylvania found high levels of a protein – prostaglandin D synthase – in hair follicle cells located in bald patches on the scalp, but not in follicles in hairy patches. Mice

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that were bred with high levels of the protein became completely bald, while transplanted human hairs stopped growing after being given the protein. Professor George Cotsarelis, Department of Dermatology, who led the research, said: “We identified a target for treating male-pattern baldness.” He said that hair growth is inhibited when the protein binds to a receptor on the cells of hair follicles, adding that several known drugs which target this pathway have been identified, including some which are in clinical trials. “The next step would be to screen for compounds that affect this receptor, and also find out whether blocking that receptor would reverse balding or just prevent balding – a question that would take a while to figure out,” he said. Source: BBC

Closing date: Jun 4, 2012 Send in your answers and stand a chance to win a piece of Backjoy worth $64.90. Five pieces to be won.

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Smoking-related diseases kill

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You might see bright spots or flashes of light because of a migraine, but it could also be a sign of retinal detachment. See a doctor immediately to prevent permanent loss of sight from retinal detachment.

The social cost of smoking ranged from

$673 million to $839 million in 1997 Source: Health Promotion Board

Source: Mayo Clinic

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Answer to In focus (Page 3): These are parts of a dental implant fitted together – the titanium screw, the abutment (plug) and the crown (prosthetic tooth). The demand for dental implants has been increasing in Singapore in recent years, and the procedure has a very high success rate. Implants are more comfortable than dentures and have advantages over other alternatives to a lost tooth, but they are not for everyone. Dentists have to check many things before concluding whether an implant is suitable for a patient. For more information, see Close to the real thing on page 10. Publishing Agent

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All rights reserved. Copyright by SGH (registration no: 198703907Z). Opinions expressed in Singapore Health are solely those of the writers and are not necessarily endorsed by SGH, SingHealth Group and/or SPH Magazines Pte Ltd (registration no: 196900476M) and their related companies. They are not responsible or liable in any way for the contents of any of the advertisements, articles, photographs or illustrations contained in this publication. Editorial enquiries should be directed to the Editor, Singapore Health, 7 Hospital Drive, #02-09 Block B, Singapore 169611. Tel:+65 6222 3322, Email: editor@ sgh.com.sg. Unsolicited material will not be returned unless accompanied by a self-addressed envelope and sufficient return postage. While every reasonable care will be taken by the Editor, no responsibility is assumed for the return of unsolicited material. ALL INFORMATION CORRECT AT TIME OF PRINTING. MICA (P) 076/06/2011. Printed in Singapore by Singapore Press Holdings Limited (registration no: 198402868E).


新加坡中央医院

5月

与新加坡保健服务

6月 2012

集团的双月刊

page 29

手掌和手指疼痛

page 30

page 31

page 30

牙痛可等到 明早再就诊

验血须医生 的许可

别忘了吃钙片

在束手无策时

“目前,年龄超过 60 岁的人口中约五 分之一患有高血压,而当中的百分之3至 5 可能患有顽固性高血压。但随着国内人 口迅速老化,成年人患高血压的比率将 增加,从而带动顽固性高血压患者人数 上升的趋势,”他说。 对某些患者,顽固性高血压可能是 因一些容易识别的因素所引起,如激素 失衡、肾功能衰竭或肾血管闭塞。也有 像玛俐亚一样的患者,没有明确的病因。 而众所皆知,高血压症状会加居于年龄 偏大、肥胖或患有糖尿病的人。

一项新的突破性微创手术能有效控制顽固性的高血压

螺旋肠镜检 查显著缩短 操作时间

最新进展的旋转式内窥镜操作降 低了患者的风险 原文 JR Wu

陈伟杰医生(左)为玛俐亚女士(右一)做了去肾交感神经术后,她的血压已保持在建议水平。

原文 Thava Rani

于她的气喘逐渐严重使她没办法去 了。不论是说话或躺下她都会感到气 喘,”优士米娜说。 优士米娜深知这样的情况持久下去只 会增加她母亲中风和心脏病的风险,尽 管如此她还是无计可施。 今年1月份,玛俐亚在新加坡国家心 脏中心做了去肾交感神经术。这项新式 微创手术是使用射频消蚀围绕肾动脉的 交感神经,把玛俐亚的血压大幅度降低 至目标水平。 “医生说,手术后一周内就能得到显 著的效果,我母亲的血压在手术当天就 降低了。最重要的是她不再感到气喘 了,”优士米娜说。

玛俐亚女士(Malia Dawan)每天即使服 用六种不同的抗高血压药物,她仍然无 法将血压降低。有时她的收缩压指数高 得连她的家用血压计都量不出血压,无 法显示读数。 超过六个月,玛俐亚女士的收缩压一 直徘徊在 200 和 210 毫米汞柱( mmHg )之 间,比她同年龄层的 140mmHg 的建议水 平还高出许多。 她的女儿优士米娜(Yusminah Yusi) 是名训练有素的护士,认为她母亲也许 是没有正确地从药盒取药。于是,她改 用小塑料袋把药品装起来,并用马来语 顽固性高血压 写上标签。玛俐亚按指示准确无误地服 高血压,也称“隐形杀手”,在一般情 用药物,但情况仍然没有改善。 况下都是等到病情进展到致命并发症如 中风或心脏病发作时才会发现,不然通 她所患的疾病 常会被忽视。可是,有些患者可能会出 现年71岁的玛俐亚所患的是顽固性高血 现诸如头痛、呼吸短促和头晕等症状。 压。这类高血压对药物治疗不会产生反 新加坡国家心脏中心心内科顾问医生 应,即使服用三种或以上的药物也无效。 陈伟杰说:“对于顽固性高血压,即使 这 种 病 情 时 常 让 她 感 到 呼 吸 困 患者按照医嘱服药,血压仍会保持在偏 难。“以前她总爱往乐龄公园走走,由 高的位置。 ”

不管是将内窥镜从喉咙向下插入或通过 肛门向上插入窥视小肠都不是件令人舒 服的事,更何况是在处于半清醒的状态 下进行。当怀疑患者患有诸如癌症的疾 病时,医生就须要进行这种检视步骤, 以便清楚视查小肠或邻近部位。 这种用于诊断、修复或取出胃肠道 病变组织(有时是致命性的病变组织) 的传统操作可能得花上几个小时。不 过,采用一种称为螺旋肠镜检查(spiral enteroscopy)的新式医疗技术,医生便 可以在一小时之内将内窥镜通过口腔或 肛门导入消化系统并进行检查,从而降 低患者的风险。 “患者在检查台上的时间越长,发生 并发症的机会就越大,因此我们得努力 尽量缩短检视时间,”新加坡中央医院 肠胃科顾问也是螺旋肠镜检查技术倡导 者江山崇医生说。 迄今为止,江医生已经做了 10 例此 类检查。患有贫血症的翁华国在江医生 解释螺旋肠镜检查的益处与风险后同意 接受此检查。由于贫血症通常是肠道出 血所引起,为了准确地找出其贫血的根 源,翁华国在 2010 年初成为第一位接受 此检视的患者。

图:ALECIA NEO

图:ALECIA NEO

突破性手术 以前,顽固性高血压患者疗法选择有限。 尽管改变膳食、生活方式和药物,患者 的血压仍无法降低。 对他们而言,去肾交感神经术是一种 突破性的疗法! 这项技术之所以有效是因为构成肾脏 交感神经的传入神经和传出神经,向大 脑发送信号,而大脑则相应地作出反应。 例如,大脑可以通过肾脏神经向肾脏发 送信号,命令肾动脉进行收缩并保留更 多盐分和水分,导致血压增高。肾脏也 会向大脑送返信号,大脑进而向心脏发 出信号,使其在应激时更快搏动,从而 影响到血压。 “在疾病状态(例如顽固性高血压) 下,经脉中的活动会失去控制。大脑和 肾脏之间总是在互相发送过多的信号, 不仅仅在应激或脱水时发送信号,甚至 连休息状态时也发送信号。因此,通过 选择性地切断围饶着肾动脉的交感神经 特定部分,即去肾交感神经术,有助于 减少过多的信号,从而降低血压,”陈 医生解释道。 扰乱大脑信号其实并非新鲜的概念。 自从上世纪30年代,外科医生就已经能 去除围绕肾动脉的神经,不过当时是项 涉及极大损伤的开放式侵入性手术。尽 管该手术能有效控制高血压,却使很多 病人发生其他并发症,比如尿失禁和性 功能障碍。在出现了有效的降压药后, 外科手术即被废弃不用。 如今,微创技术让这种手术更为安 全。而且,该手术在海外已经开展两年, 结果表明手术效果明显且持久。 虽然去肾交感神经术不能治愈高血 压,但可降低血压平均达 32/12mmHg 。 自去年9月以来,有3位病人在新加坡国 家心脏中心做过这种手术,他们的血压 > 文转 page 28

翁华国(左)在第二次接受螺旋肠镜检查时发 现小肠内有一个肿瘤。 > 文转 page 28


28

新脉动

MAY⁄ JUN 2012

新闻

图:ALVINN LIM

转内窥镜或柔韧的内窥镜时,能将其导 螺旋肠镜检查显著缩短操作时间 入粗细适中的小肠或肠道中,不仅让仪 器操作保持平稳也让肠壁继续活动。 “我们需要快速可靠的技术,”江医 生说。 经过一番检查后,江医生并没有发现 小肠前末端出现的疑似出血或异块部 任何异常。但几个月后,翁华国的贫血 位,从患者的口腔或肛门将蛇型肠镜导 症病情复发,红血球数量降至危险水平, 入至受感染的部位,然后进行修复或取出 因此被敦促再次检查小肠的情况。他在 病变组织。由于小肠的总长度可达六米 2011 年7 月再次接受螺旋肠镜检查,并 左右,它会阻碍内窥镜完全钻入小肠里。 采用球囊方法时,为了把内窥镜固定 发现了一个直径 4 公分的肿瘤。江医生 取出样本组织送往化验,并在发现肿瘤 在一个位置上,必须将长管子向肠道内 的部位上做个标记。化验结果确认病变 部移动再以外用泵将球囊充起。若要把 组织是恶性肿瘤。紧接着,外科医生引 内窥镜推进或抽出到小肠另一个新位置 用了江医生所提供的检验结果和肿瘤部 时,则需要瘪球囊。球囊方法需要两至 三个小时操作,然而它的主要问题其实 位标记图,成功地为翁华国动手术。 现年 7 2 岁的翁华国前后接受了两次 是因为肠道壁一直处于在活动状态,所 螺旋肠镜检查,因为这种检查比传统球 以当球囊瘪时,内窥镜可能会往后滑动 囊肠镜检查( balloon enteroscopy)时 或无法在小肠中保持位置。 间更短。“我知道检查的风险,不过我 采用螺旋肠镜检查,医生朝向小肠内 们必须那么做。就好比你即将要过马路 转动内窥镜,主要是因为螺纹能抓牢肠 一样,可能遇到风险或事故的比例为 3%, 道内壁,所以无须用泵。旋转的目的是 但在考虑风险和益处的机率后,你决定 使向后推压的肠道内壁产生起皱褶效果 进而容许内窥镜向前移动,同时螺纹效 过马路,”翁华国说道。 江医生说,螺旋肠镜检查操作时间 应也能将内窥镜牢牢地固定在位,不会 能够缩短是因为肠镜的螺旋形设计运用 滑动。 一旦医生确定了病变部位后,还得需 了螺丝钉和螺母的设计理念,使医生旋 要五分钟的时间准备微型手术工具,以 便修复出血部位或切除息肉。要是采用 球囊方法,在准备工具的同时,柔韧内 窥镜可能因为未能固定在小肠壁上而从 正确的位置向后滑动,如果医生还要重 新探查病变部位,则会延长操作时间并 增加患者的风险。 国外研究结果显示,螺旋肠镜检 查比球囊肠镜检查更为快速,也较为 安全。去年,《肠胃和肝脏病学期 刊》(Journal of Gastroenterology and Hepatology)曾报道,在亚裔患者群中, 螺旋内窥镜的平均插入深度为十二指肠 在进行检查前,江山崇医生与病患闲聊以助他们 悬韧带后249公分,也就是位于小肠头 放松心情。 端附近连接小肠与膈膜的节段。 江医生估计,到目前为止他所进行 的螺旋内窥镜检查操作时间最快仅需约 40分钟。 与任何内窥镜操作相同,螺旋肠镜 检查也存有穿孔、出血和胰腺炎的风险。 不过,若操作熟练,医生可以为患者在 门诊部进行螺旋肠镜检查。由于螺旋肠 镜检查在新加坡中央医院还较为新颖, 患者需要入院进行检查。然而,在检查 通过内窥镜 微型高清摄像 装置传递影像 至荧 时,患者仅需镇静剂而无需麻醉。 幕,江医生可以清楚地看到小肠内的详细情况。

小肠解剖学 小肠的主要功能是吸收食物中的营养 素。小肠内壁覆盖着数不清的指状突 起物,称为绒毛和微绒毛,这些突起 显著增加了小肠的表面积,便于吸收 营养素。在解剖学上,小肠被分为三 部分: 十二指肠-这是小肠的头端,也 是最短的一部分,主要作用是消 化。十二指肠也是胰腺的开口 处,胰液就是由此进入小肠, 促进营养的吸收。在内窥镜操作

时,在这个部位容易刺激胰腺, 引起胰腺炎。 空肠-空肠是卷曲的节段,占小 肠全长的40%左右。这一节中的 环形皱襞最明显,这些皱襞增加 了小肠的内部表面积,从而促进 吸收。 回肠-这一节占小肠全长60%左 右,起自小肠中段,其末端开口 于大肠。 对医生而言,即使经验丰富、技能娴 熟,要将内窥镜从一端推进穿过小肠 全程也绝非易事。

> 文接 page 27

在束手无策时

导管 神经 心脏 射频消 融导管 射频能量

肾动脉

通过穿刺大腿根 部,将一根射频消 融导管送到肾动脉 内,用高达60摄氏 度的射频能量阻断 肾交感神经,达到 控制血压的目的。

插图:heymans THO

> 文接 page 27

肾脏

股动脉 切口

已达到降低逾 20mmHg。即使血压只降 低 5mmHg 也能降低中风风险百分之 14 、 心脏病百分之 9 和死亡风险百分之7 。

她目前的情况 现 在 玛 俐 亚 的 血 压 已 保 持 在 140/90mmHg 的建议水平,所服用的药 物剂量也比以前更少。进一步监测血压 后,医生很可能还会减少她服用药品的 数量。 “她虽然还没开始回到公园活动,不 过她肯定比以前开心多了。我所有的姨 舅们都有高血压,而且都已经去世了, 当中也有未满50 岁的。他们都没能等到 这项新的疗法;我却很高兴我母亲有这 个机会,”优士米娜说。

导管

去肾交感神经术 的流程 病人保持清醒,但给予轻度镇静。

何谓顽固性高血压? 正常血压低于140/90mmHg (第一个数字是收缩压,第二个 数字是舒张压)。收缩压在正常 水平以上每升高 20mmHg,心血 管疾病的风险就会加倍。 对于没有其他疾病的高血 压患者,目标血压值在 140/90mmHg以下。 对于患有糖尿病、肾病或心 脏病的患者,目标血压值在 130/80mmHg以下。 顽固性高血压是在使用三种或 以上药物(包括最佳剂量的利 尿剂)后,血压没有明显降至 目标值。 高血压控制不佳可能是因为患者 没能遵从服药指示或有白大衣高 血压(病人在诊所时感到紧张) 所致,因此诊断顽固性高血压时 应十分谨慎。

经过腹股沟的一个小穿刺点,通过 股动脉(大腿中的一只血管)导入 一根导管(直径小于2mm),达到 肾动脉。 手术在荧光透视(实时X线检查)的 引导下进行。 当导管末端与肾动脉壁接触时,施 加2分钟的低功率射频能量,该能量 将产生高达60摄氏度的热量。这种 热量能在不损伤肾动脉的情况下让 神经失能。 沿着动脉的不同点进行“烧灼”, 在一根动脉通常会烧灼五至六个部 位。在另一个肾脏的肾动脉重复神 经烧灼程序。 手术完成后,将导管取出。 整个手术过程花约40分钟至1个 小时。


May⁄ Jun 2012

新脉动

29

焦点

饮食养生

癌症病患在新书中分享他们最喜爱的食谱

文 谢诗敏

正当自己需要补充体力,癌症病患麦嘉 盈女士却发现,用餐也成了另一项艰巨 的考验。 癌症治疗让她失去了味觉和嗅觉, 连吞咽也是一种酷刑。从一个喜爱享用 美食和尝试新食谱的她,如今却只限于 吃一些搅成糊状的食物。 麦嘉盈是在生下第一个孩子的五个 月后,被诊断出患上第三期鼻咽癌。然 而,这名在南洋理工大学黄金辉传播 与信息学院任职的副教授,平日用餐 时都有女儿陪伴。当时还处在幼儿期 的女儿才刚开始学吃半固体食物。她 说:“这么一来,就有人和我一起分享 粥和麦片了。” 麦嘉盈的故事是其中一个被叙述在 一本专为癌症病人所编写的新食谱《分 享》里。她的经历并不罕见。为这本新 书投稿的其他病患,也有类似的 经历。

图:alecia neo

在接受放射治疗时觉得难以吞咽食物的麦嘉盈 (右一),在新书中分享了她最喜欢的汤类食谱。

张添才先生在第二期鼻咽癌复发后 接受了脸部手术,也因此失去味觉和嗅 觉。但是,他找到了继续享受进食的方 法。他说:“我还是能够运用其他感官 来享用美食,比如欣赏食物的颜色及品 尝它的口感。我会问太太食物好不好 吃,如果她说好吃,我会多吃一些。” 同样患有鼻咽癌的吉米回想起,他 如何因接受放射治疗而引起口腔溃疡, 使吞咽成为莫大的折磨。每次吞咽时, 他总会低着头闭上眼睛,为的就是不让 家人看到自己痛得流泪。从前坚信中药 疗效的他,如今却认为简单最好。他 说:“木瓜,黄梨,杏桃核仁,姜黄和 香茅草真的能帮助舒缓副作用。” 《分享》里所有的食谱都经过新 加坡国立癌症中心高级药剂师程玉瑛 修改。程玉瑛是新书的营养顾问。她 说:“我们想要病人继续享受饮食过 程,以舒解他们接受治疗时的痛苦。”

高级药剂师程玉瑛将食谱加以改良,让它们更有 益健康。

食品

牛油果 有丰富的维生素、 食用纤维、钾、 叶酸和铜

芦笋 有丰富的抗癌成 分,如硒以及维 生素A和C

花椰菜 含异硫氰酸盐, 可帮助身体产生 抗癌酵素

南瓜 含有阿尔法红萝卜 素,是一种可加强 抵抗力的抗氧化剂

姜黄 含有姜黄素,可 帮助疏解放射治 疗和化疗的副 作用

红豆 有高度抗氧化作 用,可保护细胞 受到致癌的自由 基的侵袭

苹果 含有类黄酮和多 酚,有助抗癌 马铃薯 为身体提供能 量,拥有丰富的 维生素C,可加 强抵抗力

一旦完成治疗后,病患必须更加注意 饮食,能吃些什么,要视病情而定,但 几乎都只能吃素。她说:“我们不是要 让他们摄取较少的热量,许多医生已经 在关注病患的体重直线下降的情况。” 然而在食谱里,她调整了油、糖和 盐的含量。她说,盐会使癌细胞加速扩 散,而油也会促使癌细胞生长。她也把 原本的其中一个食谱抽出来,因为食谱 里用了腌肉。“腌肉里含有可提高癌症 风险的亚硝酸盐。” 她也对菜肴的点缀颇花心思。她 说:“让食物看起来垂涎欲滴,确实可 促进食欲。” 程玉瑛特别推荐汤类食品,因为它们 除了保存食材的营养,也容易吞食。她 说:“你甚至不用咀嚼。虽然一些维生 素C会在汤煮沸时流失,但还有肉类中的 氨基酸等营养成分。”她最喜欢喝的是 杨桃南北杏瘦肉汤,因为它咸中带甘, 味道丰富。“此外,它也很有营养。杨 桃的实用纤维高,并拥有丰富的维生素 C、铜和钾,给汤带来自然的清甜。” 程玉瑛说,这本书不但对癌症病 人有益,也适合一般大众使用。她 说:“书里介绍的菜肴不但健康美味, 也容易烹煮。” 由南洋理工大学和新加 坡国立癌症中心联合出 版的《分享》,每本售 价15元,售书所得款 项将用于癌症研究和帮 助癌症病患家属。有兴 趣购买者,可拨打新 加坡国立癌症中心热线 6236-9440或通过www. nccs.com.sg网站订购。

食谱

杨桃南北杏瘦肉汤

4人份

材料: 中型杨桃4个 蜜枣5粒 瘦肉600克 南北杏25克 水2公升 做法: 杨桃除边去芯,切片。 蜜枣洗净。 瘦肉洗净,烫熟。 将所有材料放入砂锅里,慢火熬煮 2小时即可。

1 2 3 4

注意:不适合肾脏衰竭病患饮用。

健康交流站

我们的专家为您解答有关手掌和手指疼痛的问题

扳机指

腕管综合症

我的一两根手指有时会觉得疼 痛, 通常是右手无名指的下关节 和手指指腹部位。请问这是腕管 综合症吗?或者是因为经常用电 脑打字和手机发短信所造成的?

我偶尔觉得右掌虎口部位有剧烈 的刺痛,通常是在我紧握物体时 或是以某个角度用力拉动时引起 的。当我从床上或椅子上用手支 撑身体起来时,我的手腕便开始 感到无力和顿痛。请问我是不是 患上腕管综合症?

这不太可能是腕管综合症,因为症状似 乎不是和此症有关的典型麻痹感。 根据您的工作性质来看,您很可能 是过度使用扳机指或出现早期扳机指症 状,也是导致您手指根部疼痛和指关节 僵硬的一个原因。 在治疗初期腕管综合症,要避免让 现有的因素恶化,使用符合人体工学的 工作台和服食药物如止痛药和维生素 B6。另外,也可以用夹板固定手腕来进 行调整。如果麻痹或疼痛的症状持续, 并影响到日常生活作息,那就需动手术 治疗。 如果及早进行手术,痊愈的几率会 很高。但如果患者出现这类症状已经有 好几年,并感到拇指根部无力和肌肉萎 缩,那最多只能局部复原,因为有些神 经可能已经受损而无法恢复。

腕管综合症的特点是在于拇指、食指、 中指,以及无名指下半部的麻刺感。 您的症状不是腕管综合症,因为你 手掌的肌肉神经并没有受到影响。 您可能是刺激到手腕表面附近的 神经。当您用手支撑身体从床上或椅子 上起来时,您把身体的重量都集中在 手腕上。 我建议您从床上或椅子上起来时, 避免将身体重量集中在腕部,好让神经 能自然痊愈。如果一个月后还不见好 转,就该咨询手部外科医生。

新加坡中央医院手外科主任兼顾问医生陈元辉


30

新脉动

May⁄ Jun 2012

新闻

等到明早再就诊 牙痛不是病,痛起来真要命。除非牙齿受到感染或牙龈红 肿,否则牙痛并不被视为急诊情况 新加坡中央医院急诊室约80%的牙科 病例都是牙痛。虽然牙痛令人痛苦不 堪,但也不至于需要前往急诊室而是可 以等到翌日就诊。

真正的急诊情况 新加坡国立牙科中心口腔颚面外科顾问 医生赖俊斌解释说,急诊室的配备只能 为紧急牙科患者提供救助,例如因车祸 而造成上颌、下颌、面部中央骨折或牙 齿断裂的伤者。面部骨折需立即救治, 否则骨折处的复位不平将会导致下巴错 位和随后可能出现的咀嚼问题。 紧急情况,通常为事故或创伤造成 的损伤,需立即救治。这些紧急情况包 括(牙龈)流血不止、因牙齿感染引起 的面部肿胀、牙齿松动或脱落、牙齿断 裂、面部中央骨折以及牙龈、嘴唇或面 部严重割伤。 紧急情况还包括已扩散至面部的严 重牙齿感染,造成面部或颈部肿胀。这 些情况必须立即救治,否则肿胀最终可 能导致患者窒息。

非紧急情况 相比之下,拔牙、根管治疗、洗牙、补 牙、做牙冠、做牙桥、植牙等常见的口 腔问题则属于非紧急情况。 赖医生说,急诊室没有处理这些常 见口腔问题的必要配备。例如,那里没 有牙科专用的X光机。因此,寻求急诊 救助的牙痛患者可能不愿接受如同拔牙 这种永久性的治疗,特别是在不能确定 到底是那颗牙齿出问题。 可是我们不会拒绝前来求诊的患 者。“我们还是会为他们就诊,然后再 建议他们到新加坡国立牙科中心或其他 牙科诊疗所寻求治疗。”

家庭应急止痛法 赖医生说,在多数的情况下,患者可以 在零售药房购得的非处方止痛药来缓解 牙痛。 一般的止痛药处方如扑热息痛 (paracetamol)、阿司匹林、消炎药 等,都可以在家中服用。 在急诊室,前来求诊的患者需要先

焦点

患者可在家中服用止痛药来缓解牙痛,不用到急诊室求诊。

我们会为牙痛患者提供 救助,但会建议他们随 后到新加坡国立牙科中 心或其他牙科诊疗所寻 求治疗。 新加坡国立牙科中心口腔颚面 外科顾问医生赖俊斌

挂号,让护士进行鉴别分类,再让医务 人员例行检查,然后才能根据病症的轻 重来判断是否将由牙科医生或口腔颚面 外科医生进行诊治。 医生或许也会给予局部麻醉注射和 含药物的补牙填料来暂时缓解牙痛。但 患者必须回到牙科诊疗所复诊,把暂时 性的填补料换至本来的材料。 新加坡国立牙科中心的看诊时间于 周一至周五早上8点至下午5点半。看诊 前必须预约。如欲了解更多有关牙痛、 牙创伤和急诊的信息,请咨询新加坡国 立牙科中心网站 www.ndc.com.sg上 的“病症和治疗术语表”(Conditions and Treatment Glossary)。

合剂,可是却很少会忘记其他药物。 她说:“由于一些患者也有其他病 因如糖尿病和高血压,每天都需服用多 达8种不同的药物。正因为知道漏服这 些药物会对他们带来的影响,所以都不 会忘记服用。” 例如,一位糖尿病患者如果忘了服用 他的日常药物,他的血糖水平就可能升 到危险的水平。但没定时服用钙片的影 响却在很久之后才会显现。一些患者表 示,他们已经需要服用繁多的药物,而 少服用钙片也没什么明显的影响。 “没遵从医生的嘱咐服用磷结合剂是 因为他们不了解其中的重要性,” 林薇 芬补充说。 原文 Vivien Chan 为了解决这个问题,护士们开始向 住院的患者解释服用磷结合剂的重要性。 当肾脏不能如常运作时,磷(和钙构成 每次她们送药时都会提醒患者和其看护 骨骼的元素)就会开始在人体内积聚。 者。患者出院前拿药时,护士们也会再 如不加以治疗,磷的水平便会升高继而 三提醒。提醒不只限于医院里,当登门 导致血液里的钙含量下降,之后还可能 检查时,护士们还会反复提醒患者要定 临床护理导师林薇芬提醒将要出院的肾病患们要定时服用钙片。 导致骨折、骨骼疾病和心脏病。 期服用磷结合剂。 对肾功能衰竭患者来说,钙是整个疗 藉此,该小组在2011年新加坡中央 程里最重要的元素。然而,有许多患者 约说明出院后如何用药。可是患者经常 的药物补充。于是在2010年初,连同她 医院第19届科学研讨会上,赢得了护理 没有定时服用钙片,新加坡中央医院临 在回医院复诊时,告诉医生和护士他们 的护理同仁,林薇芬开始了这项研究。 组的青年研究员奖。 床护理导师林薇芬道。 未曾服用钙片。 经过四个多月的时间,小组采访了 在新加坡中央医院服务超过十年的林 林薇芬说:“服用磷结合药剂是非常 94位患者。他们的年龄介于40至72岁 薇芬表示:“我们的研究不仅为患者解 29岁的林薇芬表示:“患者住院时, 院方会依照病情进行配药然后定时让他 重要的,因为它有助于降低血液中磷的 之间,都患有末期肾衰竭。 决了一项重要的问题,同时还强调了对 们服用,所以不服用磷结合剂(钙)也不 含量。” 94位患者当中,仅有15位依照医生 患者和其看护者进行不断的提醒是作为 许多患者没有定时服用钙片而导致病 的嘱咐服用磷结合剂。 成问题。” 良好护理程序重要的部分。” “一但出院以后,患者本身或其看护 发的情况让林薇芬感到担忧。她决定要 林薇芬表示:“那些未遵守嘱咐的患 林薇芬说:“至于获奖,我和组员们 者可能会忘记让他们服用钙片,”她补 找出该问题的原委和其普遍程度,什么 者给的原因包括,‘我用餐时把药给忘 都非常惊讶,但我们都感到很有成就感, 原因使患者不服用钙片,以及医院能够 了’,或‘我忘了带药上班’。” 充说。 特别是这项研究也让患者的看护者意识 按惯例,护士会向患者或其看护者简 做些什么来确保患者不会忽略这项重要 但林薇芬注意到,尽管他们忘了磷结 到这个问题。”

别忘了 吃钙片

图:Allen Tan

许多肾病患者并未意识 到服用钙片的重要性


MAy⁄ jun 2012

新脉动

31

意见箱 死因不明的情况

病史和家族史,才能进 行样本测试和分析结果。 测试结果可能呈假阳 性或假阴性。假阳性会 错误判读有某种疾病的存 在,而假阴性会将实际病 情漏诊为无病。 如对假阳性的测试结 果采取不当的过度反应会 导致代价高昂又具有入侵 性的诊治。 而会诊能使医生决定 适当的测试之前,先为 患者进行正确评估,然后再解读测试结 果。这样一来,医生就能为患者提供恰 当的建议。

我们的叔叔近日在医院里过世, 我们却无法马上认领遗体,院方 告知他的尸体已移交给验尸官。 既然叔叔临终前是在医院接受治 疗的,为何医生却无法证明其死 亡原因呢? 新加坡中央医院答复 :我们对您失 去亲人和无法及时认领遗体感到非常抱 歉。当医生无法明确死者的真正死亡原 因时,他们必须将遗体移交给验尸官, 让其决定是否需要通过验尸来判断死 因。验尸的过程不会损坏死者的遗容或 遗体,所以遗体仍旧可以安置在开放式 的灵柩里。 在遗体转往位于新加坡中央医院大 牌9号1楼的卫生科学局太平间之前,死 者亲属可向遗体做最后的道别。 如需验尸,警方将通知家属。与此 同时,卫生科学局太平间的工作人员也 会提供有关死亡登记预期时间以及遗体 认领程序,包括安排灵车何时抵达太平 间等相关信息。 在办理死亡登记的程序上,处理这 些规程的家属必须提供本身和死者的身 份证或护照。 程序完毕后工作人员会核发“死亡 登记证书”和“遗体埋葬或火葬许可 证”,之后家属可到太平间认领遗体。

必须有医生的许可 才能进行血液测试 我只想做血液测试,不想看医 生。新加坡中央医院能否给我一 张申请验血表? 新加坡中央医院答复:在新加坡中 央医院,只有获得医生许可的情况下才 能进行实验室测试。由于是患者管理 的复杂工具之一,实验室测试必须依 照每位患者的具体情况,包括患者的

新加坡保健服务集团综合诊疗所 表示: 每天我们都竭尽所能使更多的 患者能够就诊。当诊疗所过于拥挤时, 我们会出于对患者的安全考虑而停止挂 号,以确保我们的医生有充足的时间为 每位患者提供适当的治疗和护理。新 加坡保健服务集团属下的9间综合诊疗 所的最迟挂号时间为下午4点。但紧急 病例会得到即时救治。我们的各个诊 疗所在公共假日前后、周一和周六尤 其忙碌。公众可通过新加坡保健服务 集团综合诊疗所网站http://polyclinic. singhealth.com.sg上的“候诊查看 (Queue Watch)”以察看诊疗所当时的 患者人数。

匆忙赶到却未能挂 上号 分娩三天后,我遇到皮肤问题并 到盛港综合诊疗所进行检查。 网站上称挂号截止时间为中午 12点,为此我急忙出门并于上午 11点35分赶到,却被告知下午 再回去登记因为诊疗所太过拥挤 而停止挂号。我匆匆忙忙地及时 赶上了上午的就诊时间,却吃了 这样的闭门羹,这对我来说很不 公平!

若有任何关于入院手续、账单及程序等疑问,可 电邮至 editor@sgh.com.sg,我们会在这个栏目解 答您的问题。

Wide circulation that reaches over 100,000 readers Available at strategic locations Contains authoritative healthcare news and information Singapore Health is the official publication of Singapore General Hospital and SingHealth Group, the largest healthcare group in Singapore.  Published bi-monthly in a handy tabloid size, the newspaper aims to raise the health literacy level of Singaporeans. Singapore Health is available at Singapore General Hospital, KK Women’s and Children’s Hospital, Changi General Hospital, national speciality centres and polyclinics under the SingHealth umbrella. It is also available at high-traffic points within the CBD area. Singapore Health ensures your message gets across to your target audience. For advertising enquiries, call 6319-5712 or 6319-3022, or e-mail Jobina Ong at Jobinao@sph.com.sg


Singapore Health May/Jun 2012  

The latest issue of Singapore Health May/Jun 2012 is out. A new minimally invasive procedure is helping reduce high blood pressure in patien...

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