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Take the SWIFT lane at ED
Telemedicine
non-critical
to provide prompt medical care 24/7 for
medical conditions presenting at SGH’s Emergency Department.
by Goh Bee Lian
Suitable P3 patients without a need for emergency care have the option to teleconsult with Minmed GPs, says Assoc Prof Kenneth Tan (centre), while Assoc Prof Goh Su-Yen (second from left) says that patients are increasingly comfortable with digital health. (from left: SGH Senior Consultant, Dr Chan Jing Jing, Assoc Prof Goh, Assoc Prof Tan, and Minmed’s Dr Eric Chiam and Dr Wong Jia Yi).
Patients with non-urgent conditions can wait hours to see an emergency medicine doctor.
To avoid the long wait — three hours on average and up to seven on very busy days — Singapore General Hospital’s (SGH) Emergency Department (ED) has teamed up with Minmed Group to pilot a service to allow this group of patients to be seen promptly.
Called SWIFT (SGH-Wide Initiative for Telehealth) Care, the service offers eligible patients teleconsultation with the private healthcare group’s general practitioners (GPs). Registration and consultation are done almost immediately, and can be completed in 30–60 minutes, with the patient’s medicines delivered to his home within three hours.
“P3 (Priority 3) patients have very long wait times because we’re spending more of our efforts on the sicker P1 and P2 patients,” said Associate Professor Kenneth Tan, Head and Senior Consultant, Department of Emergency Medicine, SGH. “Our aim is to provide suitable P3 cases with an alternative to be seen by our care partners. This option will improve the patient experience for this group through a shorter wait time and prompt care. Doing so also allows us to deploy our resources
appropriately for more critically ill patients.”
P3 refers to patients with mild to moderate medical issues that do not require immediate medical treatment. Patients may have symptoms of respiratory illnesses like COVID-19, minor sprains, stomach flu, or food poisoning. Priority to receive emergency care is given to P1 and P2 patients.
The highest priority P1 patients need immediate attention and are typically treated in the ED’s resuscitation area. P1 patients are usually critically ill, having suffered cardiac arrest, severe injuries, bleeding, shock, or a severe asthma attack. P2 patients also need prompt attention although they may be stable with no resuscitation required. They may have suffered major limb fractures or dislocation, have abdominal pain, or need surgical emergencies, and are usually unable to move on their own.
With an ageing population, hospitals’ EDs have been grappling with growing numbers of patients seeking emergency attention, some of whom may not actually require urgent care. For instance, some 320 patients visit SGH’s ED every day, but about 20 per cent of them do not require urgent care.
Associate Professor Goh Su-Yen, Clinical Director (Digitalisation and Technology),
PHOTOS: VERNON WONG
Minmed staff are on hand to help patients with registration throughout the day, including a nurse to support the doctor during teleconsultation with patients.
Department of Future Health System, SGH, described the partnership with Minmed as an excellent opportunity to deliver the best possible care for the right categories of patients. Minmed boasts an island-wide network of GPs, and expertise in the use of telemedicine.
“We chose to go digital first because we think our population is increasingly comfortable with the concept of digital health,” said Assoc Prof Goh. Located in SGH’s ED, the 24-hour SWIFT Care service was launched in June 2024. Patients assessed to be eligible can register at the SWIFT Care Clinic to be seen by a Minmed doctor via video. An assistant helps with registration and other administrative tasks, while a nurse is able to support the doctor in procedures such as basic wound care and administration of intramuscular injections if necessary.
After the consultation, any medications prescribed will be delivered to patients’ homes within three hours. A flat fee for consultation and medicines is charged. Depending on their condition, patients may be referred to a specialist for further review,
Who isn’t eligible for SWIFT
or sent back to the ED if found to need emergency care or an examination in person. Should the latter happen, the patient will not be charged the MinMed fee, said Dr Eric Chiam, Chief Executive Officer and Founder, Minmed Group. Patients may also opt for the SWIFT Care Clinic services directly, without having to be examined at the ED’s Nurse Triage station.
The SWIFT Care Clinic, which has two booths for teleconsultation, is sited within SGH’s Emergency Department. Patients can undergo triage by nurses first, or proceed directly to the SWIFT clinic, where they speak to a GP via a video call.
While the SWIFT Care service is ideal for non-emergency medical conditions that can be effectively managed through telehealth, patients with certain conditions will not be accepted into the SWIFT Care Clinic. These are:
Serious emergencies like life-threatening conditions, severe abdominal pain, difficult breathing, stroke-like symptoms, chest pain, pregnancy-related conditions
Chronic conditions that are not well managed
Medical procedures such as dressing changes, stitches, or abscess drainage
Conditions that are not improving despite multiple ED visits before
P3 (Priority 3) patients have very long wait times because we’re spending more of our efforts on the sicker P1 and P2 patients.
Associate Professor Kenneth Tan Head and Senior Consultant, Department of Emergency Medicine, Sinagpore General Hospital
Learning to COUGH
A nurse-led modified respiratory care bundle for post-bariatric surgery patients has been found to cut complications and length of hospital stay.
by Goh Bee Lian
Anew Singapore General Hospital (SGH) respiratoryfocused care bundle known as COUGH was found to benefit obese patients after bariatric surgery. They needed less oxygen therapy and a shorter hospital stay, and fewer needed close monitoring in high dependency, leading to lower costs overall.
“The COUGH respiratory care bundle is an innovative strategy that basically addresses some clinical issues in the post-anaesthesia care unit (PACU, where patients are monitored closely after surgery),” said Dr Yang Jumei, Nurse Clinician (Advanced Practice Nurse), SGH. “Obesity commonly affects post-surgical pulmonary outcomes and is associated with increased oxygen usage, length of recovery and hospital stay, discharge to high levels of care, cost, morbidity, and mortality.”
Dr Yang Jumei says SGH plans to roll out the COUGH bundle this year to patients coming out of other types of surgery after more nurses have been trained in the procedure.
In a Quality Improvement project involving 151 patients at PACU from June 2022 to March 2023, 71 post-bariatric surgery patients underwent the COUGH care bundle. It found that 37 per cent of COUGH patients needed a high-dependency bed after leaving PACU, compared to 58 per cent of those not on the programme. COUGH patients needed just 45 minutes of oxygen therapy at PACU, significantly shorter than 143 minutes needed by non-COUGH patients. With a shorter hospital stay as well, overall costs for the COUGH group were lower.
Under the COUGH package, which began to be used on obese patients in November 2022, patients are taught and encouraged to perform deep diaphragmatic breathing and coughing exercises to expand their lung capacity. They are gradually weaned off oxygen therapy until their oxygen saturation level rises to normal levels.
Oxygen is needed for the body’s cells and tissues to function properly. Healthy pulse oximeter values range from 95 to 100 per cent. For patients with levels below 95 per cent, a condition known as hypoxemia,
oxygen is administered via nasal prongs or face masks. “Generally, it’s harder for obese people to breathe because the fat stored in their chest and abdomen can restrict their lungs’ ability to expand, even during rest. This can alter how they breathe regularly, and create a persistent shallow breathing pattern,” said Dr Yang.
A five-prong approach, COUGH stands for ‘Coughing and deep breathing exercises for at least 10 times per hour, guided Oxygen protocol to titrate the patient’s oxygen therapy according to their oxygen saturation, patient’s Understanding and education of the interventions, Gargling of the patient’s mouth with 20mL of 0.2 per cent chlorhexidine mouthwash solution, and Head-of-bed elevation to 30–45 degrees.’
The bundle was based on the iCOUGH — Incentive spirometry, Coughing and deep breathing, Oral care, patient’s Understanding, Getting out of bed and Head of bed elevation — respiratory care programme developed by Boston Medical Center doctors and healthcare workers. Dr Yang adapted it to local hospital conditions for her Doctor of Nursing
Practice Programme — for instance, the programme is led by nurses locally, and the incentive spirometry was removed as evidence did not show increased effectiveness for preventing pulmonary complications after surgical procedures.
According to Ministry of Health data, 30 per cent of Singaporeans are overweight and 10 per cent are obese or have a body mass index (BMI) of at least 30. At that level, the person is at greater risk of serious health problems such as heart disease, diabetes, high cholesterol, sleep apnoea, and some cancers. A BMI of 18.5 to 22.9 is considered healthy, and over 23 indicates the person’s health is at risk.
Dietary changes and exercise are usually recommended to manage obese patients’ weight, with bariatric surgery considered if the changes do not work, or for those with BMI of at least 35 and have serious weightrelated health problems.
Dr Yang said that the hospital plans to roll out the COUGH bundle this year to patients coming out of other types of surgery after more nurses have been trained to guide them in applying the bundle.
Holistic ‘backbone’ for spinal treatment
CGH-NNI Integrated Spine Centre provides one-stop care for spinal disorders.
by Sol E Solomon
“It was important to bring together both orthopaedic spinal surgeons and neurospine surgeons under one umbrella to enhance our surgical capabilities, and synergise operative theatre equipment and workflow to deliver optimum care to our patients who require surgery,” says Dr Shree Kumar Dinesh.
Nearly one in five adults in Singapore are estimated to seek treatment for back or neck problems in their lifetime. To meet the growing needs of patients, a collaborative partnership between Changi General Hospital (CGH) and National Neuroscience Institute (NNI) resulted in the setting up of the CGH-NNI Integrated Spine Centre. Located at the CGH Medical Centre, the centre provides holistic and focused care — from diagnosis and surgery to physiotherapy and rehabilitation — to patients with spinal conditions.
“This one-stop spine centre uniquely brings together a team of neurosurgeons, orthopaedic surgeons, rehabilitation medicine specialists, pain medicine physicians, spine nurses, and physiotherapists, who specialise in spinal
conditions, to deliver multidisciplinary, quality care for patients with diseases and disorders of the spine, spinal cord, and nerves,” said Dr Shree Kumar Dinesh, Head and Senior Consultant, CGH-NNI Integrated Spine Centre, and Head, SingHealth DukeNUS Spine Centre. “The integration of these specialties transforms care delivery, bringing about streamlined coordination of care and treatment for patients, thereby reducing wait time for consultations and surgeries, and improving recovery time.”
Tapping on the rapid evolution of surgical techniques and treatment options, the facility is also a centre of excellence for minimally invasive spine surgery with computer navigation. This includes minimally invasive spinal fusion with navigation and robotics, artificial disc replacements, and minimally invasive and endoscopic decompressions. “It was important to bring together both orthopaedic spinal surgeons and neurospine surgeons under one umbrella to enhance our surgical capabilities, and synergise operative theatre equipment and workflow to deliver optimum care to our patients who require surgery. Likewise, for patients who do not require surgery, it was important to harmonise our rehabilitation and physiotherapy options,” said Dr Shree.
In the past, patients with spinal disorders would mostly seek treatment from general orthopaedic surgeons or neurosurgeons who may not specialise in spinal surgery. However, as demand continues to increase,
SingHealth signed a Memorandum of Understanding with the Nepal National Academy of Medical Sciences (NAMS), which signifies a shared vision and commitment towards advancing spinal education, Memorandum of Understanding research and innovation on a global scale. Through this partnership, the two organisations aim to exchange knowledge, share best practices, and jointly develop innovative solutions to spinal health issues. The educational initiatives will focus on training the next generation of spine specialists, equipping them with the skills and knowledge needed to tackle spinal diseases in any context.
From a global health perspective, this collaboration embodies the essence of solidarity and mutual support. The potential of this partnership, which transcends borders and brings together diverse perspectives and expertise to address common challenges, is tremendous — not only will it enhance spinal care in Singapore and Nepal, but also contribute to the global body of knowledge, setting new standards in spinal health.
Common conditions treated
The most common conditions treated at the CGH-NNI Integrated Spine Centre are degenerative disorders of the spine such as spinal stenosis, spondylolisthesis, and herniated disc. Other common conditions include degenerative cervical myelopathy, spinal deformity, spine trauma and spinal cord injury, spinal infection, and spinal tumours including metastasis. There has been a 20–30 per cent year-on-year increase in spinal surgeries at CGH from 2018 to 2021, with close to half being emergency cases.
the one-stop centre has facilitated the collaboration between multidisciplinary teams of CGH orthopaedic spinal surgeons, rehabilitation physicians, and NNI neurosurgeons, who specialise in spinal surgery, to provide comprehensive treatment, including intradural spine tumour removal as well as upper cervical and cranio-cervical stabilisations for patients who require it.
“Most patients benefit from minimally invasive spinal surgery techniques, where appropriate, allowing them faster recovery and earlier discharge. We also address spinal emergencies round the clock,” added Dr Shree.
Major concern
Spinal disorders make up a fairly significant proportion of patients with musculoskeletal disorders. Diseases and disorders affecting the spinal axis range from mild back pain or neck strains to more devastating spine injuries or conditions.
In Singapore, musculoskeletal disorders (12.6 per cent) are among the top three largest contributors to the nation’s combined burden of early death and disability, just behind cardiovascular diseases (14.2 per cent) and cancers (13.4 per cent), according to a Ministry of Health report done in collaboration with the University of Washington on The Burden of Disease in Singapore between 1990 and 2017
“With our rapidly ageing demographic, degenerative disorders of the spine are becoming more prevalent. These patients may present with back and leg pain, or neck and arm pain. In some cases, they may progress to develop neurological deficits, which may impair their ability to walk and affect their independence in the activities of daily living,” said Dr Shree.
Take NOTE of new surgery technique
vNOTES surgical technique results in less pain, no visible scars, shorter hospital stay, and lower costs for patients.
by Goh Bee Lian
Mdm Massita Surif was a natural candidate for hysterectomy using the vaginal natural orifice transluminal endoscopic surgery (vNOTES) technique, an increasingly popular surgical method.
The 50-year-old needed to remove her womb, which had ballooned to the size of a five-month pregnancy due to fibroids. The fibroids had caused heavy bleeding for years and triggered a stroke in 2018. Considered a high-risk patient, she also has multiple medical conditions and had undergone two Caesarian deliveries, suggesting possible tissue adhesions that can complicate surgery.
“I didn’t want to have open surgery because of my stroke, and I have a low pain threshold,” said Mdm Massita.
Traditionally hysterectomy is performed through open surgery, where a long cut is made across the abdomen to remove the womb. Open surgery allows surgeons to have a good view of the surgical area but it also involves bleeding, sometimes heavy, possible infections and complications.
Removal can also be done by keyhole surgery, where a few small cuts are made for surgical instruments — tiny camera, forceps and scalpels — to be inserted. While the view of the surgical site may not be as good as in open surgery, minimally invasive surgery means less bleeding, smaller scars, and a quicker recovery.
Endoscopic surgery has advanced further, with few or no cuts needed, in procedures where the body’s natural openings are used instead. One of the latest methods is vNOTES, where instruments are inserted through the naturally elastic vagina to perform the procedure. “With vaginal hysterectomy, there are no external incisions, it's a shorter hospital stay, quicker recovery because of the lack of pain and fewer complications,” said Dr Yvonne Wong, Associate Consultant, Department of Obstetrics and Gynaecology (O&G), Singapore General Hospital (SGH).
Mdm Massita had cramps for a week, very little bleeding and pain, and a fast recovery.
With advantages similar to other keyhole surgical techniques — perhaps more so — hysterectomy and other previously major surgeries are becoming day surgeries, said Dr Ravichandran Nadarajah, Senior Consultant, Department of O&G, SGH.
Indeed, vNOTES has become not just an improved keyhole technique, but one that is increasingly being used with complex or difficult cases — patients who are extremely obese, have multiple medical conditions or surgical adhesions, have cancer, or are elderly, said Dr Ravichandran. “With all the expertise and multidisciplinary support on SGH Campus, SGH has become a regional referral centre for more complicated cases. We have certainly handled the largest number of multispeciality complexities, including non-O&G cases,” he said.
Dr Ravichandran Nadarajah and Dr Yvonne Wong demonstrate how vNOTES surgery is performed for O&G cases using a mannequin. Increasingly being used, vNOTES is also a preferred technique in cases that are more complex or difficult.
Mdm Massita Surif (in black) underwent hysterectomy using this technique, experiencing very little bleeding and pain, and a fast recovery.
In the first case of a non-gynaecological application of the vNOTES technique at SGH — and possibly in Singapore — Dr Joella Ang, SGH O&G Consultant, helped colorectal surgeons perform a partial colon removal by opening up the patient’s vaginal space.
KK Women’s and Children’s Hospital (KKH) is the leading tertiary centre for O&G cases, performing over 350 from March 2021, when the first such operation was done, to March 2024. In the same period, SGH performed 225, including 154 surgeries for benign indications, 66 for gynaecological oncology, and five for non-gynaecological oncology like breast cancer.
In 2023, KKH led SGH and the National Cancer Centre Singapore to be jointly accredited by the Royal College of Obstetricians and Gynaecologists as a speciality training centre in Gynaecological Oncology, the first outside Europe given the honour. SGH O&G was also ranked among the Top 100 in Newsweek’s Best Specialised Hospitals in O&G 2024.
Ms Liu Kui (above) underwent preventive surgery in 2023 to remove her fallopian tubes and ovaries to reduce the risk of ovarian cancer after testing positive for the BReast CAncer gene 1 (BRCA 1). Within hours of vNOTES surgery at KKH, she was able to eat a full diet, walk and urinate. She was discharged the same evening.
PHOTO: VERNON WONG
Post-surgery,
Managing childhood myopia safely
Atropine eye drops are a safe and effective way to mitigate childhood myopia, but efficacy depends on proper use.
by Candice Cai
Atropine eye drops are among three types of treatment options for childhood myopia, the other two being specially designed spectacles and contact lenses.
Although atropine eye drops have been used since the 1960s for the treatment of amblyopia (lazy eye) and in the past three decades for childhood myopia, there have been some concerns regarding the safety of this treatment option, especially with prolonged usage. A 2024 study by researchers at the Singapore National Eye Centre (SNEC) and Singapore Eye Research Institute (SERI) has shown that the long-term use of atropine eye drops is safe. The first-of-itskind study examined the longterm effects of these eye drops and found no complications arising in patients 10 to 20 years after treatment. There was also no association between those who had undergone atropine treatment and the increased incidence of treatment- or myopia-related ocular complications.
“One of the most common issues we come across is patients not adhering to regular use of the drops. If eye drops are not used as frequently as prescribed, the effect may be suboptimal. This is especially true for the low-dose range,” says Dr Loh Kai Lyn.
Treatments of the
future
There may soon be more options available when it comes to the treatment of myopia in children.
One of them is the Repeated Low Level Red Light (RLRL) treatment. “RLRL is a new form of myopia control treatment that started in China and has shown good results in terms of efficacy,” said Dr Loh. “It requires patients to have a device at home and receive therapy for three minutes at a time, twice daily. In contrast to myopia control glasses or contact lenses, RLRL, like atropine, is not restricted by the patient’s degree of myopia or astigmatism for effective treatment. This would be useful, for example, in patients with very high myopia or high astigmatism.” She added that many studies are now being performed to assess its efficacy and safety profile in other countries, including Singapore.
(left) and HALT.
Side effects of atropine eye drops
Earlier studies have shown that, while high-dose atropine was safe and effective in reducing myopia progression, it caused side effects such as glare and blurring for reading and near work, said Dr Loh Kai Lyn, Consultant, Myopia Centre, SNEC. But these side effects can be mitigated by using photochromic and progressive lenses, she added.
A subsequent study showed that lowdose atropine was an effective alternative to high-dose atropine, leading to much reduced side effects.
Dr Loh shared that low-dose atropine is more commonly prescribed nowadays. “Most of the time, when we start with low-dose atropine, the child should be able to cope well. If they should have glare issues, they can use headgear or clip-on sunglasses while out in the sun, or have photochromic or tinted glasses. For reading issues, they can use progressive glasses to help them read well,” she said.
Importance of follow-ups
The effectiveness of atropine eyedrops in managing childhood myopia also hinges on its proper and consistent use.
“One of the most common issues we come across is patients not adhering to regular use of the drops. If eye drops are not used as frequently as prescribed, the effect
may be suboptimal. This is especially true for the low-dose range. We try to engage patients and their caregivers to see what the underlying issue is, and give tips or alternatives as appropriate,” said Dr Loh. Patients should also continue with their long-term follow-up appointments so that doctors can evaluate the appropriateness of the treatment. “Unlike a short course of antibiotics, atropine eye drops should be used as long as they are still effective in reducing myopia progression,” advised Dr Loh. “This usually means that they should be continued till the patient’s myopia naturally stops progressing, meaning the eyeball itself stops growing, which usually occurs around 13 to 15 years of age.”
Other treatment options
Other treatment options to curb the progression of childhood myopia include specially designed myopia-control spectacle lenses, such as the ones using defocus incorporated multiple segments (DIMS) technology, or contact lenses with highly aspherical lenslets target (HALT) technology. Contact lenses, such as daily disposable multifocal soft lenses (used in the day) or orthokeratology (OK) rigid lenses that are used at night, may also be prescribed. These alternative treatment options can be used in conjunction with atropine eye drops to provide a more optimal response in some patients, said Dr Loh.
However, she warned that parents should be wary of other treatments touted as myopia-control options. “It is important that parents educate themselves on separating those that have legitimate effects from those that have no effect or, worse, may cause increased myopia progression.”
Dr Loh recommends that parents bring their children for an evaluation with their eye care practitioner to get customised treatments.
Tips to manage myopia in children and reduce risk of high myopia and ocular diseases
Maintain good functional vision for daily activities by getting the right visual aid such as spectacles
Form good eye habits, including
• More outdoor time
• Having regular breaks (every 30 minutes) from near work such as reading, homework or screen-time
• Maintaining a good distance of 30–40cm between themselves and their focus of attention
• Making sure there is sufficient light while doing near work
An alternative to atropine drops is the use of special lenses, like the DIMS
Witnessing lives renewed
Transplant
coordinator Joycelyn
Tan describes facets of her job as an emotional roller coaster, but finds it extremely fulfilling despite the challenges.
by Candice Cai
She began her career in healthcare as a registered nurse.
Now, Ms Joycelyn Tan coordinates heart and lung transplants at National Heart Centre Singapore (NHCS), assisting recipients and their families through the entire process — a career that she has pursued for 13 years.
Her work involves educating patients on what to expect pre- and post-transplant, liaising with coordinators for the donor when an organ is available, and keeping recipients and their families informed once the organ is deemed suitable. Ms Tan and her team at NHCS also assist patients through their post-operative period and even when they are discharged. “We are the link between the patients and their doctors. For example, if the patient experiences post-operative discomfort or any signs of being unwell, we are the first point of contact,” Ms Tan explained.
Transplant coordinators work with healthcare professionals such as cardiologists, cardiothoracic surgeons, infectious disease doctors, psychiatrists, supportive care doctors, nurses, medical social workers, and physiotherapists — forming a multidisciplinary team.
As part of her job, there are difficult moments when she has to inform recipients that the donor organ is found to be unsuitable for transplantation. This can sometimes happen right before the surgery, when expectations to undergo a transplant is at its highest.
“Even more devastating is when you have to break bad news to the (recipient’s) family, such as when an operation didn’t go as expected or when the patient’s
outcome is undesirable,” she said.
The situation can be tough to handle emotionally, Ms Tan admitted, as many patients become familiar faces over the years and close relationships have been formed.
When faced with such adverse situations, Ms Tan puts up a strong front to provide support for the patients and their family, but she acknowledged that emotions can get the better of her. “Sometimes, I will cry together with the family,” she said. She shared that expressing such emotions on the job is not taboo. “I tell my juniors that we don’t always have to withhold our emotions.”
Ms Tan is also required to be on call 24/7 on days when she is rostered; being activated in the middle of the night is par for the course. “Activation happens in the wee hours most of the time,” said Ms Tan, adding that each team member gets rostered seven to eight calls a month.
The mother of two is thankful that she has a supportive husband, who understands the demands of her job and readily holds the fort whenever she has to rush off to work in the middle of the night. But the job has its rewards, especially when the patient’s outcome is positive.
One case that Ms Tan remembers vividly is when she was seven months pregnant and on her last rostered on-call duty before giving birth. “I was woken up by the call but was excited because this patient had experienced complications such as brain haemorrhage, which led to the need for multiple surgeries due to anti-coagulation. This affected his speech and memory, and he took a long time to recover. Knowing the risk of a bleeding recurrence, I knew he would benefit greatly from a heart transplant,” she recalled.
“Sometimes, I will cry together with the family. I tell my juniors that we don’t always have to withhold our emotions,” says Joycelyn Tan.
She stayed up all night to coordinate the operation. Thankfully, the procedure was a success. “I was very happy for him,” she said, joy still palpable in her voice.
Another case that touched Ms Tan deeply involved a patient who expressed his thanks to her just before he was anaesthetised in the operating theatre to undergo a heart transplant. “He held my hand, and thanked me for my patience and for taking care of him through the years. I recall him saying, ‘Without you, I wouldn’t be here today.’” Unfortunately, the patient passed away. “His son told me that going through with the transplant surgery was what his father had wanted, even if the outcome didn’t turn out to be good,” Ms Tan recounted.
As a transplant coordinator, one has to be prepared to ride on an “emotional roller coaster”, Ms Tan shared. Despite the challenges, she remains enthusiastic about her job. “I love what I’m doing,” she affirmed, describing how she is drawn to the holistic care administered to patients, and the rapport she has with them.
What gives Ms Tan the most satisfaction is when patients recover and go on to lead healthy, normal lives. “After a transplant or left ventricular assist device (LVAD) implantation (for patients with heart failure), many patients can go back to their daily life and activities. Seeing that is a very heartwarming sight,” she described.
We
are the link between the patients and their doctors. For example, if the patient experiences post-operative discomfort or any signs of being unwell, we are the first point of contact.
Joycelyn Tan Principal Transplant Coordinator, Mechanical Circulatory Support, Heart & Lung Transplant Unit, National Heart Centre Singapore
Upskilling through team learning
The SKH Lymphoedema Service team is equipped with modern treatment modalities for lymphoedema and microsurgical reconstruction.
by Goh Bee Lian
Lymphoedema is a condition characterised by swelling, usually in the arms or legs, due to a build-up of lymph fluid. It often occurs after lymph node removal or damage from cancer treatment, infections or injuries.
Modern treatments include compression therapy, manual lymphatic drainage, and surgery. Surgical options include lymphatic bypass, vascularised lymph node transfer, and liposuction. Lymphatic bypass is a technique that joins the lymphatic vessel to a vein, allowing the lymphatic fluid to bypass the obstruction. In vascularised lymph node transfer, healthy and viable nodes are transferred from an abundant area onto the affected limb, allowing new lymphatic vessels to grow and solve the issue of lymphatic obstruction. Liposuction is an important additional procedure to directly reduce the size of the limb.
In February 2023, Dr Allen Wong, Consultant, Plastic, Reconstructive and Aesthetics Service, Sengkang General Hospital (SKH), headed to Chang Gung Memorial Hospital in Linkou, Taiwan, for a year-long fellowship under the Singapore Ministry of Health’s Health Manpower Development Plan (HMDP) programme, together with a team of colleagues.
In line with the HMDP theme, ‘Comprehensive and Preventative Management of Lymphoedema, and Microsurgical Reconstruction’, the team trained in modern treatment modalities for lymphoedema, from prevention, diagnosis and treatment to long-term follow-up. They also learnt about the latest in microsurgical reconstruction, including how to set up and maintain a highvolume microsurgical reconstruction unit.
Under the HMDP programme, individuals who have identified a service need or gap
in Singapore can prepare a proposal for a training centre that can address this service requirement. The SKH team, comprising operating theatre nurse Ms Feng Fangfang, Nurse Clinician Ms Teh Shi Yun from the High Dependency Unit, and Principal Physiotherapist Ms Phoebe Ting Su-Yuin, led by Dr Wong, trained at the world-renowned plastic surgery service at Chang Gung Memorial Hospital under fellowship director Professor Fu Chan Wei, who is ranked among the top-10 most influential plastic surgeons in the world.
“The programme’s greatest value lies in its team-based approach, allowing healthcare professionals from diverse disciplines to undergo training together,” Dr Wong explained. “As a result of this training, the team now collaborates seamlessly, collectively advancing the field.”
For Dr Wong, the most memorable part of the HMDP programme was the mentors and friends he met during the fellowship. “The mentorship and teaching extended beyond clinical matters, and I’ve grown professionally to be a more wellrounded plastic surgeon. I’m grateful for the camaraderie and opportunity to share experiences with fellow colleagues,” he said.
Outside of work, Dr Wong volunteers his time as President of the Lymphoedema Society of Singapore, helping to raise awareness of lymphoedema among the public, advocating evidence-based care for lymphoedema, and empowering patients through advocacy.
Fishing is one of his favourite ways to relax. Being familiar with the tying of fishing knots is directly relevant to the field of surgery, as one must be adept and nimble with the surgical sutures, he said. It is also a hobby that he feels one can learn many life skills from, the most important being patience.
The SKH team trained at Chang Gung Memorial Hospital under fellowship director Professor Fu Chan Wei (second from left), who is ranked among the top-10 most influential plastic surgeons in the world.
The programme’s greatest value lies in its team-based approach, allowing healthcare professionals from diverse disciplines to undergo training together.
Dr Allen Wong
Consultant, Plastic, Reconstructive and Aesthetics Service, Sengkang General Hospital
SKH Lymphoedema Service
To serve the needs of patients with diseases related to the lymphatic system, the SKH Lymphoedema Service was introduced in SKH in 2021 as a one-stop multidisciplinary service that prevents, treats and rehabilitates patients. Patients include those who have had cancer treatment such as surgery or radiotherapy.
The SKH team developed a novel technique, the Distallybased Lymphatic Microsurgical Healing Approach (dLYMPHA), to reduce the risk of lymphoedema in breast cancer patients undergoing treatment. A lymphatic bypass procedure in the upper limb is done at the same time as the breast cancer surgery to significantly reduce the likelihood of developing lymphoedema in the future.
Microsurgical reconstruction is a type of surgery that uses a microscope to help surgeons work on very small parts of the body, such as tiny blood vessels and nerves. It allows tissue to be moved from one place to another, ensuring the tissues stay alive by connecting their blood vessels, and helps restore function and appearance, improving patients’ lives after serious health issues. Some common medical applications are breast reconstruction after cancer treatment, limb reconstruction after traumatic accidents or severe diabetic infection, and restoration of the lymphatic system in lymphoedema.
Seamless and convenient approach for paediatric patients
New programme ensures that the Children’s Emergency Department is not overwhelmed with less severe cases.
by Sol E Solomon
Each month, the Children’s Emergency Departments (CE) of the KK Women’s and Children’s Hospital (KKH) and National University Hospital (NUH) see about 15,000 and 3,800 cases respectively. A large number of these children have common ailments that do not require emergency care. The newly launched PaedsENGAGE GP programme, jointly launched by KKH and NUH, aims to encourage parents and caregivers with children who have mild to moderate conditions to visit general practitioners (GPs) enrolled in the programme instead of the emergency department.
The objective of PaedsENGAGE GP is to ensure that children who really need emergency care can be attended to as soon as possible. “Timely medical attention prevents further deterioration of their symptoms or mitigates any longterm effects the condition may cause. Sometimes, it is even life-saving,” said Dr Nur Adila, Consultant, General Paediatrics Service, KKH. “We strongly encourage parents to visit PaedsENGAGE GP instead of the CE for mild to moderate conditions, including fever, vomiting, diarrhoea, rash and minor injuries.” KKH also has the Urgent Paediatric Advice Line (U-PAL), a complimentary 24-hour online service that helps caregivers assess whether their child requires a visit to the CE.
PaedsENGAGE GP, which is short for ENGagement And GP Empowerment, expands the role of GPs in the community through dedicated training, to equip them with the skills and knowledge required to manage paediatric medical conditions. This ensures that the child receives appropriate and timely treatment while also getting an assessment on whether a trip to the CE is necessary.
Through the programme, the partnering hospitals aim to develop and strengthen intermediate- and long-term paediatric services in the community, and enable the right-siting of care for children with mild to moderately acute conditions. In turn, it enables children to receive comprehensive care within the community while offering parents and caregivers greater access to care close to home. To be eligible for PaedsENGAGE GP, patients have to be below 18 years of age.
There are currently over 400 accredited GPs throughout Singapore who are part of the programme. One of the main successes of PaedsENGAGE GP, which has been in place for about a year, is that more patients are now treated at GP clinics. “According to our recent data analysis, there has been a significant 12 per cent reduction in non-emergency attendance at KKH CE compared to the previous year,” said Dr Adila. “We have also received numerous positive feedback from both GPs and caregivers.” A parent, sharing her experience about her child’s referral to KKH, said: “Our GP referred my child to the CE when her condition did not improve. I really appreciate that we don’t need to visit the paediatrician for every health episode now that GPs are trained to treat paediatric conditions.”
Doctors under the programme are certified as PaedsENGAGE GP Partners after completing a comprehensive training programme designed by KKH and NUH. Modules include clinical approaches to common paediatric conditions such as abdominal pain, common eye, ear, nose and throat conditions, minor injuries, common infections, antibiotic use, and assessment on the need to refer a child to the CE. If a referral is required, the child must be brought to the CE within 12 hours, along with the original copy of the referral form. In such situations, GPs typically refer patients to the nearest children’s emergency department. However, parents can decide whether they prefer to be referred to KKH CE or NUH CE. A caregiver shared that she appreciated how smooth and efficient the whole referral process was, as the triage at KKH CE took into consideration the information provided by the GP, which expedited the process.
At the CE, patients are triaged based on the severity of their conditions. Children with life-threatening conditions are attended to first, and those assessed to have less severe ailments may have to wait longer for their turn. After the child has received the appropriate treatment, the GP who gave the referral will be updated on the outcome of the child’s condition for continuity of care by the GP where needed. This enables GPs to also have a better understanding of the child’s medical history, and will be able to play a bigger role in supporting the child’s healthcare needs.
Visit PaedsENGAGE GP instead of the CE for mild to moderate conditions, including fever, vomiting, diarrhoea, rash and minor injuries.
Dr Nur Adila Consultant, General Paediatrics Service, KK Women's and Children's Hospital
Keeping up to date
Regular education forums are also organised for the PaedsENGAGE GP Partners. These forums aim to ensure that doctors stay updated with the latest knowledge and skills required to manage common paediatric conditions. “We also introduced clinical observerships, where GPs are invited to come to the KKH CE to observe the management of cases, processes and procedures. As at June 2024, about 30 GPs have completed their clinical observerships with KKH CE.
GPs who are part of the PaedsENGAGE GP programme can be identified by a decal at the entrance of the GPs' clinics. Paediatric patients who are referred to KKH CE or NUH CE by these GPs will receive a $50 subsidy on the prevailing attendance fees.
Find out more at kkh.com.sg/paedsengage
Comprehensive trauma support for healing and recovery
Patients may experience traumatic stress reactions for a long time after a traumatic experience, and a team of clinical psychologists is on hand to help.
by Sol E Solomon
Dr Melissa Chang says that some patients may continue to experience traumatic stress reactions for a prolonged period, at times impacting their daily functioning, relationships, sense of safety and self-worth.
The birth of a child should be a joyous occasion; but, for some mothers, it can be a traumatic experience. Similarly, childhood should be the most carefree period of one’s life; but, for some children, it too can be a period of anguish.
The Psychosocial Trauma Support Service (PTSS) of the KK Women’s and Children’s Hospital (KKH) provides professional support to women and children who have had traumatic experiences. It runs outpatient clinics and inpatient services for both women and children, offering timely psychological review and intervention that are essential to reduce distress and prevent long-term health implications.
Apart from traumatic birthing experiences, women may also suffer psychological trauma from sexual and/ or relationship violence and losses. In children, the most common cases of trauma seen by PTSS are for accidental injuries such as falls, burns, or neardrownings, as well as non-accidental injuries such as abuse, said Dr Melissa Chang, Principal Psychologist, PTSS, KKH. Some patients may continue to experience traumatic stress reactions for a prolonged period, at times impacting
their daily functioning, relationships, sense of safety and self-worth. Some may even self-harm or attempt suicide.
With support available at PTSS, patients can regain or improve quality of life. Clinical psychologists who specialise in providing trauma assessment and intervention for children three to 18 years old, and women, offer psychological support to patients, helping them to better cope with the aftereffects of traumatic experiences.
For women and children who have experienced traumatic event, PTSS provides evidence-based psychological therapy to reduce their distress. This can include reducing avoidant behaviours (i.e., avoiding places, people, things, thoughts, memories and feelings that remind them of the event), resuming engagement in activities and relationships, and increasing their self-efficacy to better manage traumatic stress. If needed, PTSS also educates family members to provide better understanding of psychological trauma. This empowers the families to support their loved ones in managing symptoms.
“We are in the midst of increasing trauma screening for women who have experienced sexual violence and traumatic birthing experiences or losses, developing e-learning trauma modules for KKH professionals, and
providing a range of in-service talks to create a trauma-informed culture as well,” said Dr Chang.
For both women and paediatric patients, PTSS usually collaborates with clinical counsellors and medical social workers to manage risks around safety and for case management matters, including management of patients' psychosocial stressors — such as financial assistance, spousal or familial relationships — that could affect their mental health and ability to engage in therapy.
Community programmes
PTSS also believes in enhancing the community’s capability to provide psychosocial support to children, youth and their families after crises or traumatic events. It works closely with medical and allied health professionals, community organisations, and schools to minimise trauma-related distress and symptoms among children, women and their families.
“We want to expand our network of professional collaborations. We have organised talks on trauma-related issues to community providers, including counsellors from Care Corner, Singapore Association for Mental Health, and the public, in addition to providing training on ways to manage crises and traumas,” said Dr Chang.
PTSS has also created social media campaigns using animated videos targeted at youths and their families to raise trauma awareness and encourage affected individuals to seek support when needed. Some past community projects by PTSS include developing crisis response prevention plans with selected community partners such as counselling centres and agencies. There are also resources like storybooks and engagement tools for preschool children that can be used by parents and community partners.
With training on how to be empathetic and mindful of their body language, tone of voice, and choice of words, healthcare and community professionals too can help build rapport with and instil a sense of psychological safety in the patient. They can also empower patients to make informed choices by explaining the required procedures, symptoms to look out for, and treatment options. By organising network sessions with its community practitioners, both these practitioners and the PTSS team have learnt from one another’s practice in trauma work, said Dr Chang.
PHOTO: VERNON WONG
Singapore Health wins APEX Award
We are thrilled to announce that Singapore Health has been honoured with the prestigious APEX Award for Publication Excellence 2024!
The 36th annual APEX Awards, by Communications Concepts, Inc., recognises the outstanding quality and exceptional design of our publication.
This accolade reflects our commitment to delivering useful health information and engaging content to our readers.
THANK YOU FOR YOUR CONTINUOUS SUPPORT
A big thank you for making Singapore Health part of your healthy living routine. We could not have received the above accolades without your invaluable support.
Aside from the hard copy, you can also check out our social media platforms for more healthcare-related stories that you can easily share with friends and family.
The APEX Awards for Publication Excellence are an annual competition for corporate and nonprofit publishers, editors, writers and designers who create for print, web, electronic and social media platforms.
Feeling unwell?
Don’t play doctor!
Over-the-counter medications are generally safe, but care must still be observed when taking them. A pharmacist gives advice on how to use these drugs safely.
by Eveline Gan
Say “acetaminophen” and chances are that the name would not be familiar to those around you. But say “paracetamol” and most people would recognise it as a medication for fever. Ditto for Panadol and Tylenol, the trade names under which the drug is sold.
All three are similar — a widely available over-the-counter (OTC) medication used to provide temporary relief of fever and mild-to-moderate pain. For many other types of drugs, the story is the same: they can be known by different chemical, generic or trade names. “Even as a pharmacist, I find them a mouthful to remember. You might take two similar medicines, and that can cause an overdose,” said Dr Lim Kiat Wee, Senior Principal Clinical Pharmacist, Singapore General Hospital (SGH).
“There are so many different brands (of a drug) in the market. Within the same brand, there are also different ingredients and the actual dose per tablet may vary from one product to another,” says Dr Lim Kiat Wee about over-the-counter medications.
Confusion over their names aside, not knowing exactly what the drugs are can cause serious problems. Overdosing on paracetamol, for instance, can cause liver damage, said Dr Lim. Medications bought OTC at pharmacies without a doctor’s prescription can be taken safely, but they should still be taken with care as all medications and supplements can cause side effects, especially when taken in excess or with other drugs.
Some drugs, supplements and even food can either stimulate or inhibit the production of enzymes in the liver, said Dr Lim. “If enzyme production is inhibited, the drug starts to accumulate and become toxic, causing more side effects. If enzyme production is stimulated and the drug is cleared from the body faster than it should, then you wouldn’t be treated optimally,” she said.
For those on prescribed medications for existing medical conditions, extra care must be taken when consuming OTC drugs or supplements. Dr Lim advises consumers to
For more on OTC meds, tune in to SGH’s Perfectly Imperfect podcast on this issue. Visit this weblink https://for.sg/ perfectly-imperfecthealthmeds or scan the QR code.
read the label carefully, taking heed of the medication’s active and inactive ingredients, how it should be taken (amount and number of times to take a day), whether it should be taken before or after meals, as well as the possible side effects or reactions with other drugs or food. “There are so many different brands (of a drug) in the market. Within the same brand, there are also different ingredients and the actual dose per tablet may vary from one product to another,” said Dr Lim.
When in doubt, ask a doctor or pharmacist. A pharmacist is not just someone who packs medication and advises on dosage and other drug-related instructions. Pharmacists are healthcare professionals who ensure that medications contribute to the best possible health outcomes while minimising adverse effects; they provide advice ranging from whether prescribed tablets are too difficult to swallow to what happens if a dose is missed, as well as medication side effects and drug interactions.
“If your prescription requires you to take one tablet three times a day and you’ve missed your afternoon dose but it’s already close to your next dose, which is the evening dose, skip your afternoon dose and go ahead with your scheduled evening dose,” said Dr Lim. Following the dosing instructions is important for certain medications, such as antibiotics, for maximum effectiveness, she added.
What about needing to take the medication after food? “When a patient is required to take the medication after a meal, there are usually two reasons. Firstly, this type of medicine may
cause a stomach upset if taken on an empty stomach,” said Dr Lim. “Another reason is that taking this group of medication after a meal improves its absorption, meaning the medication will be more effective.” If the patient has no appetite and cannot eat a proper meal before taking his medication, Dr Lim suggests having a snack, such as a cup of milk with a slice of bread, before taking the medication.
For people who have trouble swallowing large pills, pharmacists can provide guidance on whether a chewable or liquid form is available. “We advise patients against breaking certain pills into smaller pieces. For example, pills that have an extended or prolonged release mechanism allow the active ingredient to be slowly released into the body. Cutting or breaking the pill damages that mechanism,” said Dr Lim.
1 October is the International Day of Older Persons
Will you be sprightly or infirm?
Getting old does not necessarily mean being feeble and infirm, but you need to be prepared for and mitigate certain medical conditions. You’re not alone on this journey — the numbers show you’re in good company.
by Candice Cai, with Dr Tay Yu Ling, Consultant, Department of Geriatric Medicine, Singapore General Hospital
Older people can be prone to malnutrition, with both under- and over-nutrition contributing to frailty, a physical condition associated with ageing. Frailty increases the risk of falls, hospitalisation, disability and death.
As more people live well into their 80s in Singapore, and above their 60s for many places around the world, it is important that they age well as the risk of disease — both physical and mental — rises.
Following a healthy diet and lifestyle is key to mitigate the emergence of diseases commonly associated with the elderly. Healthy ageing will not only reduce the risk of disease but also improve physical and mental capacity, and delay the likelihood of care dependency. Ageing is usually accompanied by a gradual decrease in physical and mental capacity over time.
• Musculoskeletal: arthritis, osteoporosis, cancer
• Physical impairments: visual and hearing loss
Malnutrition can lead to weight gain or loss
Malnutrition is a condition resulting from an imbalance between nutrient needs and actual intake. It is common in the elderly, who often suffer from myriad factors such as dental or swallowing problems, diseases, drugs, cognitive impairment, mood problems, financial or mobility issues.
Chronic under-nutrition can result in unintentional weight loss and loss of muscle mass, known as sarcopenia. Over-nutrition, meanwhile, can result in weight gain and obesity. Both can lead to weakness, slowness and exhaustion, contributing to frailty. Good nutrition, adequate protein intake, and exercise can help reduce frailty.
Sarcopenia is age-associated loss of muscle mass and strength that heightens the risk of falls, disability, hospitalisation and death. Regular physical activity, resistance exercises, and adequate protein intake can help prevent sarcopenia.
Tips on ageing well
• Eat a balanced diet
• Engage in regular physical activity or exercise
Signs of ageing well
• Physical health (having a well-nourished, hydrated body, with muscles in good function)
• Cognitive health (having the ability to think clearly, learn and remember)
• Being socially engaged and active in one’s community
Singapore numbers
By 2030, an estimated 1 in 4 citizens will be 65 years and above
In 2023, the proportion of citizens aged 65 and above reached 19 per cent; in 2013, it was 12 per cent
Babies born in 2023 can expect to live up to 83 years; for those born in 2013, their life expectancy was 82.4 years
Global numbers
In 2023, the average life expectancy at birth was 73.4 years (76.0 years for females, 70.8 years for males) — an increase of more than six years from 2000
• Ensure adequate sleep
• Limit alcohol consumption
• Avoid smoking
• By 2050, this is expected to rise to 77.3 years
In 1980, the number of people aged 65 years and above was around 260 million
• In 2021, it tripled to 761 million
• By 2050, this figure is projected to more than double to 1.6 billion
By 2050, the number of people aged 65 years and above will be twice the number of children under the age of 5 years, and almost equal to the number of children under the age of 12 years
Preventing deep vein thrombosis among air travellers
My family has been itching to travel but we’re a little wary about deep vein thrombosis as we’ve heard that air travellers are prone to the condition. Why is that so?
Deep vein thrombosis (DVT) is a blood clot that forms in a vein deep in the body. Clots occur when something slows or changes the blood flow, making it thicken and coagulate. While most of such clots occur in the lower leg or thigh, they can form in the arms, abdomen and pelvis.
Symptoms of DVT include pain, swelling and redness of the affected limb. DVT can be asymptomatic and is diagnosed only by ultrasound or computed tomography (CT) scans.
Not moving for a long time, after suffering a stroke or after undergoing surgery, in particular after major orthopaedic surgeries like hip or knee replacements, can increase the risk of developing DVT. Medical conditions like cancer, infections and autoimmune conditions, too, can heighten the risk of DVT.
Be sure to move intermittently when seated in a plane on a long flight. Do some stretching exercises or get up and take a short walk. Adopt a healthy lifestyle — exercise regularly, stay hydrated, maintain a healthy weight, and avoid or stop smoking.
When a blood clot breaks off and travels through the bloodstream to an artery in the lungs, it can block blood flow to the lungs and cut off the oxygenation of blood. This condition is called pulmonary embolism (PE), which can be fatal. Symptoms of PE include chest pain, breathlessness and fast heart rate (palpitations). If severe, there can be drop in blood pressure and the patient may faint or collapse, resulting in sudden death. Like DVT, PE can be asymptomatic and can only be diagnosed by ultrasound or CT scan.
Professor Lee Lai Heng
Senior Consultant, Department of Haematology, Singapore General Hospital
Getting hepatitis B vaccination after COVID-19 infection
I contracted COVID-19 in April. How long should I wait before getting a vaccination for hepatitis B? Does a hepatitis B vaccination provide lifetime immunity?
There is currently insufficient scientific literature about the duration one must wait before getting the hepatitis B vaccine after a COVID-19 infection. It is advisable to speak to your doctor before getting the hepatitis B vaccine. If necessary, do get a liver panel test to ensure that your liver has recovered from the COVID-19 infection.
After vaccination against hepatitis B, some people develop immunity that lasts for the rest of their lives. However, in some individuals, the immunity wanes off. After 10 to 15 years of initial vaccination, it is advisable to check your antibody levels. A booster dose of the vaccine might be required for some.
Individuals who are not suitable for a hepatitis vaccine include those who:
• have had severe allergic reactions after a previous dose or any component of the hepatitis vaccines
• have a yeast allergy
• have an allergy to neomycin, which is a component in one of the vaccines
Please discuss your concerns with your doctor about getting vaccinated and let them know if you have any allergies.
Clinical Assistant Professor Rahul Kumar Senior Consultant, Department of Gastroenterology and Hepatology, Changi General Hospital
that the Vanda SingHealth orchid first bloomed in April 2023, showcasing stunning golden blooms with orange-brown speckles inherited from its parent, Vanda M.V. Tannins? This remarkable orchid was unveiled at the Singapore General Hospital (SGH) Bicentennial Genomic Garden, the world’s first genomic garden, which houses over 100 meticulously curated regional plants. Through collaboration among SGH, SingHealth DukeNUS Institute of Biodiversity Medicine, and the Genome Institute of Singapore, half of these plants’ genomes have been sequenced, with the remainder to be completed this year. The resulting genomes — to be made publicly available — will deepen our understanding of the biological nature of these plants, particularly their health-promoting properties, potentially leading to advancements in medicine and healthcare.
that some blood, sputum, urine or stool tests ordered by patients’ Singapore General Hospital (SGH) medical team can be drawn at SingHealth Polyclinics (SHP)? This offers convenience to patients living near a polyclinic as they will not have to travel to SGH for their tests. Samples drawn at SHPs are sent back to SGH’s pathology laboratories for examination and diagnosis. However, not all tests can be done at SHPs. For instance, patients whose tests need to be interpreted immediately will need to have the samples drawn at SGH.
