jul aug
2014 a Bimonthly Publication of Singapore General Hospital and SingHealth ACADEMIC HEALTHCARE CLUSTER MCI (P) 173/05/2014 www.sgh.com.sg | www.singhealth.com.sg
Best Overall Editorial
Bronze
COntent Marketing Awards 2013
Faster Pain relief on the Go
更快捷、 便于携带的 急性止痛药
P3
P27
coming in august
AWARD OF EXCELLENCE
APEX Awards 2014
A SPECIAL EDITION ON NURSING
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An increase in toy-related injuries prompts study on toy safety
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New family medicine clinic offers care for patients with stabilised chronic illnesses
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Photo: tan wei te
Flu viruses are constantly mutating, creating new identities that can be lethal
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互助小组提供药物无法寄予的帮助，如 倾听的耳朵和随时伸出的援手
23/6/14 8:33 PM
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singapore health
jul– aug 2014 Publisher
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For editorial enquiries, please e-mail editor@sgh.com.sg For advertising enquiries, please call 6319-3022 or e-mail jrani@sph.com.sg All rights reser ved. 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. MCI (P) 173/05/2014. Printed in Singapore by Singapore Press Holdings Limited (registration no: 198402868E).
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18/6/14 5:02 PM
jul– aug 2014
singapore health
NEWS
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Pain relief on the run SGH and SCDF are trying out two painkillers as easily carried options for use by paramedics By Sol E Solomon
Controlling pain is important not only for humanitarian reasons but also because it helps prevent the condition from deteriorating and allows better pre-hospital assessment. The SGH-SCDF trial will take about a year to recruit the target 400 patients. Their ambulances will be separated into two groups, with each group carrying one of the two trial drugs for six months. At the end of the period, they will swap and carry the other drug for the second six months. The ambulances will continue to carry Entonox as a backup for those not eligible for the Penthrox or Tramadol. Penthrox provides pain relief in seconds. The patient is able to control the amount used, and will stop breathing in the medication when he no longer feels pain. A 3ml bottle gives 20 to 25 minutes of pain relief. If required, a second bottle can be given to extend the relief to about 50 to 55 minutes. Penthrox has been used in Australia for the past 20 years, and Singapore will be the first ambulance service outside of that country to investigate its use, said Prof Ong. Tramadol, a powerful analgesic, is given by injection. It is commonly used to
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horrific road accident has just occurred. Paramedics rush to the scene to try and pull the injured from their vehicles, crumpled by the impact of the crash. The patients are in pain, but paramedics cannot do much to help them. Getting the large and heavy cylinders of the pain-numbing gas, nitrous oxide (Entonox), to the injured is not easy when access to the accident scene is limited. Such a scenario, however, is common at accident sites. As a victim is being “extricated from the crash, he is likely to be suffering from broken limbs – a fractured arm, for instance – and that is the time when he needs the pain medication most”, said Associate Professor Marcus Ong, Senior Consultant, Department of Emergency Medicine, Singapore General Hospital (SGH).
PhotoS: tan wei te
If Penthrox or Tramadol proves its efficacy for use in the pre-hospital setting, paramedics will have much better ability in administering early pain relief.
Delivered via a palm-sized inhaler, Penthrox provides pain relief in seconds. The patient is able to control the amount used, and will stop breathing in the medication when he no longer feels pain.
Associate Professor Marcus Ong, Senior Consultant, Department of Emergency Medicine, SGH
By The Numbers
To address this shortcoming in first aid, SGH has teamed up with the Singapore Civil Defence Force (SCDF) to evaluate the effectiveness and suitability of two alternatives, methoxyflurane (known commercially as Penthrox) and Tramadol. Entonox is the current standard. “If Penthrox or Tramadol proves its efficacy for use in the pre-hospital setting, paramedics will have much better
ability in administering early pain relief,” said Prof Ong, who is the lead investigator of the study. Since February, the 30 SCDF ambulances that respond to 995 calls have been carrying either Penthrox or Tramadol for early pain relief, in addition to Entonox. Compared to the latter, the trial drugs are more portable, and easier to set up and administer. Penthrox is delivered via a palm-sized inhaler while Tramadol is injected. Being small and easily carried, they can be included in the bags of emer-
gency equipment that are carried to every accident scene. So logistically, they are easier to use. Entonox tanks are not carried in the bags of emergency equipment, and are usually used only in the ambulance, or the paramedics will make a second trip for it to be used at the emergency site. Saving an accident victim’s life is the first priority of paramedics. Once the person’s condition is stable and his life is no longer in danger, “our next priority is to improve his condition, and part of that is to relieve pain,” said Prof Ong.
The trial drugs are more portable and easier to set up and administer than the curent standard, Entonox, which is delivered via large cylinder gas tanks, according to Associate Professor Marcus Ong (in foreground). > Continued on page 4 ( 华文版本请翻阅至27页 )
400 2 20-25 4-6 30 A target
The
patients will be recruited for the SGH-SCDF trial
trial drugs are Penthrox and Tramadol
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A 3ml bottle of Penthrox gives
minutes of pain relief
A 50mg dose of Tramadol is effective for
hours
The
SCDF ambulances that respond to 995 calls will carry either Penthrox or Tramadol for early pain relief, in addition to Entonox
18/6/14 1:16 PM
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NEWS
singapore health
jul– aug 2014
> Continued from page 3
Pain relief on the run
ease pain at all emergency departments in Singapore, but not in Singapore ambulances. A 50mg dose is effective for four to six hours. To evaluate the effectiveness of the drugs, patients will be asked to score their pain level (from 1 to 10, with 10 the most severe), the time taken for the pain level to ease after the trial drug has been administered, and their level of satisfaction with the treatment and the use of the inhaler versus an injection. The trial will also ask health care staff, including paramedics, for feedback. As the ones administering pain relief to patients, they will be asked about their level of satisfaction in using the alternative treatments, as well as the side effects, if any, that patients face in using the drugs. Both trial drugs have their merits and shortcomings. For instance, Tramadol is a powerful analgesic, and unlike morphine, it is not a controlled drug and so does not need to go through lengthy security protocol before use. But as it needs to be injected, there is a risk of needle and other injuries and contamination while preparing to administer the drug, said Prof Ong.
Children, pregnant women won’t get it
People will be given the trial drug if they: • Are in acute pain, described as scoring 3 out of 10 (most severe) on the pain scale • Have musculoskeletal trauma, meaning injury of the arms, back or legs Are conscious • Are in stable condition, with normal • blood pressure • Are above 16 years of age
Not everyone will participate in the trial to evaluate the effectiveness of Penthrox and Tramadol as a more portable alternative to Entonox in treating acute pain. For a start, children under 16, pregnant women and nursing mothers will be excluded, not because the trial drugs are not safe, but because one requirement of the trial’s ethics board is to ensure that they are effective in simple, straightforward trauma cases first. Those will be among the additional questions that paramedics will ask, said Dr Ng Yih Yng, Chief Medical Officer, Singapore Civil Defence Force. They are already trained to take the medical history of the patient at the scene of the emergency, and to assess his condition.
They will be excluded from the trial if they: • Are pregnant or nursing • Have major head injury or are drowsy • Are intoxicated with drugs or alcohol (these can interact with the drugs and intensify their effects), or have chronic pain and are likely to be on medication for the condition • Have abdominal/chest pain or kidney/liver disease (Penthrox cannot be used for these patients) Have an allergy to the trial drug • Are on certain antibiotics or are aller• gic to painkillers • Have a history of fits or are on antidepressants
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18/6/14 1:17 PM
jul– aug 2014
singapore health
No child’s play
Babies under 1 Choose large rattles and squeeze toys that cannot be put in the mouth and swallowed
Children under 3
By Wong Sher Maine
Avoid toys with long strings, and toys with removable parts like small eyes or noses
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wo-year-old Jasmine was fascinated by the bright red buttons on her teddy bear’s suit. They were coming loose. As she tugged at them, two fell off. They looked like sweets. She popped one into her mouth. It tasted funny, so she took it out and put it up her nose. Her mother, who was in the same room, was engrossed working on the computer. Jasmine ran to her crying and pointing to her nose. Seeing the ragged teddy bear and the other button on the floor, Jasmine’s mother realised what had happened and frantically rushed the toddler to hospital. Doctors managed to remove the button from Jasmine’s nose, but only after holding her down and wrapping her in a blanket to keep her still, because she was crying and refusing to cooperate.
Dr Chong Shu-Ling, Senior Staff Registrar, KKH Department of Emergency Medicine
Jasmine’s story is a composite profile of children under five who have been hurt while playing with age-inappropriate toys. This case involved a teddy bear with buttons that could come off. However, if a child swallows a button battery and it is found to be in the oesophagus, he will have to go under general anaesthesia to have it removed. In 2013, more than 500 children were treated at the KK Women’s and Children’s Hospital (KKH) for toy-related injuries. Most cases are minor, but serious ones include bruises, fractures needing surgery, wounds needing stitches, or buttons, coins and pen lids painfully lodged in mouths, noses or ears. Last year, the hospital saw a 15
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The right toy for the right age
An increase in toy-related injuries last year compared to the previous one, prompted a study on parental knowledge about toy safety
Never hang toys that come with long strings which could become entangled in cribs or playpens Check rigid eyes and noses on soft toys; make sure they cannot be pulled off
Children under 8 Avoid toys with sharp points, especially those with glass or metal edges
Keeping toys safe
Caregivers have responsibilities that go beyond just buying a toy. They should:
Photo: Mareen Fischinger/Westend61/Corbis
It may be a true increase in the number of toyrelated injuries, or it may be that caregivers are more aware of these injuries and more likely to take their children to the emergency department for treatment.
NEWS
Last year, more than 500 children were treated at KKH for toy-related injuries. Most of the children were under five years old and half were under three.
per cent increase in the incidence of toy-related injuries in a nine-month period, compared to a similar period the previous year. Most of the children were under five years old. Half were under three. Dr Chong Shu-Ling, Senior Staff Registrar, KKH Department of Emergency Medicine, said, “It may be a true increase in the number of toy-related injuries, or it may be that caregivers are more aware of these injuries and more likely to take their children to the emergency department for treatment.” Understanding why toys can hurt The increase prompted the hospital to study parental knowledge of toy safety and practices in Singapore. It surveyed 93 parents and caregivers at its children’s emergency department from February to April 2012. Results showed that 81.7 per cent ensured their children’s toys were age-appropriate, 72 per cent checked labels for age recommendations, and 63.4 per cent read safety labels and followed the instructions. However, 92.5 per cent still bought toys not appropri-
ate for their child’s use. Survey respondents said they made this decision because they believed that the toy had an educational benefit, or believed that their child had met the appropriate developmental milestone and was able to play with the toy safely. Age recommendations on toys are labelled based on each toy’s safety aspects, the physical and cognitive abilities of children, and children’s level of interest. Common mistakes include buying toys with small parts for children under three, or putting small children on overly large riding toys from which they can fall, resulting in wounds or fractures. About 87 per cent of the participants had experienced at least one toy-related incident. About 44 per cent said it was due to the child using the toy wrongly, and 37.6 percent blamed this on lack of supervision by the caregiver. Young children playing with potentially dangerous toys should always be supervised, said Dr Chong. “Preschoolers have a strong exploratory nature, but are not fully aware of the dangers that their acts may cause.”
Throw away all packaging like plastic, styrofoam and cellophane Check toys occasionally for broken parts that may fall off, as well as splinters and rust Throw away irreparably broken toys Throw away broken pieces of balloons as these can be swallowed
Watch Out For TOys with... Small parts like buttons which can be wrenched off and put into the mouth, nose or ears Button batteries which may become detached despite having protective covers Rough surfaces or sharp edges that can cut and scratch, like old wooden or broken plastic toys, as well as moving ones such as tricycles and skate scooters.
20/6/14 1:20 PM
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NEWS
singapore health
jul– aug 2014
Trumping adversity
These two are among this year’s 33 Singapore Health Inspirational Patient and Caregiver Award winners, honoured for their extraordinary courage, resilience and strength
According to Mr Akhil Jain, his wife, Mrs Priya Jain’s illness has given them a changed perspective on life – once high-fliers going from strength to strength, they have adapted their lifestyle to prioritise her needs.
Mr Akhil Jain Winner (Caregiver)
A serious illness could not destroy this young couple’s devotion to each other. When Mrs Priya Jain, 29, found out she had a brain tumour in 2012, she turned to the one person who would be her support: her husband, Mr Akhil Jain, 29. The couple, who are permanent residents and Ministry of Education scholars, met at Nanyang Technological University, where they studied computer engineering. Both are from India and found friendship, and later love in each other, marrying in late 2010. The news of her illness came as a shock to both, who were then working as banking professionals. She recalled how they broke down and cried together one night, confiding their worst fears. She asked him to carry on with his life, but he was intent on attacking the problem with a clear mind. Although the tumour in her brain stem was benign, it was large, and putting pressure on her vital nerves. She underwent a nine-hour operation at the Singapore General Hospital to remove it in May 2012. It left her with 21 stitches and a 15cm-long scar from her right ear to the nape of her neck. Mr Jain was the perfect caregiver. He made sure she was never alone, staying by her bedside from morning to night, and even sleeping in the ward whenever possible. He said having a supportive manager at work helped immensely, because he was allowed to work from home or the hospital. The operation was successful but it was not the end of the story. The tumour, which was initially diagnosed as slow
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growing, returned 10 months later. It was then that they had to make the most difficult decision of their lives, said Mr Jain. To remove the tumour a second time would mean risking a loss of hearing in her right ear or partial paralysis of the facial nerve. On the other hand, if they opted for radiation therapy, it would mean risking cancer 10 to 15 years down the road. But the couple did not panic. Mrs Jain said her husband’s logical nature helped. “His biggest ability was to look at the issue and problem-solve. We went through all the possible scenarios and risks...we talked about it up to the night before the surgery. Instead of worrying, we were able to distance ourselves from it and look at the issues clearly,” she said. They decided she would go for the second operation in October last year and agreed with the doctors that the tumour removal would be done as far as possible without moving the facial nerve. This might mean radiation therapy later, but to a much smaller area, with lower risks. The operation took 14 hours and left her with another 15cm scar on her neck that she calls “my battle scar”. Back at work Today, Mrs Jain is back at work as an associate director in a multinational bank. The hearing in her right ear is damaged and her right vocal chord is paralysed. Her voice is soft, and people need to lean in close to hear her. She also has difficulty swallowing and must avoid spicy food. She cannot swallow her pills whole, so Mr Jain grinds them for her. The ordeal has not diminished their devotion to each other. Rather, it has brought them closer. They refuse to let these problems get them down and prefer
to think positively and see the lighter side, even jesting with each other. “If her food has chillies, I eat it,” he joked. It has also given them a changed perspective on life. Once high-fliers going from strength to strength, they have adapted their lifestyle to prioritise her needs. Mr Jain said: “We have a typical profile – good Indian kids, scholars, always doing the right thing. But this has given us a reality check on what life should really be about. Now, our instinct is to spend more time together and stop worrying about the materialistic world out there.” He has plans to start his own business creating a smartphone app on financial education, while she will be doing her master’s in Business Administration at INSEAD this year. For now, the couple are happiest simply spending time together, chatting, taking long walks around their condominium in Paya Lebar and playing board games. When they have friends over, it is usually a small group, so that she can be easily heard. “He’s been very good to me throughout,” said Mrs Jain, adding jokingly, “I got a great deal (marrying him). To which her husband responded, “I also got an excellent deal. I couldn’t have asked for anything better and I wouldn’t change anything.”
Photo: vernon wong
Photo: Alvinn lim
By Denyse Yeo
For Mr Vincent Francis Spykerman, happiness is about finding joy and pleasure in the simplest things.
Mr Vincent Francis Spykerman Winner (Patient)
A painful condition has not stopped him from living the life he wants.
Former school principal Mr Vincent Francis Spykerman is 84 years old, but he is as active as he was in his younger days. As a young teacher in the 1960s, he played football and hockey, and made music with a local band called Barney Morier and His Hawaiinairs. He also went
fishing near his house in Upper East Coast, where he has lived for 48 years with the sea almost at his doorstep. Today, that area has been reclaimed and tall condominiums built. But Mr Spykerman has not changed much. He is still fighting fit for his age and fully engaged with life. His days are still full of activity. Most mornings, he can be found cycling to the wet market nearby to buy food. Most afternoons, this avid gardener can be found pottering about in his vegetable and fruit garden. At night he plays Sudoku, or strums Spanish ballads on his guitar, which he has fondly dubbed his “first wife”. His late wife died from cancer nine years ago. Living life to the fullest Even a chronic health condition has not fazed him. For as long as he can remember, he has suffered from sebaceous cysts that can become swollen and painful, sometimes swelling to the size of a golf ball. Day surgery is sometimes needed and he has had several operations. Despite this, he is determined to live life as usual. The devout Roman Catholic says his secret is simple – patience. “I just ignore the pain and go about my business. I learnt to be patient like this as a youngster, fishing, waiting for a fish to bite.” His stoic nature shows when he talks about how important it is to be healthy, even at his age, and how he stayed positive even after his wife died. He offers health tips of his own, such as mixing ground ginger with hot water to ease digestion. He attributes his overall good health to several factors. “I live an active life and keep to my faith. I’ve never smoked a cigarette in my life. I don’t drink and gamble, and I eat healthily.” For educating others on the importance of taking ownership of their health, and practising what he preaches, Mr Spykerman was nominated for the Singapore Health Inspirational Patient award by a nurse at SingHealth Polyclinics - Tampines, where he goes for regular check-ups. On receiving the award, he said: “I am very blessed. The doctors and nurses at the polyclinic have been very good to me, and I am grateful to them.” What motivates him is the strong support from his family. His daughter, her husband and their two grown-up sons live with him, and Mr Spykerman remains close to them. Every month, he also takes the overnight train to Kuala Lumpur – where he was born and has a house – on his own to visit his sister’s children. “My family cares for me and I care for them. For me, family support and faith are most important.” On taking the train to Malaysia alone, he said, “It’s alright. I’m not afraid.” For Mr Spykerman, happiness is about finding joy and pleasure in the simplest things, from strumming his guitar to tending his fruit and vegetable garden. He said: “I’m in the sunset of my life and I can drop dead any time. But Spykerman is still alive. I’m not dead yet. Life goes on. I’m a happy character and that has helped.”
18/6/14 1:25 PM
jul– aug 2014
singapore health
Hello, podiatrist
New on-call podiatry hotline for the Emergency Department saves patients from inpatient admission By Sol E Solomon
Photo: zaphs zhang
M
dm Jane Tan* got a small cut on the top of her foot when she dropped a pair of scissors on it. Instead of healing, the cut grew larger until it measured 3cm by 3cm weeks later. In severe pain, the 70-year-old sought treatment at the Singapore General Hospital’s (SGH) Accident and Emergency department (A&E). A diabetic and at risk of developing complications, Mdm Tan could have been admitted to hospital for treatment. But due to a new A&E on-call podiatry service, she was seen as an outpatient instead. “We did a vascular assessment to check that her blood circulation was okay. Her infection was then treated with oral antibiotics, and she was seen at the Podiatry Department that same morning to have her ulcer cleaned and dressed,” said Ms Sophie Whitelaw, Principal Podiatrist, SGH. “We initiated this ser vice par tly because of an observation by our inpatient podiatry team that some patients could have been seen in outpatient podiatry instead of being admitted,” said Ms Whitelaw. Diabetic patient s with serious wounds have to be treated in hospital if the infection is affecting them “systemically” – the patient develops a fever or his white blood cells have gone up
According to Ms Sophie Whitelaw, Principal Podiatrist, the A&E on-call podiatry service at SGH gets three calls a week on average, mostly for ulcers.
NEWS
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insensitive to pain or extreme temperature. “We wanted to develop links with the Emergency Department so that if an attending clinician wants a second opinion on the best course of action for a patient, we can provide that collaboration,” Ms Whitelaw said. When an A&E doctor calls the Podiatry Department for a second opinion about whether to admit a patient, an on-call podiatrist will respond within 15 minutes. Patients who do not have to be admitted will be seen at the Podiatry Department either on the same day or the next working day. The main referrals the podiatrists receive are for various types of ulcers. Ingrown toenails are another condition that commonly requires outpatient treatment, not a hospital stay. Patients usually need oral antibiotics for infected ingrown toenails, and a procedure to remove the offending portion of the nail under local anaesthesia later. Podiatrists at the outpatient clinic follow up with them regularly until their wounds heal, Ms Whitelaw said. On average, the A&E on-call podiatry service gets three calls a week, mostly for ulcers. Many of those patients would have been admitted if they had not been referred to the podiatrists, she said. * Name of patient has been changed to protect her privacy.
sharply – or causing severe pain. But if diabetic patients like Mdm Tan are found to need outpatient treatment only, A&E doctors might refer them to a polyclinic to be seen by a family care practitioner who might not be a specialist in diabetic foot problems, said Ms Whitelaw. At the same time, diabetic patients often do not realise that their foot problems are serious. Long-term diabetics can develop nerve damage and become
Foot notes
Diabetics need to take better care of their feet because of the higher risk of problems.
Clean feet
• Wash daily with mild soap and warm water. • Dry well, especially between the toes. • Apply moisturiser daily to prevent feet and heels from cracking. Do not put moisturiser between the toes.
Cut nails
• Cut toenails straight across and do not trim them too short. Do not cut into the corners. • Use a nail file across the edge of the nail.
Check feet
• Check the feet every day for cuts, swelling, redness, blisters or pus. • Look between the toes and around the heels and soles.
corns, calluses
• Do not use acid treatments or corn plasters. • Use 10 per cent urea cream to soften corns or calluses. If it does not work, see a podiatrist or a doctor. • Do not use sharp instruments to cut away thickened or hard skin on the feet.
Footwear
• Shoes should be comfortable and fit
07 NEWS_Podiatry v3.ab.indd 7
well. Always wear shoes. Never go barefoot, even at home. • Check the insides of shoes for stones or sharp objects. • Wear cotton socks or stockings with shoes at all times. Socks and stockings should not be too tight.
Avoid
• Do not soak feet in very cold or very hot water. • Do not wear open toe or massage slippers. • Avoid massage machines, foot reflexology and acupuncture.
18/6/14 1:29 PM
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jul– aug 2014
Designated shuttle for wheelchair users New wheelchair shuttle is third SGH Campus bus service for patients By Desmond Ng
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Pick-up/drop-off points SGH Campus Wheelchair Shuttle Bus Service Campus Shuttle Bus Service
SGH Campus shuttle bus services, routes and pick-up/drop-off points
Multi-Storey Car Park H Shuttle Bus Service
SGH Campus Wheelchair Shuttle Bus Service Board or alight at: a) NEL’s Outram Park Station – Exit F (Handicapped Bay) b) SNEC – main porch c) SGH – Block 5 porch d) NCCS – main porch e) NHCS – main porch MON – FRI 7am to 7pm SAT 8am to 2pm SUN & Public Holiday No shuttle bus service available
Photo: ALVINN LIM
hee l ch a i r u s e r s t r a v e l ling to t h e Singap ore G en eral Hospital (SGH) and other SingHealth hospitals on SGH Campus by public transport can now take a new dedicated wheelchair-accessible shuttle bus service from SMRT’s North East (purple) Line’s (NEL) Outram Park MRT station. The SGH Campus Wheelchair Shuttle Bus Service ferries wheelchair users to and from designated pick-up and drop-off points at the NEL’s Outram Park MRT station, the National Heart Centre Singapore (NHCS), the National Cancer Centre Singapore (NCC S), and the Singapore National Eye Centre (SNEC). The new service is the third shuttle bus service for patients and visitors of SingHealth institutions. The regular Campus Shuttle Bus Service is a loop service that stops at both the North East and East West (green) Lines’ Outram Park stations, SGH, NHCS, NCCS and SNEC. Another regular service is the Multi-Storey Car Park H Shuttle Bus Service that takes passengers from SGH Block 4 to the Multi-Storey Car Park H on MacAlister Road. This latest service is for wheelchair users and a limited number of accompanying caregivers and family members. Each shuttle bus can carry up to two wheelchairs, and no more than two companions are allowed to board the bus with each wheelchair user. Because the wheelchairs will be secured to the floor of the bus by restraints, the wheelchairs cannot be larger than 750mm by 1200mm. The service is also for motorised wheelchair users. The pick-up/drop-off bay is at Exit F of the NEL’s Outram Park station on Eu Tong Sen Street. There is no designated pick-up/drop-off bay at the East West Line’s Outram Park station. Patients who want to use the Wheelchair Shuttle Bus Service must wait at the designated Handicapped Bay at Exit F of the NEL’s Outram Park station. They can use the lift to the Handicapped Bay from the station concourse. Passengers and visitors should look out for signs at the MRT stations to guide them to the waiting area for wheelchair-bound passengers. The wheelchair shuttle bus service runs every 20 minutes or so, from 7am to 7pm on Mondays to Fridays, and from 8am to 2pm on Saturdays.
(CT ay
Each wheelchair shuttle bus – clearly indicated (insert) – can carry up to two wheelchair users and four companions (two to each patient).
20/6/14 1:21 PM
jul– aug 2014
08 NEWS_Wheelchair_V5.indd 9
singapore health
NEWS
9
18/6/14 3:13 PM
10
NEWS
singapore health
jul– aug 2014
Geylang Polyclinic now has physiotherapy service It is the second SingHealth polyclinic to offer patients this treatment By Suki Lor
Appointments & Fees
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10 NEWS_Physiotherapy v5.ab_R3.indd 10
Help yourself keep pain at bay
Photo: Vee chin
inghealth polyclinics (SHP) - Geylang is now offering physiotherapy after SingHealth Polyclinics - Tampines, which started its service in November 2013. It was introduced because of the rising demand for physiotherapy from patients with musculoskeletal problems, said SHP’s Physiotherapy Manager, Mr Yang Ming Xing. The polyclinic can treat the full spectrum of musculoskeletal problems, with exercises, manual therapy, ultrasound, and back and neck traction (using a mechanical pulling force to reduce compression at the spine for pain relief.)
To see a physiotherapist at SingHealth Polyclinics (SHP) Geylang or SingHealth Polyclinics - Tampines, get a referral from any of SHP’s nine polyclinics. For Singaporeans, the first visit costs $46.70 and subsequent sessions are priced at $39.25.
Mr Yang Ming Xing, Physiotherapy Manager, helping Ms Nirwati Selamat with physiotherapy, a new service launched at Geylang Polyclinic earlier this year.
On any given day, Geylang Polyclinic has four physiotherapists available. Each sees about 14 patients a day. Most are discharged within four sessions, but more complicated cases need up to six sessions. Seven out of every 10 patients are between 30 and 70 years old. Mr Yang said that 30- to 40-year-olds usually have work-related, ergonomic-related neck and back pain. Many are office workers. Glued to their computers and smartphones for long spells, they strain their necks and shoulders. “Desk-bound jobs and a sedentary lifestyle contribute to the problem. People are not as active as before. The older adults come more for osteoarthritis treatment, and tend to have knee or shoulder problems because of degeneration.” To cope with a potential increase in patients, the polyclinic is exploring offering group therapy where a few patients with the same problem can be attended to at the same time. SHP also plans to offer physiotherapy at a third location. “We plan to extend our service to SingHealth Polyclinics - Bedok in 2017,” said Mr Yang. The service is helpful to patients who live nearby. Ms Nirwati Selamat, a massage therapist, used to be plagued by a constant pain in her right shoulder and upper arm, which surfaced in October last year. Ms Nirwati, who lives in Kembangan, comes for regular physiotherapy sessions and is also having her neck treated at the same time.
See below for SHP’s Physiotherapy Manager, Mr Yang Ming Xing’s advice for those with pain in the back, shoulders, neck and knees – the top four areas of treatment at SHP’s physiotherapy centres: For the knees • Walk, cycle or do other exercises to strengthen the knees • Exercise should not cause pain • Avoid using the stairs • Lose weight For the shoulders • Do gentle shoulder stretches • Avoid lying down on the shoulder that hurts • Avoid reaching overhead or lifting heavy objects with the affected arm For the back • Resume normal activities as soon as possible • Swim regularly • Avoid bending forward, sustained lifting of objects, or lifting an object and twisting your back simultaneously • Sit with your back well-supported and have frequent breaks For the neck • Stay active; gentle movements will not harm the neck • If using a computer, ensure that the monitor is at eye level and avoid leaning forward • Sit with your back well-supported and take frequent breaks • If using a smar tphone or tablet, avoid looking down for long periods of time
23/6/14 3:52 PM
jul– aug 2014
singapore health
NEWS
11
Family medicine clinic opens in Chinatown Singapore’s fifth clinic offers comprehensive care for people with stabilised chronic illnesses By Suki Lor
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need to transform the model of care. We need to work closely with primary care partners so that once patients are stable, they can be taken care of, for the longer term, in the community,” he said.
family physicians are able to address the longer-term medical and social needs of our patients, ensure good treatment outcomes and also help patients curb the escalation of long-term health care costs.
Prof Fong said family physicians are key partners in patient care. “Family physicians are able to address the longer-term medical and social needs of our patients, ensure good treatment outcomes and also help patients curb the escalation of long-term health care costs.” Dr Lily Neo, Member of Parliament for Tanjong Pagar GRC, hailed the clinic as a boon for residents in the constituency, many of whom are elderly. She said they do not have to travel far or wait long to see a doctor, and the mall setting is inviting to those who get anxious going to a hospital. The FMC’s other services include health screening and examination, development assessment for babies
and children, vaccinations, minor surgeries and procedures. Lower- and middle-income patients on the Community Health Assist Scheme (CHAS) will continue to enjoy subsidised health care, while patients under the Chronic Disease Management Programme (CDMP) can tap on their Medisave to pay their bills.
Family Medicine Clinic Chinatown
Chinatown Point, #02/09-10, 133, New Bridge Road Tel: 6225-5155 Email: info@chinatownfmc.com.sg Operating hours: Mondays to Fridays (9am-6pm) Saturdays (9am-1pm)
Professor Fong Kok Yong, SingHealth’s Group Director (Medical)
SingHealth specialists work closely with the clinic’s family medicine specialists. Each patient is assigned a personal doctor, who has access to his medical history through the National Electronic Health Record.
Photo: alvinn lim
esidents of Chinatown, especially those with stable chronic illnesses, can now be treated closer to home at SingHealth’s first family medicine clinic there. Called Family Medicine Clinic (FMC) Chinatown, and located at Chinatown Point, it started seeing patients in January this year. By the time of its official opening in May, it had more than 630 visits. The clinic sees patients referred from the Singapore General Hospital (SGH) and SingHealth Polyclinics - Outram, as well as walk-ins. There are plans to refer patients from more clinical specialities within SGH and the National Heart Centre Singapore, as well as SingHealth Polyclinics - Bukit Merah and SingHealth Polyclinics - Queenstown. A tie-up between SingHealth and private general practitioner group TriLink FMC, the clinic is part of the Government’s Primary Care Masterplan to leverage on expertise in the public and private sector to offer comprehensive and integrated care to patients with stabilised chronic illnesses. Professor Fong Kok Yong, SingHealth’s Group Director (Medical), said that the clinic will better meet the complex and long-term needs of the rapidly ageing population. “Many of our aged patients actually have multiple chronic conditions. An acute care setting cannot meet their long-term needs. Therefore we
(From left) Dr Loke Kam Weng, Director of TriLink FMC; Dr Lily Neo, Member of Parliament for Tanjong Pagar GRC and Professor Ivy Ng, Group Chief Executive Officer of SingHealth at the recent FMC Chinatown opening.
11 NEWS_FMC v4.abx_R.indd 11
20/6/14 1:22 PM
12
upclose
singapore health
jul– aug 2014
World hepatitis day
Get protected against
hepatitis On World Hepatitis Day, which falls on July 28, the spotlight shines on hepatitis B, the most prevalent form of the disease in Singapore
5
main types of Hepatitis A
causes liver inflammation; is caused by consuming contaminated food or water; or having close physical contact or sex with a person infected with the hepatitis A virus.
B is a serious infection caused by the hepatitis B virus; can become chronic or lifelong, leading to liver failure, liver cancer or cirrhosis (scarring of the organ).
keep hepatitis at bay Complete all three vaccination doses to be effectively immune against the hepatitis B virus. The vaccination is safe, effective and the best protection against hepatitis Brelated liver cancer. Go to reliable practitioners for acupuncture, body piercing or tattooing, and ensure they
sterilise and dispose of used needles properly. Avoid sharing needles, blades and razors. Avoid having multiple sex partners. Have protected sex. Maintain good hygiene always. Wash hands with soap before and after meals. Cook shellfish properly before eating. Practise good food handling methods.
C
of chronic hepatitis B carriers are in the Asia Pacific
1
D is caused by the hepatitis D virus, and can only be transmitted if the carrier is infected with hepatitis B; is spread through contact with infected blood or needles, or having unprotected sex with a carrier.
causes swelling of the liver; is caused by the hepatitis E virus and can only be transmitted by drinking water contaminated with the virus, or through oral or anal contact.
per cent
managing the disease
Individuals with chronic
is caused by the hepatitis C virus; is spread the same way as hepatitis B, through contact with an infected person’s blood, semen, or body fluids.
E
75
About 1 in 35 adult Singaporeans are hepatitis B carriers
hepatitis B should have six-monthly blood tests and a yearly ultrasound examination of the liver. All individuals at high risk need to be closely monitored. The main treatment for chronic hepatitis B is ANTIVIRAL DRUGS to stop the virus from damaging the liver.
2
300,000,000 Worldwide, there are about
chronic hepatitis B carriers
Sources: www.moh.gov.sg, hpb.gov.sg, World Health Organization
12 UPCLOSE hepatitis_V4.ab.ed.abx_R.indd 12
20/6/14 2:52 PM
– Jun 2014 singapore health jul– aug 2014 May singapore health people
25 13
Restoring appearances
AtheRosCleRosis in otheR PARts of the body
can be so gradual that the body’s natural compensation mechanism causes small If it is a brain injury, he will work with a Atherosclerosis can occur not just in the heart, but also in any artery in the body. capillaries to form, bridging the blockage neurosurgeon. before the artery is completely blocked. His interest lies in perforator flaps. this “natural bypass” prevents patients Peripheral arteries patients with diabetes, and opening can sometimes detected byand putThis is when a patientberequires skin Breast reconstruction, patching up open fractures and re-attaching parts are with stents or surfrom having a heart attack even though these are arteries in the arms andbody up such arteries stethoscope a carotid artery fat toting be aremoved fromtoone part of the an artery may bework 100 per cent blocked. surgeon legs. Blockages in leg arteries may gery may prevent limbs from being for a whistling sound with bodytotolisten be grafted onto another. For all in a day’s for a plastic however, the patient may have angina cause pain in the legs when walking. amputated. every to heart pulsation. a breast lost instance, reconstruct – the feeling of pain or tightness in his if the pain is bearable, the doctor due to mastectomy for a breast cancer By Wong Sher Maine chest during physical exertion – with the may advise the patient totic keep Carotid arteries Renal surgeon.” When he travels with his patient. To arteries use skin from the abdomen, pain typically going away when he stops on walking through the pain, thetocarotid arteries, which are atherosclerosis in these arteries, wife,to he tries visit famous architectural muscle and fat are usually removed. But to rest. encourage the body’s coping landmarks, mech- located along the sides which supply to the kidneys, r Mohamed Zulfikar Rasheed and occasionally dropsofinthe on neck, Dr Zulfikar uses a blood technique that careWhen plaque build-up the anism to build capillaries around supply oxygen to the brain. When a gradual loss of kidney is notthe only a surgeon, he isinalso Internet forums dedicated to architecfully causes extracts blood vessels whichfuncgo artery ruptures, platelets in the blockage. limb artery blockages blockagesthe develop these arteries, tion.the it can lead and to uncontrolled ansuddenly artist. ture. He admires designinof condothrough muscle leaves morehigh of theThe blood will rapidly cover up theGenrupcause poor healing of wounds in Reflections a stroke mayatoccur. a blockage blood pressure and Consultant at the Singapore minium Keppel Bay and here the abdominal muscle in kidney place. failure. ture,Hospital’s leading to aDepartment clot forming,ofwhich nareral Plastic, architects like Daniel Libeskind. “By preserving what you don’t really rows the artery and further. if blood flow is Reconstruction Aesthetic Surgery At work, about half the cases he deals need to take, like muscle, the patient will completely blocked, surgical the affected muscle employs meticulous techniques with concern reconstruction, mainly of experience less pain, bulges or hernia, loses its oxygen supplythe andtissues a heartof attack to mould and tailor the breasts affected by cancer, and limbs and can go home faster and exercise occurs. if the blockage is not opened a stent – a metal mesh tube – can be damaged lesterol levels, high accidents. blood pressure and better. the This best is way to keep heartisdisease at body to restore form to patients whose through He also what we think the gold within 12 hours, the muscle by inserted into the blocked artery to performs diabetes are advised to surgery keep these condibay is to for adopt a healthy lifestyle, which appearances were marredsupplied by injury craniofacial such as standard breast reconstruction.” that artery will be irreversibly damaged. keep it open so that blood can flow the tions in check through properand medication, regular exercise, a healthy diet, or illness. repair of facial fractures deformi- includes What is challenging is not just time Depending on its severity, heart attack through. this method is typically ties, as they are risksurgery, factors for disease. not smoking, and maintaining a normal Dr Zulfikar, 39, said hea decided to cosmetic andheart attends to the management, which Dr Zulfikar grapcould leadin toplastic death. surgery after a stint used in patients with less severe or effects in addition, advises patients ples weight. this willrushes not only protectsurgery against specialise of burns Dr on Wong the skin. with, as he between patients withasatherosclerosis may complex blockages. who have been treated for heart and disease to appointments, heart disease, but also stavetooffpatients a host of in the discipline a medical student “Much of reconstruction aesattending Dr Mohamed Zulfikar Rasheed, show symptoms for decades, until a the To patient can undergo a heart thetic be particularly with theirhe lifestyle other at the no National University of Singapore. surgery vigilant is interlinked,” said. in the health clinic problems. and giving presentations. plastic surgery is both science and sudden heart attack occurs. bypass, in which a vein or artery is habits and to continue with their medicaMr sivarajoo, who is nowtoalso a dia“You are treating all parts of the body and “For instance, some of the patients “It is also sometimes difficult manage art, as it is not only about function takenbut from another part of the body tion, even if their symptoms go away. betic, is off cigarettes, remains conscious are not confined to any particular area. who come to us for reconstruction patients’ expectations of what we also form. Treatment and used to create a bridge around follow up with aesthetic procedures can of his diet, and stays active by taking You also getoptions instant gratification from deliver.” once you atherosclerosis is diagnosed, the blockage. Reducing the risk weekly walks for exercise. what do, because the resultsthere are after we have built up a relationship Whathour-long keeps him satisfied in his job is are three main forms of treatment. the effective to reduce thealso risk seeing he patients is glad do that madethem that quite immediate. Whether a procedure also form.” Indeed, his keen appreciation withmost them. Doing way aesthetic work well.he“Seeing Medicine, aspirin or statins, heartform bypasses done inextends severe conof atherosclerosis becoming fatal is to happy life-changing decision threethat decades ago. succeeds, you such knowassooner rather than for both and are function to helps reconstruction.” with the service we procan prescribed to reduce the risk architecture. ditions when all three arteries to the heart have as early he said thatour if he hadsucceed not, he might not later,” hebe said. Hefrequent works health closelycheck-ups, with other sur- vide, seeing flaps and how of a heart attack and treat risk areHe blocked, and“Iwill usually lastbecome for about geons detection best way the patients have beenget alive to see his only daughter “It’s both science andtoart, as the plastic added: would have too.isIf the a patient hasto ancounter eye injury, back to their daily lives, factors the patient has. function, but an 10 architect years or more. those with high cho- he degenerative theeye disease. get married in 2013. surgery is not only about if I didn’t become a plaswill workeffects with ofan surgeon. gives me personal satisfaction.” Photo: Alvinn lim
D
Wide circulation that reaches over 200,000 readers Available at strategic locations Contains authoritative health care news and information Singapore Health is the official publication of singapore general hospital and singhealth
published bimonthly in a handy group, the largest health care group in singapore. 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, e-mail bernard Chen at bernchen@sph.com.sg
13 PEOPLE_Plastic Surgeon_V3.aw.ab.indd 13
18/6/14 2:12 PM
14
people
singapore health
jul– aug 2014
Communicating hope
This senior medical social worker has a keen interest in palliative and end-of-life care By Suki Lor
Photo: Vernon Wong
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upp orting k idn ey pat ie nt s through tough times and touching their lives is what gives Mr Andy Sim, Senior Medical Social Worker (MSW), Medical Social Services, Singapore General Hospital (SGH), a sense of satisfaction. “When I am able to round the sharp edges off very bad news and give patients the ability to cope, that is what drives me,� Mr Sim, 35, said. Having a warm personality, an ability to understand and appreciate other people’s circumstances, and a liking for working with people, the affable bachelor joined SGH as an MSW for the Department of Renal Medicine about eight years ago. “We provide counselling and psycho-education to patients with chronic or end-stage renal disease and their family members to help them cope with the disease. Before patients are discharged, especially the elderly or those requiring rehabilitation care, we
MSWs like Andy Sim (right) provide counselling and psycho-education to patients with chronic or end-stage renal disease and their family members to help them cope with the disease.
also provide discharge care arrangements,� Mr Sim said. He facilitates patients’ applications for financial assistance to pay for their hospitalisation bills and recommends community resources to help reintegrate them into the community. When he realised that his interest lay in palliative and end-of-life care, he took
courses on grief and bereavement and end-of-life care. “I am also a certified thanatologist – someone who deals with end-of-life education and counselling,� said Mr Sim. So intent was he on furthering his interest that he headed to New York University on an SGH scholarship to pursue a Master of Social Work degree, special-
ising in palliative and end-of-life care. He returned home last September. For his degree, he had to complete 1,200 hours of clinical work. “I was placed for a year in a palliative and oncology setting and had the chance to work with patients and doctors on advance care discussions and planning,� Mr Sim said. Learning about advance care processes in the US has come in handy as Mr Sim’s department is participating in an SGH pilot project to formalise advance care planning. “At least 40 per cent of my time is spent on advance care because I am not only doing the facilitation, but I am also the coordinator for developing the curriculum and training of advocates at SGH,� said Mr Sim. The facilitator engages the patient and his family in completing the discussions and documents to formalise their care plan. The advocate is someone who initiates and introduces advance care planning to the patient. Mr Sim’s job puts him in a position where he constantly experiences the pain and suffering of those who sometimes have little hope of recovery, but support from friends, family and colleagues helps him take things in stride. He also runs regularly to de-stress. During his US sojourn, the avid runner completed nine half-marathons and one full marathon.
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18/6/14 2:32 PM
jul– aug 2014
singapore health
Money
15
Medisave for more chronic diseases
Patients can now use Medisave to pay for treatment of more chronic conditions such as anxiety and chronic kidney disease By Francis Kan
A
S OF January THIS YEAR, Medisave can be used for outpatient treatment of five more chronic conditions, on top of the 10 already covered under the scheme. The five are osteoarthritis (degenerative joint disease), benign prostatic hyperplasia (enlargement of the prostate gland), anxiety, Parkinson’s disease and nephritis/ nephrosis (forms of kidney disease). Previously, the 10 conditions covered were diabetes, hyper tension, lipid disorders, stroke, asthma, chronic obstructive pulmonary disease, major depression, schizophrenia, dementia, and bipolar disorder. As in many developed countries, chronic diseases in Singapore are a major cause of death and illness, mainly because many patients seek treatment when it is already too late. Early treatment for these conditions can include
diet and lifestyle changes, as well as regular medication and consultation. Patients who start to manage their conditions in the early stages often avoid serious problems and complications that can come with poor treatment. When complications set in, health care costs can become very costly. For instance, poor diabetes management can lead to a limb being amputated. The patient will then have to pay for undergoing surgery, hospitalisation and follow-up specialist consultations. In 2006, the Ministry of Health (MOH) launched the Chronic Disease Management Programme as part of a national effort to improve the care and management of chronic diseases by helping patients defray their outpatient costs of these conditions. MOH included the additional conditions covered under Medisave after
public feedback, and because the diseases are among the most prevalent in Singapore. The expanded list now covers 90 per cent of the chronic care conditions seen in the primary care sector. The cost of treating these conditions will be subsidised by up to $400 every year for each Medisave account at specialist clinics, polyclinics and Medisave-accredited GP clinics. Patients who qualify under the Community Health Assist Scheme (CHAS) can enjoy subsidies of up to $480 a year, further reducing cash outlays. CHAS is an MOH programme that helps provide Singaporeans with accessible and affordable medical and dental care.
CHAS was recently expanded to include middle-income households, with the income ceiling to qualify raised from the current $1,500 to a per capita monthly household income of $1,800, or up to $21,000 in annual value of their residential property. The expansion to include these five additional chronic conditions under Medisave coverage is timely in view of Singapore’s ageing population, but some doctors said they hope that the scheme will be expanded further to include more chronic diseases such as autoimmune disorders. Thyroid disease and rheumatoid arthritis are two common autoimmune disorders.
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Medication for the management of the identified condition and/or its complications. Allied Health ser vices such as nursing, physiotherapy, occupational therapy, speech therapy, and dietician or podiatry services as referred by a doctor. Three safeguards put in place under the Medisave for Chronic Disease Management Pro-
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20/6/14 1:26 PM
16
singapore health
jul– aug 2014
Health Xchange
Our experts answer all your questions about health
Protection against third-hand smoke
Dr Teoh Oon Hoe, Head and Senior Consultant, Respiratory Medicine Service, KK Women’s and Children’s Hospital
Photo: GETTY IMAGES
What are the dangers of third-hand smoke? How can we protect ourselves against it? Third-hand smoke refers to the harmful residues of nicotine and chemicals left on indoor surfaces by tobacco smoke. They can be released back into the air as gases and inhaled long after cigarettes are put out. They can also react with common indoor pollutants to create a toxic mix containing cancer-causing substances, which pose potential health hazards to non-smokers exposed to it. Studies show that third-hand smoke can cling to hair, skin, clothes, floors, walls, furniture, carpets, vehicles and various other surfaces, long after smoking has stopped. Infants and children are at a higher risk as they are more likely to inhale or ingest it by touching surfaces with these harmful residues and then put their fingers into their mouths. The residues build up on surfaces over time and cannot be removed by airing the affected rooms, or using fans and air conditioners. The best and only way is to create a smoke-free environment at home, in the family vehicle, on public transport and in public places. Third-hand smoke can also affect pregnant women and their unborn babies, but the majority of studies have been on the effect of second-hand smoke on them.
Can asthmatics train to be sportsmen?
Severe and frequent lower back pain I suffer from lower back pain occasionally. Using a medicated patch usually made the pain go away quite quickly. Recently, the pain has become more frequent and sometimes, it was so severe that I could not even drive. My job requires me to drive frequently. Lower back pain is very common, with some references noting that up to 90 per cent of the population are likely to encounter a severe episode of lower back pain some time in their lives. On many occasions, the pain goes away on its own and requires minimal treatment. However, you should seek medical opinion if the pain worsens and is not relieved by rest or medication; if there are symptoms of nerve compression such as pain, weakness or numbness down the legs; if you have difficulty walking steadily; or if you have fever,
Flashing lights in eye
Why do I see flashing lights going on and off in my right eye? I am 65 years old and have hypertension, high cholesterol and diabetes, all of which are under control. These flashes are termed photopsia. They indicate traction of degenerated vitreous (jelly) on the retina, which it is attached to, when your eyes move. No treatment is necessary as they generally subside with time. However, if you experience a sudden appearance of a swarm of black
16 HEX V3_R.indd 16
chills, lost weight or appetite. One common misconception that people have is that standing stresses the back more than sitting down. However, the sitting posture puts 50 per cent more stress on the intervertebral disc in the lower back. So driving, especially for long periods of time, can contribute to your lower back problem. One simple way to mitigate this problem is to take short breaks between journeys. Likewise, those who sit at a desk for extended periods should get up and walk about after 30 to 60 minutes. Another simple measure is to make sure that your car seat is not too low. Raise the seat and add a lumbar support to help reduce the pressure on your lower back and relieve your pain symptoms. Dr Guo Chang Ming, Senior Consultant, Department of Orthopaedic Surgery, Singapore General Hospital
dots followed quickly by the appearance of cobwebs in your vision (this indicates bleeding), it is the result of tearing and bleeding of the retina. In another scenario, a big black “curtain” can cover vision in the affected eye. This is a sign of retinal detachment. In both instances, please go to a hospital emergency department immediately. Dr Wang Jenn Chyuan, Senior Consultant, General Cataract & Comprehensive Ophthalmology Service, Singapore National Eye Centre
I suffer from asthma and need to use an inhaler every day and night. Can I train to be a sportsman? How long can I exercise without getting an asthma attack? I am in primary school. Exercise regularly as long as your asthma is well controlled. Increase your fitness by exercising regularly. There are many examples of sportsmen who are asthmatics. World record-breaking English marathoner Paula Radcliffe has had asthma since the age of 14, while England midfielder Paul Scholes was diagnosed with asthma when he was 21 years old, yet he went on to help Manchester United clinch a Premiership. Swimming and water sports are recommended exercises for asthmatics. Avoid jogging and running in open areas during periods of haze to avoid aggravating your asthma. Exercise-induced asthma often suggests that the asthma is not adequately controlled. Appropriate anti-inflammatory (controller) therapy can help reduce exercise-related symptoms. If you have exercise-induced asthma, you should use a reliever (for example, a salbutamol inhaler) 15 minutes before exercising, in addition to your regular controller medication. Always warm up by doing 15-20 minutes of light exercise and stretching before any sport or exercise to lower the incidence and severity of exercise-induced asthma. Dr Tan Keng Leong, Senior Consultant, Department of Respiratory and Critical Care Medicine, Singapore General Hospital
These articles are from www.healthxchange.com.sg, Singapore’s first interactive health and lifestyle portal.
Please visit our website listed above to see the topics for discussion in Jul-Aug 2014.
23/6/14 3:59 PM
jul– aug 2014
singapore health
Opinion
17
“Excuse me, auntie, we are medical students. May we…?” Nurturing respect and empathy between patients and doctors is vital to ensure patients continue voluntarily to take part in medical education By Associate Professor Chin Jing Jih
M
edical schools in Singapore and Malaysia are facing challenges finding adequate clinical materials involving real patients for teaching and examinations. This is largely due to two developments in the health care landscape. First, patients with clinical features suitable for teaching and training are becoming increasingly scarce. Many once-common physical signs, like heart murmurs and severely deformed joints, are fast diminishing as a result of successful prevention programmes, and wider and earlier access to treatments. This is good for patients and society, but poses difficulties for a learning model that requires direct observation and interaction with patients with actual symptoms. Second, patients are increasingly reluctant to participate in medical education. While most are amenable when asked, many complain of “fatigue” from repeated rounds of history-giving and physical examinations purely to benefit students and trainees.
Patients should not be seen merely as providers of suitable clinical materials, but as part of the education and training faculty. Patients are also more aware of their rights and know they can say “no” to the requests of medical students. Right or obligation? Do patients have a right to decline participation in the medical education and training of future doctors, when they themselves are likely to have been beneficiaries of well-trained, competent doctors? It would be difficult, legally and professionally, to mandate patients to participate in a teaching programme as the laws on individual privacy rights and the right to be left alone will prevail. What is an appropriate balance between protecting patients’ right to privacy and well-being, and producing well-trained, competent doctors? For a start, medical teachers and
17 OPINION_Medical students_V2.abx_R.indd 17
students must ensure that educational activities do not harm patients, and set reasonable limits to achieve this. Patients must not be coerced into agreeing to be “clinical training materials”, but they do have a moral obligation – distinct from legal compulsion – to help sharpen the clinical skills of future doctors. The reality is that only patients with relevant diseases can provide future doctors with the experiential training to hone their clinical skills. Many teaching hospitals in other countries notify their patients that by choosing to have treatment at a teaching hospital, they benefit from the school’s excellent academic activities and cutting-edge medicine. They should, therefore, be willing to assist in clinical training, with consent for medical education implied. Some have argued that in Singapore, only subsidised patients should be obliged to assist in clinical training while the right to refuse is a privilege reserved exclusively for private patients.
I disagree as the obligation towards clinical education does not stem from a patient’s inability to pay for extra, non-clinical comforts and frills. Easing volunteer shortage The development and use of simulation has helped ease the shortage of real clinical material in medical education. Simulation using dummies or actors provides a legally-protected, highly-realistic, more predictable, and more controlled learning environment for medical students. But the predictability of simulation means that medical students will never have the chance to face the hundred and one unexpected scenarios that can arise when dealing with a real patient, and learn how to respond appropriately. Simulation may reduce patient risk and a reliance on patient cooperation in medical education, but it can never completely replace interaction with real patients. Patients should not be seen merely as providers of suitable clinical materials, but as part of the education and train-
ing faculty. Medical teaching institutions need to devote resources and attention to nurturing a relationship of empathy and respect so that patients feel valued as part of the medical education endeavour when they volunteer. An example of mutual respec t between patients and the medical community in medical education is the 18-year-old Silent Mentor programme at Taiwan’s Tzu Chi University. Before dissecting donors’ bodies to learn about the human anatomy or in simulated surgery, medical students and trainees visit the families of the deceased donors. They learn about the donors’ lives and get to know them as persons – a process that teaches the students to “respect the lives” of the donors. After dissection has concluded, the students hold a ceremony and respectfully suture the parts of their silent mentors together. At donors’ funerals, students publicly read letters of gratitude to their silent mentors and bow respectfully to pay their final respects. After cremation, the ashes of the donors are placed in specially-designed crystal urns in a reserved area of the columbarium at Tzu Chi’s medical faculty. The open respect shown by medical students in this programme has led to more people donating their bodies to medical education. Medical students, meanwhile, are enriched through the learning of important human and professional values like altruism, respect and empathy. Medicine is a noble profession. It is apt that the noble intentions of patients sustain the teaching and training of future doctors, and that future doctors reciprocate with respect and empathy. A strong partnership with our patients is critical to producing future generations of technically and ethically competent doctors.
This article is adapted from “Excuse me auntie, we are medical students. May we…?”, SMA News (February 2014). Associate Professor Chin Jing Jih is the President of the Singapore Medical Association and Senior Consultant in Geriatric Medicine at Tan Tock Seng Hospital (TTSH). He is also the Assistant Dean for Care Integration at the Lee Kong Chian School of Medicine at Nanyang Technological University, and the Director for TTSH’s Institute for Geriatrics and Active Aging.
20/6/14 1:29 PM
18
your say
singapore health
jul– aug 2014
Renewal of CHAS card Thank you for the excellent article about a new kidney transplant treatment plan at the Singapore General Hospital in the May-June issue of Singapore Health. I recently attended the wake of a friend, who underwent kidney dialysis for nine years and who eventually succumbed to complications. News of medical developments like this one about a new procedure for people with very high antibody levels (who would otherwise have difficulties finding a matching donor) offer fresh hope, especially for those who have been on waiting list for some time. Hopefully, the staggering number of people waiting for a transplant will be reduced substantially in time to come. Ms Joy Lim
This letter wins a box of Kyäni Sunset™ (30 packs) and a bottle of Kyäni Sunset™ (90 softgels). The products, worth $160, are sponsored by Kyäni Singapore Pte. Ltd.
Consider impact on premiums The article Health coverage: Are you overinsured? in the May-June issue of Singapore Health is very relevant for Singaporeans, with medical costs rising and people generally living longer. The tendency to buy many insurance policies is true, especially for people like me in our late twenties, when premiums are still affordable. But we forget to consider the longer term impact on our finances. Will we be able to continue paying the premiums on our insurance policies after retirement? Thanks for the informative article. Ms Poh Jia Yee
AIC
Submit an application form three months before the says CHAS card expires. The application form must include details of all family members living at the same NRIC-registered address. You must also attach all relevant supporting documents together with the application form. As of Jan 1 this year, there is no
I would like to compliment two nurses from the Singapore General Hospital (SGH) Ward 58, Enrolled Nurse Maziah Mohamed Bashir and Staff Nurse Fu Xiaoyun. They showed excellent care and concern for the patients they attended to and I feel that both have lived up to SGH’s values of compassion, integrity and collaboration. SGH is very fortunate to have both of them on staff. Well done! - Mr BW Lee
tributes
Hoping for shorter wait for kidney
How do I renew my parents’ Community Health Assist Scheme (CHAS) cards which are expiring? They live with me. Can I apply for a Health Assist card for my daughter as well?
I had a pleasant experience at SGH’s Department of Diagnostic Radiology, thanks to the professionalism of the staff – especially those at the registration and payment counters. Everyone was friendly and helpful. I had asked about a biopsy, and to my surprise, various people came to my assistance, including a radiologist who gave me a clear explanation of the procedure. Thank you SGH, and good job to your team of professionals! - Ms YB Chua I would like to compliment Dr Andrew Tay, Senior Consultant and Director, Department of Oral and Maxillofacial Surgery, National Dental Centre Singapore (NDCS), and his nurses. My son, a full-time national serviceman, had a terrible toothache and was in great pain. My wife called NDCS and was advised to bring him in. During consultation, we were told that his wisdom tooth was causing the pain and he needed an operation. Treating it as an emergency, the nurses contacted Dr Tay who skipped his lunch to do the operation. My son is well now. I really wish to express my gratitude to Dr Tay and the nurses who made my day. - Mr P Goh
longer an age criteria for CHAS. This means that you can apply for CHAS for the whole family if you meet the following criteria: Household monthly income per person of $1,800 and below; or Annual value of NRIC-registered residence is $21,000 and below for households with no income. CHAS enables you to receive subsidies for medical and dental care at participating GPs and dental clinics near your home. For more information about applying for financial assistance, visit www.chas.sg.
I wish to thank Adjunct Associate Professor Sharon Tow, Senior Consultant and Head, and Dr Deborah Tan, Registrar, both of the Singapore National Eye Centre’s Neuro-Ophthalmology Service, for their kindness and excellent service. I was there for a regular check-up by both doctors and the results indicated complications. Dr Tan patiently got more information from me. Dr Tow, who is experienced, knowledgeable and professional, immediately ordered a blood test. Her friendly and competent nurse, Staff Nurse Wee Bee Choo, arranged for my test at once and I got the results later that night. I was advised to seek immediate medical attention as my haemoglobin level was low. I told her that I was tired and preferred to rest and assured her I would go in the following day. The next day, I had an email and phone call, and an appointment fixed for a few days later at the Obstetrics & Gynaecology Centre for a repeat blood test. I was amazed at their remarkable passion and commitment, and how they make such extra effort for their patients. My sincere thanks to all. - Ms A Khoo I would like to commend the nurses of SGH Ward 64, where my mum was recently warded. The nurses, in particular Staff Nurse Faridah Abdul Majid, were very patient and professional. I witnessed several incidents where patients shouted at them and made unreasonable demands. Although they were clearly very busy, they took the complaints in their stride. I salute them for their professionalism and for taking good care of my mother. - Mr Hisham
about your health experience 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 of Heritage® American Ginseng (60 capsules). The product, worth $92.40, is sponsored by HST Medical, Singapore.
18 YOUR SAY V2.abx.indd 18
18/6/14 2:43 PM
jul– aug 2014
singapore health
your say
19
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20/6/14 1:34 PM
20
FYI
singapore health
jul– aug 2014
Young blood
event Calendar
▲
recharges old brains in mice study
Date July 19, Saturday Time 1.30pm-4.45pm (registration starts
at 1pm) VENUE KK Women’s and Children’s Hospital (KKH) Auditorium, Women’s Tower, Training Centre (Level 1) Fee $10 per person (tea will be provided) REGISTRATION Call 6394-5038 (MondayFriday, 8.30am-5.30pm) or log on to www.kkh.com.sg for more information or to sign up. Learn about fighting body flab, dental aesthetics, and looking after your skin during and after pregnancy. Suitable for expectant mothers and mothers.
Something in the blood of young mice can restore mental capabilities in old mice, American investigators have found. If the same goes for humans, it might mean new therapeutic approaches for treating dementia such as Alzheimer’s disease. “It was as if these old brains were recharged by young blood,” said Dr Tony Wyss-Coray, senior author of the study and a professor of neurology and neurological sciences at Stanford University. “There are factors present in blood from young mice that can recharge an old mouse’s brain so that it functions more like a younger one. We’re working intensively to find out what those factors might be and from exactly which tissues they originate.” Source: Stanford University
A study revealed that Wikipedia, the popular online encyclopaedia, contains errors in nine out of 10 of its health entries, and should be treated with caution. Scientists in the US compared entries with peer-reviewed medical research. The site’s openaccess nature has raised concern among doctors about its reliability. It can be edited by anybody, but many volunteers from the medical field check the pages for errors, said Wikimedia UK, its British arm. Source: BBC News
made survivors healthier repeated bouts of plague, shaped mortality patterns for generations. These findings have important implications for understanding emerging diseases and their impact on the health of individuals and populations today. “Knowing how strongly diseases can actually shape human biology can give us tools to work with in the future, to understand disease and how it might affect us,” said the study’s author, biological anthropologist Sharon DeWitte. Source: University of South Carolina
contest
1. Name one of the trial drugs used in the SGHSCDF trial to provide pain relief more quickly. 2. Which story in this issue did you find the most informative? Closing date: Aug 1, 2014 Send in your answers and stand to win a bottle of Spirulina 100% Extra 10% Deep Ocean Water (750 tablets) worth $59, sponsored by IMI Lifestyle Products Pte. Ltd., and a Buddie the Badger plush toy. Buddie, the National Cancer Centre Singapore (NCCS) mascot, is also on sale in aid of cancer charities at the NCCS Retail Pharmacy (Level 1).
20 FYI_Jul-Aug14_V3.abxx_R2.indd 20
6, Deck on 9 (Level 9)
FEE Free/ 免费 REGISTRATION Call Vieon at 9646-
4626 (Monday-Friday, 8.30am-5.30pm) or e-mail name and contact details to omulifesgh@gmail.com with “Public Forum” as the subject to sign up (first come first served). Find out about fad diets and meal plans, fat loss, whether surgery can cure diabetes at this public forum. It is in both English and Chinese.
12.45pm) FEE $25 per adult (KKJC member); $35 per adult (non-KKJC member) VENUE KKH Life Support Training Centre (Children’s Tower, Level 3) REGISTRATION Closes on July 4, Friday. Call 6394-1268 (Monday-Friday, 9am-5.30pm) or log on to www.kkh.com.sg for more information or to sign up. Every caregiver should know when and how to administer cardiopulmonary resuscitation (CPR) or relieve choking in a child or infant safely, quickly and effectively. Done correctly, these skills can save lives by restoring blood and airflow to vital organs until professional help arrives. This hands-on workshop is suitable for parents with children from one month to eight years old, but it is not recommended for expectant mothers.
First National Review of Asthma Deaths from the UK’s Royal College of Physicians (2014)
50% Did not have medical help during their final attack
33%
did not seek help
11% did not get help in time
Source: Royal College of Physicians (UK)
Include your name, age, gender, address and telephone number. Winners will be notified via phone or e-mail. Incomplete or multiple entries will not be considered. E-mail editor@sgh.com.sg Post The Editor, Singapore Health, Singapore General Hospital, Communications Department, #13-01 Surbana One, Blk 168, Jalan Bukit Merah, Singapore 150168 Winners of Contest 28: Each will receive a bottle of VitaHealth Resveratrol Lifecare (60 capsules) worth $78, sponsored by VitaHealth Asia Pacific (S) Pte Ltd. Prizes must be claimed by Aug 1, 2014. 1. John Chan 2. Choo Jia Yi 3. Kiong Choon Meng 4. Jean Tan 5. Tay Ah Moey
Child and Infant CPR Workshop DATE July 19, Saturday TIME 1pm-4pm (registration starts at
▲
The medieval Black Death or bubonic plague killed millions in Europe but those who survived enjoyed better health and longevity, new research has found. University of South Carolina researchers studied more than 1,000 skeletons of people who survived it, and found that it was not an indiscriminate killer – it targeted frail people of all ages. The study, released in the journal PLOS ONE, said survivors had improved health and many more lived into their 70s and 80s, compared to pre-Black Death populations. Their hardiness in enduring disease, including
People with asthma are dying needlessly because of complacency among patients and medical staff, and more must be done to save lives, according to the first National Review of Asthma Deaths from the UK’s Royal College of Physicians. The 2014 report investigated asthma deaths in the UK between February 2012 and January 2013. Dr Kevin Stewart, Clinical Director, Clinical Effectiveness and Evaluation Unit, Royal College of Physicians, said, “We haven’t paid enough attention to the importance of good routine asthma care by clinicians with the right training and experience, and the part that patients themselves play in this. Too often we have also been slow to detect signs of poor asthma control and slow to act when these have been present, with tragic consequences for some families. We can and we must do better.”
Too Fat Too Furious (肥胖是福?)
DATE July 19, 2014, Saturday TIME 1.30pm-5pm VENUE Singapore General Hospital, Block
▲
Black Death
Asthma still kills
▲
Consult your doc, not Wikipedia
Super Mummy: Gorgeous Body, Skin and Smile!
Optimising Your Fertility: What You Need To Know
DATE Aug 16, Saturday TIME 2pm-4.30pm (registration starts at
1.30pm) FEE $8 per single participant; $10 per couple. Refreshments provided. VENUE KKH Auditorium, Women’s Tower, Training Centre (Level 1) REGISTRATION Call 6394-5038 (MondayFriday, 8.30am-5.30pm) or log on to www.kkh.com.sg to find out more or to sign up (first come first served). Find out how to optimise your fertility potential, learn about advancements in fertility treatments, and much more. Visit www.singhealth.com.sg/events or the websites of respective institutions for any changes, more information, and other listings.
20/6/14 2:57 PM
jul– aug 2014
singapore health
21
YOUR GUIDE TO BETTER LIVING
In a constant state of
flux
Flu viruses are always mutating, creating new identities that are sometimes lethal. By Suki Lor
F
lu viruses are constantly mutating, and once in a while, big changes occur that create waves around the world. When that happens, masses of people are caught with little or no immunity against what is essentially a new influenza virus. Many fall sick and the effects may be severe. That is one reason why health authorities around the world, led by the World Health Organization, are constantly on guard, monitoring the continual changes that flu viruses undergo to make sure that the world is prepared in the event of a new virulent strain or virus emerging. “Relatively minor mutations are not an issue as people would have developed some immunity from previous flu episodes that can potentially cross-protect against them. But when there are bigger deviations, antibodies from previous seasonal influenza may not offer much protection,” said Dr Chan Kwai Peng, Senior Consultant and Head, Virology, Department of
Pathology, Singapore General Hospital. Flu causes a spectrum of disease ranging from mild to severe. Sometimes, it can cause complications and even death. The very young, the pregnant, the very old and the sickly are most at risk of developing complications, and vaccinations are often recommended for these groups of people. Vaccines are developed yearly because of the viruses’ changing profiles. Currently, the viruses circulating are two subtypes of the A virus – H3N2 and H1N1-2009 – and the B virus. The H1N1-2009 virus is the virus that caused a pandemic in 2009, and which has undergone minor mutations since, said Dr Chan. Flu viruses are basically of three types – A, B and C. Type A viruses are further sub-typed based on the two main proteins on the surface of the virus, called haemagglutinin (H) and neuraminidase (N). For example, an H1N1 virus refers to a flu A virus subtype with an H1 protein and an N1 protein. As 18 different H proteins and 11
ABcs – and H and N – of Flu viruses
Flu viruses are basically of three types – A, B and C. Type A viruses are further sub-typed based on the two main proteins on the surface of the virus called haemagglutinin (H) and neuraminidase (N). For example, an H1N1 virus refers to a flu A virus subtype with an H1 protein and an N1 protein.
different N proteins have been described, many different permutations of subtypes are possible, said Dr Chan. However, only three H subtypes and two N subtypes have been found to infect humans. “The other
watch the droplets
Flu viruses are transmitted when droplets dispelled by infected people while they cough, talk or sneeze are breathed in by or land on the mucous membranes of the eyes, noses or mouths of other people. Flu can also be passed on when a person touches surfaces contaminated by an infected person and then rubs his eyes or touches his nose or mouth.
subtypes are found in water fowl,” she added. Subtypes of the A virus can be further categorised into strains. Influenza type B viruses are classified under different strains, but are not divided into subtypes.
Who is at risk?
illustrations: heymans tho
from birds to pigs to men
21-22 HEALTH+ Flu Virus_V5.ab.indd 21
The H1N1-2009 virus that caused a pandemic is now a regular human flu virus and continues to circulate seasonally worldwide. It is made up of genetic pieces from four different flu viruses, according to the US government’s Centers for Disease Control and Prevention (CDC). These
are the North American swine influenza, North American avian influenza, human influenza, and swine influenza virus typically found in Asia and Europe. Pigs have long been considered a possible mixing vessel for flu viruses that originate within pigs, birds and humans.
In general, pregnant women, the very young and the elderly are more susceptible to developing complications from flu. The immune systems of small children are not fully developed, and the elderly face declining immunity. People of any age with chronic health problems such as lung diseases (eg asthma) or heart disease, as well as those with endocrine problems such as diabetes, are also more vulnerable, as are people with suppressed immune systems (eg transplant and HIV patients). In serious cases, hospitalisation is needed. > Continued on page 22
18/6/14 12:54 PM
22
singapore health
jul– aug 2014
> Continued from page 21
In a constant state of flux
Influenza type C infections tend to cause mild respiratory illnesses and are not monitored nor tracked closely, unlike types A and B, which are associated with annual outbreaks and epidemics, said Dr Chan. Flu epidemics, where big clusters of people are infected, occur often, she said. “When the flu spreads to many parts of the world at about the same time, then that’s a pandemic,” Dr Chan said. The latest flu pandemic, in 2009, was the first in decades. A new influenza A (H1N1) virus, very different from previous H1N1 viruses that had been circulating among humans, spread rapidly around the world after early outbreaks in North America in April 2009. The new bug – the H1N1-2009 virus – has continued to circulate, replacing the previous seasonal H1N1 flu which had been around since 1977. The 2009 H1N1 flu pandemic was relatively mild especially when compared with the H1N1 pandemic in 1918 when the estimated death toll worldwide ranged from 20 million to 100 million people. Dr Chan pointed out that fortunately, most cases of influenza are mild and don’t require medical care. But in others, serious complications can arise and turn fatal. Not everyone who gets infected falls sick, but if they do, they may experience symptoms like cough, fever, muscle ache, fatigue, malaise, headache and sore throat. “Typically, flu comes on suddenly and contrary to what people think,
a runny nose is not so common in flu. Sometimes, influenza can cause nausea, vomiting and diarrhoea, symptoms more common in children,” said Dr Chan.
Typically, flu comes on suddenly and contrary to what people think, a runny nose is not so common in flu. Sometimes, influenza can cause nausea, vomiting and diarrhoea, symptoms more common in children. Dr Chan Kwai Peng, Senior Consultant and Head, Virology, Department of Pathology, SGH
The most common complication from influenza is pneumonia caused either by the flu virus itself or by a superimposed bacterial infection, said Dr Chan. Apart from that, “there could be ear infection, sinus infection, other infection of the lower respiratory tract, and sometimes the heart or the brain may be affected.” Whether someone will succumb to a flu infection depends on several factors. If the quantity of virus infect-
Don't pass it on
Those at greater risk of developing complications from flu should get vaccinated annually, Dr Chan said. But everyone can play his part to stay healthy and prevent the spread of flu by • Avoiding close contact with people who are sick • Staying home and resting when sick, and avoiding contact with others • Coughing and sneezing into a piece of tissue paper, which should then be disposed of properly as trash. Wash hands after that • Wearing a mask to avoid spreading the virus • Washing hands with soap and water regularly, and if soap and water is not available, using alcohol-based hand rubs Not touching the eyes, nose or mouth with unclean hands • Regularly cleaning and disinfecting frequently touched sur• faces and objects • Refraining from visiting wet markets and coming into direct contact with live poultry if travelling in a country where avian flu has been reported to have been passed to humans Not touching poultry that is sick • Keeping tabs on advisories from the Government and the • World Health Organization on flu outbreaks
21-22 HEALTH+ Flu Virus_V5.ab.indd 22
ing it is high, the body may not be able to rid itself of the onslaught of the virus. Also, “if it is a very nasty virulent strain that is able to attach itself very readily to a lot of cells in my body, then I will fall sick. It also depends on my state of health,” Dr Chan said. “Most times, people recover from flu on their own. It’s selflimiting. If they are feeling bad, they can see a doctor. So what can a doctor do? There are specific antiviral agents available that target influenza, but the effects are best when the person goes to see the doctor within 48 hours of falling sick,” she added. Antiviral medication can shorten the duration of flu symptoms by one or two days at best. Moreover, such drugs are useless against other viral infections such as the common cold, which can show similar symptoms to flu. Nevertheless, people who are at higher risk of developing complications from flu might be prescribed antiviral drugs. Any other medicine prescribed for flu would be for symptomatic relief. While flu cases occur throughout the year in Singapore, Dr Chan cites two particular periods with increased flu activity. One is from May to July, and the other from November to January. Why there are more flu cases during these months is a mystery.
MERS on the rise
The number of people infected with the MERS-CoV (Middle East respiratory syndrome coronavirus) virus has seen a marked rise in recent months. While this is cause for concern, the disease has been confined mostly to countries on the Arabian Peninsula, and has not spread to the broader community nor has there been evidence of a change in the virus’s ability to spread. Little is known about MERS-CoV, how it is spread, where it originated, and how it is transmitted. What is known is that it belongs to a large family of viruses known as coronaviruses, that includes the common cold and SARS (severe acute respiratory syndrome), which caused some 800 deaths globally in 2003. According to the World Health Organization (WHO), this strain of coronavirus that causes MERS was first identified in 2012 in Saudi Arabia. Globally, 681 laboratory-confirmed cases of infection with MERS-CoV, including 204 related deaths, have officially been reported, the WHO said in a June 4 update. The majority of these cases were in Saudi Arabia. “Coronaviruses cause respiratory infections in humans and animals. Patients have presented with fever, cough and breathing difficulties,” said Dr Chan Kwai Peng, Senior Consultant and Head, Virology, Department of Pathology, Singapore General Hospital. MERS has caused pneumonia and even kidney failure, Dr Chan said, adding that most of the infected have been older men, often with other medical conditions. “Doctors do not yet know what the best treatment is, but people with severe symptoms will need intensive medical care to help them breathe. There is no vaccine to prevent infection,” she said. Most coronaviruses – the name comes from the crown-like spikes that cover their surfaces – usually infect only one animal species or, at most, a small number of closely related species. SARS was different as the virus was able to infect people and animals like monkeys, cats, dogs, and rodents. Some reports suggest that MERS may be linked to sick camels. “It may have been the result of a new mutation of an existing virus. Or it may be an infection that has been circulating in animals and has now made the jump to humans,” said Dr Chan. Without knowing the source of the MERS virus and its mode of transmission, no specific advice on preventing infection is available. Common sense dictates that contact with obviously sick animals should be avoided, and basic hygiene measures be observed, especially frequent hand washing and changing of clothes and shoes or boots, after handling animals or animal products.
18/6/14 12:54 PM
jul– aug 2014
Maybe Baby
Getting pregnant Sometimes, medication to stimulate ovulation, or surgery to treat endometriosis or unblock fallopian tubes, can help solve the problem. Doctors may recommend Assisted Reproductive Technology (ART), which may have a higher success rate, if these treatments fail. ART includes treatments such as IVF, Intra-Cytoplasmic Sperm Injection (ICSI), and Superovulation & Intrauterine Insemination (SOIUI). Each has its own risks and success rates. Dr Teo said KKH’s fertility treatment programme is comparable to those of most other developed countries. The average pregnancy rate for IVF or ICSI at KKH is more than 35 per cent, and 5 to 20 per cent for SOIUI. Getting pregnant depends on the woman’s age, her past history of pregnancy and childbirth, or failed attempts at ART, and her response to treatment. The outcome is also affected by the type and severity of the couple’s disorders and the ability to correct them.
photo: corbis
During In-Vitro Fertilisation, the eggs are retrieved from the woman and then fertilised in the lab with the partner’s sperm.
When to seek medical help? Mdm Tay and her husband are among many couples who seek help each year at KKH to conceive. But how long should a couple try on their own before seeking help? Dr Teo advises healthy couples to try on their
23 HEALTH+ Fertility v3.ab_R.indd 23
own for at least a year first. Those who need help early are women above 38, those with endometriosis (where the womb lining is outside the womb, causing pain), women who fail to ovulate and so have irregular menstrual cycles, and couples with known disorders that affect fertility. Common causes of female infertility are ovulation disorders, damaged or blocked fallopian tubes, and endometriosis. In men it is usually low sperm count, abnormality in sperm shape, or even
photos: Darren chang
M
Dr Steven Teo advises healthy couples to try on their own to conceive for at least a year before seeking medical help.
23
the total absence of sperm in the semen, resulting in the inability to fertilise any eggs.
When should couples, desperately trying for a baby, seek professional help? By Lediati Tan
dm Celeste Tay* and her husband had been married for five years before they considered having a child. By that time, she was 40 years old. They saw a fertility specialist who found that Mdm Tay had a blocked fallopian tube and reduced egg reserves due to a cyst removal done 10 years before. After consulting Dr Steven Teo, Consultant, Department of Reproductive Medicine, KK Women’s and Children’s Hospital (KKH), the couple decided to undergo In-Vitro Fertilisation (IVF). Treatment meant Mdm Tay had to have injections every morning for two weeks. Despite her fear of needles, she persisted, as she really wanted a child. Her husband was supportive and administered the injections. He also helped with the household chores and cooked special meals for her on weekends. They were disappointed when the first cycle of IVF failed, but delighted when the second one took. Mdm Tay became pregnant, and nine months later became the mother of a healthy baby boy. Her advice to other couples going down the same route: “Stay calm, relaxed and free from external pressures.”
singapore health
While the intention is to achieve a healthy baby, couples should know that the failure rate is high, and the physical and psychological stress experienced during therapy may be phenomenal for some. Dr Steven Teo, Consultant, Department of Reproductive Medicine, KKH
In Singapore, women under 45 who meet the clinical requirements for ART are eligible for treatment. At KKH, Singaporeans pay between $10,000 and $13,000 for a conventional IVF or ICSI cycle. Couples can use Medisave and also enjoy co-funding from the Government. Before opting for fertility treatment, a couple should be prepared for parenthood, have a stable relationship to withstand the stress of fertility treatment, and have realistic expectations. “While the intention is to achieve a healthy baby, couples should know that the failure rate is high, and the physical and psychological stress experienced during therapy may be phenomenal for some,” said Dr Teo. They must also be prepared to commit to treatment cycles which can range from four to eight weeks. They may have to return to the clinic as and when required, because in some instances, a difference of one to two days can affect the results. * Name of patient has been changed to protect her privacy.
In Singapore, women under 45 who meet the clinical requirements for Assisted Reproductive Technology, are eligible for treatment.
The treatments In-Vitro Fertilisation (IVF): Eggs are retrieved from the woman and then fertilised in the lab with her partner’s sperm. A partially grown embryo is then placed into the womb for pregnancy to occur. A successful pregnancy can be confirmed two weeks later. Intra-Cytoplasmic Sperm Injection (ICSI): A single sperm is injected into each mature egg that is retrieved from the woman. This technique is commonly used nowadays and it benefits couples with poor sperm quality. A resulting embryo is then placed in the womb, as described above in IVF. Superovulation & Intrauterine Insemination (SOIUI): The ovaries are stimulated with drugs with the aim of maturing two to three eggs. Prepared sperm is then placed directly into the womb when the eggs are ready and ovulation occurs.
The risks Treatment may be cancelled if the woman responds poorly. Those on IVF or ICSI may have few or no usable eggs for retrieval. Ovaries, artificially stimulated, can over-respond. Untreated, this may be potentially life-threatening. There is a higher chance of miscarriage and ectopic pregnancy (pregnancy outside the uterus). Egg extraction can be complicated by bowel, bladder and vascular injuries, or pelvic infection. There is a higher chance of multiple pregnancies and premature delivery.
23/6/14 7:08 PM
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singapore health
jul– Aug 2014
Falling asleep on the job
photo: TPG Images/CLICK PHOTOS
Nodding off at work even after a full night’s sleep can be a sign of narcolepsy, a chronic sleep disorder. There is no cure, but the condition can be brought under control and sufferers can go on to lead normal lives. By Karen Tee
Undiagnosed narcoleptic sufferers can face problems at work, with their sudden bouts of sleepiness often mistaken for laziness.
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shows up in the teens and early 20s. The exact cause of narcolepsy is not yet known, but doctors believe it might be linked to genes, virus attacks and head traumas. Besides excessive daytime sleepiness, sufferers may experience other symptoms including cataplexy (where intense emotion like laughter or anger or strenuous exercise triggers a loss of muscle control), sleep paralysis (where the person is unable to talk or move for brief periods when falling asleep or wakening), as well as hypnagogic halluci- * Name of patient has been changed to protect nations (where the person experiences her privacy. vivid dreams and sounds as he is about to fall asleep). Sufferers tend to be depressed, with According to obesity commonly seen in child sufferers. Dr WS Shahul To diagnose narcolepsy, the patient Hameed, a lack of awareness or must first undergo a detailed medical understanding history and physical examination, and of narcolepsy keep a sleep diary to rule out bad sleepmay lead many ing habits such as frequent late nights to think that they and insufficient sleep as the cause of are merely sleepy. his symptoms. This is followed by an overnight polysomnogram: the patient’s sleep is monitored in a hospital, and various bodily functions and indicators like breathing, blood oxygen levels, snoring and heart rate are taken through the night. A multiple sleep latency test is also photo: vernon wong
M
dm Christine Leong* often fell asleep at work. She did not stay up late, often went to bed early, and usually had a good night’s sleep. Yet, she was always feeling tired and sleepy during the day, often nodding off at her desk no matter how hard she tried not to. She decided to see a doctor, who ran some tests and found her to be suffering from narcolepsy. Narcolepsy is a sleep disorder characterised by overwhelming daytime drowsiness and sudden attacks of sleep which can seriously disrupt a sufferer’s work routine. Left untreated, it may even endanger the lives of the patient and those around him. Imagine a driver falling asleep while driving. There is no cure for narcolepsy, but with the right treatment and lifestyle changes, the condition can be kept in check, helping sufferers lead normal lives. Narcolepsy is estimated to affect 25 to 50 people in every 100,000, but this may be understated. A lack of awareness or understanding about this ailment may lead many to think that they are merely sleepy, said Dr WS Shahul Hameed, Consultant, Department of Neurology, National Neuroscience Institute (SGH Campus). The condition is equally common among men and women, and typically
performed to assess how easily the patient falls asleep in the day, and the type of sleep patterns produced during these bouts of sleep. As part of the treatment, a specialist may prescribe medication and lifestyle modifications to boost alertness and control symptoms. For example, a postlunch power nap can be a simple and effective way to keep daytime sleepiness in check. Dr Hameed said: “Health awareness is high in Singapore and bosses are generally understanding when their employees approach them (about their diagnoses). They often don’t have a problem with their employees taking a catnap during the day if that helps to manage the sleepiness caused by narcolepsy.” Undiagnosed narcoleptic sufferers can face problems at work, with their sudden bouts of sleepiness often mistaken for laziness, said Dr Hameed. However, once they have been diagnosed and receive treatment, the situation can change “dramatically” for the better, he added. For example, patients can take 20 to 30 minutes of their hourlong lunch break for a nap in a quiet spot in the office, before getting back to their daily responsibilities. Besides power naps, medication can be prescribed to help patients stay alert during long meetings. Dr Hameed recalled the case of a teenage patient whose cataplexic episodes caused problems at school. He prescribed medication to help keep her attacks under control. Patients can also cultivate lifestyle habits like keeping to a healthy regimen of sleeping seven to eight hours a night, not drinking excessively, and avoiding medication that causes drowsiness.
I'm not lazy Doctors commonly use this simple questionnaire to find out how sleepy their patients are during the day and whether they are likely to be suffering from narcolepsy or other sleep disorders. 0 = no chance of dozing 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing Situation
Chance of dozing
Sitting and reading
0 1 2 3
Watching TV
0 1 2 3
Sitting inactive in a public place (eg a theatre or a meeting)
0 1 2 3
As a passenger in a car for an hour without a break
0 1 2 3
Lying down to rest in the afternoon when circumstances permit
0 1 2 3
Sitting and talking to someone
0 1 2 3
Sitting quietly after a lunch without alcohol
0 1 2 3
In a car, while stopped for a few minutes in traffic
0 1 2 3
Score (add up the numbers selected) 1-6: Gets enough sleep 7-8: Experiences a normal amount of sleepiness Above 9: Should seek help from a specialist to determine the cause of daytime sleepiness Source: The Epworth Sleepiness Scale
20/6/14 2:15 PM
Jul– AuG 2014
singapore health
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Wigs to the rescue T
he second time Ms Linda Ee, 63, cried during her cancer journey was when a nurse gently removed her headscarf and fitted a wig over her head. She stared at the mirror in amazement. No longer was she bald – but with shoulder-length, dark brown hair, and a fringe artfully swept to the side. She looked like she did three months ago, before she was diagnosed with breast cancer and before chemotherapy robbed her of her hair. Tears rolled down her cheeks. “The transformation was out of this world. One minute I had no hair, and then I had. The wig made such a huge difference,” recalled Ms Ee.
The service was so personal and the nurse was so caring and gentle, from the way she spoke to telling me how to handle the wig. I was very grateful.
over, but when she woke up one day with clumps of hair on her pillow, she was stunned. “Even though we were briefed by the cancer centre about hair loss and other possible side effects, nothing quite prepares you for when it happens. It was quite a shock,” she said. “You do feel vain after all, and you do hope that maybe you would be among the 99.9 per cent who would not lose their hair!” She stoically got used to her baldness, looking forward to the day when her hair would grow back, and relying on hats which she had knitted herself. Then she received an invitation to a formal wedding dinner. Soon after, Ms Ee spotted a poster on the Wig Bank at NCCS, and made an appointment at which she chose one out of four wigs, pre-selected for her based on her preferred hair length. “The experience that I had was completely unexpected. The service was so personal and the nurse was so caring and gentle, from the way she spoke to telling me how to handle the wig. I was very grateful.” Although Ms Ee eventually missed the dinner as she fell sick, she proudly wore
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For Ms Linda Ee who suffered hair loss during her chemotherapy, stumbling across NCCS’ Wig Bank was one of the brighter moments in the typically arduous journey of a cancer patient.
the wig to several church outings. “Those who saw me said I looked so nice! And it was very comfortable and not at all irritating. I felt like I was wearing one of my hats.” The wig was also free, which made a huge difference to Ms Ee, who is single and is now based in Singapore as a fulltime volunteer. “I could not have afforded to buy a wig which would have cost me several hundred dollars. The Wig Bank is therefore a fantastic idea for people who cannot afford wigs or who only need a wig for a short time,” she said.
ms LindA Ee, cancer survivor
A boon to cancer patients For Ms Ee, stumbling across the National Cancer Centre Singapore’s (NCCS) Wig Bank was one of the brighter moments in the typically arduous journey of a cancer patient. Having lived in Thailand for 31 years, working as a project coordinator for a freelance author, she discovered a 3cm lump in her breast while soaping herself in the shower in 2012. She hurried back to Singapore, was diagnosed with Stage 2 breast cancer, and had a mastectomy soon after. The first time she cried was when the appointment for surgery was made. “It was the first time I felt sad, for I realised that I was really going to lose a breast.” Like many cancer patients, her ordeal did not end with surgery. Chemotherapy was trying. She underwent four three-weekly cycles of chemotherapy between mid-July and mid-September, experiencing almost every possible side effect including nausea, dizziness and mouth sores. Two weeks in, she lost her hair. It was a loss she did not think she would cry
photos: Alecia Neo
A Wig Bank, run by the National Cancer Centre Singapore, has been bringing joy to cancer patients since 1998. By Wong Sher Maine
Senior Staff Nurse Serene Goh, who is in charge of the Wig Bank, hopes that more cancer patients will make use of this free service.
Donate or borrow a wig If you have a wig to donate, drop it into the box (pictured) at NCCS Level 3, Ambulatory Treatment Unit. If you want to borrow a wig, call 6225-5655.
About the Wig Bank Started by NCCS in 1998, the Wig Bank is a collection of donated wigs which are loaned out to cancer patients suffering hair loss in the course of chemo therapy. Each month, bet ween eight to 10 wigs are loaned out . It is a boon to patient s who cannot afford to buy wigs, which can cost from $250 to about $1,000 depending
on the length and quality of the hair. A handful of male cancer patients, too, have asked for wigs, although they have had to make do with short female styles because there are no male wigs in the collection. Patients can keep the wigs for as long as they are required. Some never return them. It is up to the patients to wash the wigs, although nurses do a basic conditioning regime when wigs are returned. Senior Staff Nurse Serene Goh, who is in charge of the Wig Bank, hopes that more cancer patients will make use of this free service. “It could be that they are not aware of it, or have misconceptions that wigs look unnatural or are hot and uncomfortable to wear,” she said. “These days, even synthetic wigs are very authentic and easy to don. We do receive some pre-used wig donations, some of which are even made with real human hair. “At the end of the day, after every wig fitting session, it is the smiles on patients’ faces that keep us going. Most patients find that the wigs give them more confidence to face others and themselves in the mirror, which is important during this trying period. We are glad to be able to support them in their fight against cancer.”
20/6/14 2:29 PM
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singapore health
Jul– AuG 2014
Pulat Yunusmetov MDIS Student (2014)
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18/6/14 12:32 PM
2014 年7– 8月刊
新加坡中央医院与新加坡保健服务集团的双月刊
快捷、急缓、止痛! 原文 Sol E Solomon
车
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儿童和孕妇不可 参与研究计划
新加坡中央医院和新加坡民防部队尝试使用两种止痛药，以更 迅速地为严重受伤的伤者减轻痛苦。
这项研究计划是要评估甲氧氟烷 和曲马多是否适合用来替代笑气， 作为比较便于携带的急性疼痛治 疗药物。不是所有人士都可参与 计划。 首先，16岁以下的儿童、孕妇 和 正在 喂 养 母 乳 的 女 性 都 不 可 参 加 研 究 。这 不 是 因 为 试 验 药 物不安全，而是因为研究计划的 道德委员会的其中一项要求是首 先确认试用药物在简单直接的严 重创伤个案中是否有效。 新 加 坡 民 防 部 队 医 疗总 监 黄 毅 莹 医 生 说 ，已 受 过 训 练 在 意外现场为伤者做好医疗记录和 评估其状况的救护人员，将会额外 询问伤者关于以上条件的问题。 如果伤者符合下列条件，救护 人员将为他们提供试验药物： • 经历急性疼痛，形容疼痛程度 为3或以上（10为最严重的疼痛） • 承受着肌肉骨骼创伤（手臂、背 部或腿部受伤） • 神志清醒 • 身体情况稳定，血压正常 • 年龄为16岁以上
PhotoS: tan wei te
辆停顿，人群围观，救护 车已在 第一时间到 达车 祸现场，救护人员试着把 伤者从撞毁的车子里救出。救护人 员当下应该得先给伤者一种俗称笑 气的一氧化二氮气体（Entonox）， 让伤者暂时失去 痛觉 从而止 痛。 可是 往 往碍于笑气储 罐的体 积 大 和 环 境限制，面 对 伤 者 的 痛 楚 却 心有余而力不足，无法为他们减轻 疼痛。 这种情况在意外现场是非常普 遍的。新加坡中央医院急症科高级 顾 问医 生 王 英 福 副 教 授 说，当伤 者被救护人员从“车祸残骸中救出 时，他很可能承受着断肢、骨折等创 伤，正是最需要止痛药的时候。” 为了解决在急救上的不足， 新加坡中央医院和新加坡民防 部队联手进行一项研究，以评 估另外两种止痛药—甲氧氟烷 （商用名称为Penthrox）和曲马多 （Tramadol）的效用和适用性。 目前，笑气是标准药物。 这项 研 究计划的主要 研 究者 王 教 授 说 ：“ 如 果 甲 氧 氟 烷 或 曲马多被证实能够在送院前发挥功 效，救护人员将能够比现在更有效 地为伤者及早止痛。” 从2月起，负责处理9 95紧急热 线求助个案的30辆新加坡民防部队 救护车内，除了备有笑气之外，也备 有甲氧氟烷或曲马多，以便为伤者 及早止痛。与笑气相比，这两种试用 药物更容易使用。甲氧氟烷是通过 一个掌心般大小的吸入器来传送， 曲马多则是一种注射剂。 由于体积小，易于携带，救护人 员可以预先把它们放进装置紧急设 备的袋子里，一次过把所有用品带 到现场。以这点来说，笑气储罐一 般都不会与紧急设备一同被带到意 外现场，而是在救护车上使用，或由 救护人员再次送到现场。 对于救护人员来说，拯救伤者的 生命是首要任务。王教授说，一旦伤 者的情况稳定下来，生命不再有危 险， “下个步骤就是改善伤者的情 况，而其中一环就是缓解疼痛。” 除了人道原因之外，控制痛楚 的重要性在于可以预防病情或伤势 恶化，并让医疗人员做好入院前的 检查。 这项研究计划将为期一年，以 招募400名伤者为目标。参与计划 的救护队伍将被分成两组，并在
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甲氧氟烷是通过一个掌心般大小的吸入器来传送，能够在一瞬间缓解疼 痛。伤者能控制吸入的剂量，当他不再感到疼痛时，可立即停止吸入。
六个月期间带备两种试验药物之一 出动。此后，两组救护队伍将互相 对换所带备的试验药物，并展开另 一段六个月的试验。在计划期间， 这些救护车还是会带备笑气，以照 顾不适合使用甲氧氟烷或曲马多的 人士的需要。 甲氧氟烷能够在一瞬间缓解疼 痛。伤者能控制吸入的剂量，当他 不 再 感 到 疼 痛 时，可立 即 停止吸 入。一瓶3毫升的甲氧氟 烷可缓解 疼痛20至25分钟。如有需要，伤者 可使用第二瓶甲氧氟烷，以延长止 痛时间到大约50至55分钟。 王 教 授 说 ，在 过 去 2 0 年 来 ， 澳洲一直都有使用甲氧氟烷作救护 用途。新加坡的救护车服务将会是 澳洲以外的第一个组织，去研究这 种药物的用途。 曲马多是一种效用很强的注射 止痛剂。新加坡的所有急诊部都常 用它来为病人止痛，但本地的救护 车在此以前并无使用这种药物。一
剂50毫克的曲马多足以为病人止痛 4至6个小时。 为评估两种试验药物的效用，医 护人员将询问伤者他们所感受到的 疼痛程度（从1到10，以10表示最严 重的疼痛），试验药物发挥效用的所 需时间，以及他们对于止痛治疗和 使用吸入器或注射剂的满意程度。 参与研究计划的医院急诊部和 救伤车的医护人员都将提供反馈。 负责施用止痛药的救护人员将会反 映他们在使用替代治疗时的满意程 度，以及伤者在用药后有否出现副 作用。 两种试用药物各有优点和缺 点。举例说，曲马多是一种效用很 强的止痛剂，但它不像吗啡一样是 受法律管制的药物，因此在使用之 前无需通过冗长的安全协议审查。 不过，王教授说，由于它是注射 剂，因此在准备至使用药物之间， 会有关于注射针、其他伤势和污染 的风险。
如果病人有下列特征，他们将 不可参与研究： • 怀有身孕或正在喂养母乳 • 头部严重受创或昏昏欲睡 • 处 于 毒 品 或 酒 精 中 毒 状 态 ； 因为这可能会与试验药物产生 作用，导致效果加强 • 可能因慢性疼痛而正服药 • 有腹痛或胸痛 • 是肾病或肝疾患者；因为他们 不可使用甲氧氟烷 • 对试用药物过敏 • 正在服用某些抗生素 • 对止痛药过敏 • 曾经痉挛发作 • 正在服用抗抑郁剂
新加坡中央医院急症科高级 顾问医生 王英福副教授(右)解释道，与笑气相比， 该研究的两种试用止痛药更容易使用。 这是碍于笑气储 罐的体 积 大和环 境 限制。
18/6/14 12:25 PM
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新闻
2014 年7– 8月刊
当身体成为 它自己的敌人
免疫系统防御细菌伤害身体，有时也会将身体误认为“敌人”而伤害身体
图：winston chuang
刘医生说，症状有可能在明示其他 潜在疾病，因此从典型症状表现模式 来识别自体免疫疾病是确诊关键，她补 充说，为患者及其病历进行详细检查 也非常重要。 她说： “每个细节都要彻底调查，犹 如侦查工作一样。” 然而，一些自体免疫疾病也会危及 生命。像狼疮，就是一种可以影响身体 的任何部位，殃及各种组织的自体免疫 疾病。譬如说疫病影响到肾脏或导致 肺出血，患者就可能会有生命危害。 自体免疫病通常是以免疫抑制药物 来治疗。虽然它们能够抑制患者过于活 跃的免疫系统，但还是必须谨慎使用， 因为药物可能会削弱患者自身的免疫 力，提高感染的风险。 其实，情况并没有那么悲观。例如， 狼疮患者的10年生存率超过90%。 刘医生说道： “越早确诊就能越早 给予治疗，这样一来也能更好地控制病 情，防止或抢救已损伤的器官。
当一个人的免疫系统转而攻击其自己的身体时，自体免疫病就出现了。 刘秀玲医生力劝患者保持乐观态度，对控制病情有好处。
原文 Sol E Solomon
免
疫系统是我们身体的防 御 者，保 护 着 我 们，不 让“ 外 敌 ”如 病 毒 和 细 菌 等 侵 略伤害。可是，当身 体 本身受到自体 免疫疾病（autoimmune disorders） 的 困 扰 时，免 疫 系 统 便 会 视 身 体 为 “外敌”，向身体展开攻势。 新加坡中央医院关节炎与免疫科高 级顾问刘秀玲医生说： “最贴切的说法 就是把你的身体想像成爆发/发生内战 的国家一样。” 自体免疫疾病是一种相信是由某种 遗传或遗传缺陷因素，或某些环境的因 素如感染和病毒攻击、药物或化学物 质，导致体内引发疾病。 疾 病可以 影响身 体的 任 何 部分， 包 括 关 节 、皮 肤 、血 管、肺 部 和 内 脏 器 官 如 肾 脏 或 脑 部 。疾 病 种 类 超 过 8 0 种，以 风 湿 性 关 节炎、脊 柱 关节炎和狼疮是本地最为常见的自体 免疫疾病。
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由于受影响的部位各不相同，所以 出现的症状也会不同，譬如有些患者可 能会发烧或体重锐减的情况，有些则可 能会遭受皮疹或皮肤炎症的困扰。
综合性自体免疫中心 新加坡中央医院开设了一间自体免疫 与关节炎中心，为特定的自体免疫病患 者，诸如硬皮病、系统性红斑狼疮和风 湿性关节炎等提供综合医疗服务。该中 心也促进教学与研究，为研发新疗法和 改善患者护理出一分力。 由于需要接受长期的治疗，患者心 情难免会表现低落。刘医生说道，除了 定期复检之外，保持乐观的态度对控制 病情也有好处。 她还建议： “与朋友和家人一起建立 一个支持网络。再去结识其他患者，了 解该疾病，为自己打上强心针，无须对 疾病感到恐惧。”
怀孕是安全的 新加坡中央医院关节炎与免疫科高级顾问刘秀玲医生说，被诊断出患有 狼疮的女性还是可以做生育计划。 狼疮不会直接影响生育能力。刘医生指出，自己也曾遇过不少患者 成功怀孕生子，她们的孩子们也健康长大的例子。 “过去，我们会建议女性狼疮患者避孕，但现在我们可以通过生存 和管理疗法，建议患者如何在至少六个月内控制疾病，继而与他们的主 治医生一起安排生育计划。” 对于许多女性患者而言，关键在于确保在她们开始实施生育计划 前，他们的自体免疫病不会急性发作并攻击主要器官。 刘医生说： “我们将监测诸如肾脏功能等一些情况，并确保患者正确 服药。”
狼疮是什么？ 是本地最常见的自身免疫
疾病之一。 约30%的患者身上会出现典
型的蝴蝶状皮疹。 患者通常会有某种关节问
题，也会不时感到疲倦或患 超过一个月的间歇性发烧。 其他可能影响的部位包括心
脏、肺和肾脏。
硬皮病是什么？ 本地较少见的一种自体免疫
疾病。 影响部位有血管和身体的纤
维组织。 通常以皮肤硬化为首要特
征。若疾病攻击血管，手指 和脚趾会因血液循环不良而 呈蓝紫色或白色，皮肤会逐 渐出现溃疡，伤口也需要会 比平常更久的时间愈合。在 更严重的情况下，可能还会 开始坏疽。 另一种常见症状是手部肿
胀。皮肤变厚且变得十分紧 绷，手部看起来发亮。在某 些患者身上，关节会受到影 响，使手部难以（弯曲）活 动。 如果硬皮病影响到的是为
心脏、肺和肾脏供血的血 管，可能就会危及到患者的 生命。
女性更易于 患上此病
90% 超过
的狼疮患者是 年龄介于
20至40 岁之间的女性。
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2014 年7– 8月刊
健康
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向照护者伸出援助之手 照顾不能辨认家人或记住日常活动的病人对照护者而言是 很大的负担
每
天凌晨两点起床要吃早饭。 吃完了还要吃，对保姆大喊 大叫，指责其想饿死他。每 天要洗几次澡，原因是 他忘记自己已 经洗过了。 这 是 一 位 九十多岁 高 龄 老 年 痴 呆 症 患 者 的日常生 活 。痴 呆 症 是 一 种 失能 性 疾 病，其 特 征 包 括 进 行 性记忆丧失，尤其是记住新近事件的 能力。随着患者人格和行为的改变， 照 顾 一 个 痴 呆 症 病 人会 让 照护人 身 心疲惫，而他们通常是病患的配偶或 保姆。 “痴呆症对一个家庭的影响是 灾 难 性 的，有 如 失 去了一 位 成 员 。 病 患 可 能 不 再 认 识 亲 人，无 形 中 增 加了家 庭 的 痛 苦与 负 担 。病 患 还 可 能 产 生 幻觉，或 者 做 一 些 重 复性 的 机 械 动 作，导 致 病 患 和 照 护人 之 间 的 摩 擦 增 多，”新 加 坡 中 央 医 院 老 年病科主任 兼记忆门诊高级 顾问 医生萧俊才说。 “对于 像 患 上高血 压这些疾 病的 病人，护理人只需给他们喂药，等待药 物起作用便可。但是痴呆症影响着病 患多方面的生活，而良 好的照料与药 效一样不可或缺，甚至更为重要，”萧 医生说。
为照护者开设课程 很多人不了解要照顾一个痴呆症病患 和应付他的行为问题有多么困难。为了 协助照护人照顾痴呆症病人，老年病科 的记忆门诊从2011年7月份起为照护人 开设了一门为期六周的课程。目的是帮 助照护者了解痴呆症的病理、病程改变 情况、对病患的影响、以及如何应对令
人头痛的行为问题，例如不想洗澡， 吃饭或者病患出现幻觉。 这门课程也涉及到与痴呆症相关 的法 律 和 社 会问题。包括处 理 遗嘱 以 及明晰痴呆症患者家庭可 利用的 社区资源。 “当某人被诊断患有痴呆 症时，随即会出现众多个人、伦 理、 社会、职业和法律问题，”萧医生强 调说。 萧 医 生介 绍说：“此 课程 也 教 授 照护人照顾痴呆症病人的实用技巧， 例如如何预防患者跌倒。在学习过程 中，照护人也有机会畅谈自己的看法 并与其他照护人分享资讯和经验。 新加坡中央医院痴呆症临床 护理导师李惠敏说，在医院老年病门 诊看到痴呆症患者的照护人各个筋疲 力尽。根本无法持续一周七天、一天二 十四小时全天候工作。他们似乎对如 何应付病患的攻击性或不理智的行为 毫无头绪。 她 还说，一些病人教育手册可以 简要介绍病人的情况，但是通常不足 以帮助全职照护人处理可能出现的各 种问题。 参与这门课程的学员提供了大量正 面的反馈意见。很多人觉得此课程对 他们深入了解这种疾病和病患的行为 有很大帮助。 “这有助于他们更好的 照顾他们所爱的人，”李惠敏说。 目前，这门课程有中英双语教授。
新加坡中央医院老年病科主任兼记忆 门诊高级顾问医生萧俊才（右）和痴 呆症临床护理导师李惠敏（左）帮助 照护者了解老年痴呆症，以及如何应 付和照顾患者。
图：roger chua
原文 Stacey Chia
玩游戏保持大脑健康 能摸出麻将牌上刻的图案不仅仅是 玩这种中国游戏的一项特技。摸牌 上的字、在头脑中“看”其形状、然 后理解并记住其含义，这些都有助 于保持大脑灵敏健康，有利于延缓 因年龄增长而出现的多种大脑功能 减退趋势。 “大脑健康老化的定义与‘健康 老化’本身的定义几乎相同，”新加 坡中央医院老年病科主任兼记忆门 诊高级顾问医生萧俊才说。 “健康老化的人通常是那些对 自己的身体健康很重视的人，他们 致力于控制任何疾病，例如高血压 或糖尿病，并有活跃的社交生活。 同样，这些因素也有利于大脑的健 康老化过程，”萧医生补充道。
参与有益的游戏 大脑健康与日常生活休戚相关。一 项治疗记忆减退的方法表明，生物 因素、心理因素和社会因素在维持 人体功能和治疗疾病方面均起着重 要作用。 “从生物、心理和社会模式 来看，麻将是一种很好的游戏，因 为它囊括了所有这些有利因素，”萧 医生介绍说。 他还说： “从90年代开始积累的
数 据中最 新 现 象 显示，60岁以下 的 人 群 中 有 3%的 人 会出 现 某 种 类 型的 记忆 缺 陷，包 括 痴 呆 症 和 阿尔茨海默病。65岁人群的患病率 则升为5%，此后年龄每增加五岁则 患病率番倍，直至80岁以上的患病 率高达40%至45%。” 不仅 麻将有助于 保持大 脑健 康。其他游戏，例如数独游戏、下 棋、填字游戏以及越来越普遍的电 脑游戏，只要能刺激记忆、速度、 注意力、回忆和组织能力的都有助 于 延 缓 大 脑 功能 衰 退。当然也不 是所有游戏都能满足诉求。由于缺 乏监管和经医学界认可的标准，一 种游 戏到底多有用还 只是各人的 猜测。 麻将是亲友间的社 交活 动。这 种游戏将人们从家中吸引出来，参 与互动。萧医生强调说： “对于大脑 健康，社会交往不是生活中最重要 的部分，但也不可或缺。不合群的 人容易产生抑郁情绪。而当他们与 朋友和家人分享时光，兴高采烈的 心情有助于释放自己，心智和精神 便得到了滋养。” “抑郁是痴呆症的危险 诱发 因素。”
图：alecia Neo
排除痴呆症的可能性
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60岁时的大 脑功能远不 如20岁时。与后者相比， 前者的反应更慢，也不容 易记住事情。 不 过 ，这 是 衰 老 的 正常现 象，新 加 坡中央 医院 老年病科主任 兼 记忆门诊高级 顾问医生 萧 俊 才 说：“ 随 着 年 龄 增 加，在 处 理 信 息 、回
忆事情或进行有组织的 活 动时，头 脑的反 应会 减速。” “当头 脑 的 反 应 变 慢影响到我们的日常生 活时，才算是问题。”可 是，记忆力出现衰退时， 人们不能一致认为就是 患 上了痴 呆 症 。记 忆 力 丧失和其他类型的记忆
力减 退可能会有其他的 原 因，比 如 糖 尿 病 、未 控制的高血 压或甲状腺 疾病。 同时，老年人由于牙 齿不好，肉类和富含纤维 的蔬 菜 吃 得少，维 生素 如 维 生素 B12和叶 酸的 摄入不足，这些因素也可 导致记忆功能减退。
18/6/14 4:50 PM
30
焦点
2014 年7– 8月刊
你不是孑然独行
新加坡国立癌症中心鼻癌互助小组提供了药物无法寄予的帮助：倾听的耳朵、 随时伸出的援手和在有需要时可让你靠着哭泣的肩膀 度。 “如果他们没有与我分享，我可能 到现在还不知道呢。” 女儿的努力是值得的。沈先生在 确诊一年后第一次参加了小组聚会。 他的治疗效果相当不错，只是听力和 味蕾受到了些影响。“这个互助小组 让我们与癌症的战斗和康复之旅变 得轻松、快乐、温馨。没有它，我们 应该还在黑暗中摸索，”沈时玲感慨 的说。
学习和分享
图：alecia neo
其他组员也有类似的经历。44岁的税 务官 张 成 远 先 生 对自己 患有鼻 癌的 诊断郁郁寡欢。身为互助小组的组长
沈时玲（左）从互助小组听取有关营养方面的建议后为父亲（中）安排特 别的食谱。她与母亲（右）一同照顾患上了鼻癌的父亲。
沈
时玲女士在2011年3月，辞 去营销工作以帮忙照顾患上 了第4期鼻咽癌（鼻癌）的
父亲 。 39岁的沈时玲知道，对同样70岁高 龄、并患有糖尿病的母亲来说，要单独 照顾患病的父亲，每天陪 他去接受治 疗，并非易事。 “虽然很艰难，但他是我的爸爸，我 必须全力以赴，”她说道。 沈 时玲 全身心 投 入去了解这 种 癌 症。她加入了新加坡国立癌症中心的鼻 癌互助小组，这活动给了她和家人很大 的帮助。
同舟共济皆朋友 开始 时，由于父 亲病情严重，无法 参 加，她便独自前往，回到家中再与父亲 分享收获和心得。她意识到自己的情况 并不是唯一的案例，鼻癌患者众多，其 中还有很多病人经过治疗后都恢复了 健康。 “我了解了他们的做法和生还之道。 在此之前，我们对鼻癌知之甚少，只依 稀记得有一位远房亲戚曾得过。” 沈时玲积极听取有关营养方面的建 议，从而努力降低治疗的副作用。 “我 了解到芸香草有助于保护细胞，因 互助小组的组长和鼻癌幸存者张添才 先生说妻子是他的生活支柱。
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此我爸爸每天在化疗前都会喝芸香 草饮料。我还听说麦卢卡蜂蜜能减 轻电疗引起的喉咙痛，因此他也在 坚持服用。” 沈时玲每天必做的任务是去购买各 种食材，为父亲安排特别的食谱，以便 起到最佳辅助效果。 “确实辛苦，不过 效果显著。我爸爸化疗后不再那么难受 了，所以他就能坚持治疗。” 沈时玲还听说，在8至10年内，父亲 的面部肌肉会变得僵硬。因此他现在 就咨询言语治疗师，并透过一些简单的 锻炼从而尽量减缓肌肉硬化的发展速
和鼻癌幸存者张添才先生特为此上门 慰问。 “当时我很担心，不知所措，张添才 描述了整个治疗过程，还与我分享了他 与病魔战斗的经历。那晚是我确诊后第 一次能安稳的睡觉。这个小组令我受益 匪浅，最重要的是我不再感到孤独，” 张成远说。 互助小组在2005年成立时只有20名 成员，现在已达到了300名，几乎全部 都是幸存者和少数的照护者。小组还 不断收到来自其他医院、甚至海外的 问询。 “我们欢迎任何人的参与。目前小 组的成员不只是鼻癌患者，也有结肠 癌、淋巴瘤和头颈部癌的患者。他们来 这里是为了建立 联系和得到支持，” 张添才说。 张 添 才走 过了一段 坎 坷的 康复 之 路，他认为自己有责任帮助新病人，特 别是在接受电疗和化疗的期间，实在 难熬。 “我们小组的座右铭是：任何人 都不应该独自承受癌症。” 他还说： “这是一个真正的互助小 组。这里有温暖、承诺、资讯、支持
病人互助小组 新加坡国家心脏中心 (只对其病人开放) 心血管康复病人互助小组 护士长电话：6436-7603 心肺移植病人互助小组 移植协调员电话：6436-7635 电邮：transplant.office@nhcs.com.sg 心脏起搏器/ ICD 病人互助小组 心脏实验室经理电话：6436-7867 电邮：chiong.siau.chien@nhcs.com.sg 新加坡国立癌症中心 (对所有新加坡病人开放) 晚期及复发的癌症患者互助小组 鼻咽癌(鼻癌)互助小组 华语互助小组 马来语互助小组 肺病互助护理计划 从悲痛中恢复互助项目(逝世癌症 病人的配偶) 要联系不同的互助群体，请致电 6436-8126或6436-8117或发送电子 邮件至mss@nccs.com.sg。 竹脚妇幼医院 (向公众开放) 产前抑郁症互助小组 电话： 6394-2205(周一至周五上午 8时至下午5点30分)。 患者在加入之前必须接受评估 腭裂和颅面疾病互助小组 协调员Josephine Tan 电话：6394-5034或9100-3978 电邮：Josephine.Tan.CH@kkh.com.sg 临床护师 Aini Dahlan 电话：9180-0186 电邮：Aini.Dahlan@kkh.com.sg KK Alpine Blossoms 乳腺癌互助小组 电话：6394-5816 乳房护理护士电话：8121-7943
新加坡中央医院 乳腺癌互助小组 (对新加坡中央医院和新加坡国立 癌症中心的病人开放) 护士导师Saraswathi 电话：6321-4474 血液病互助小组 为慢性粒细胞白血病、多发性骨髓 瘤、地中海贫血、血友病和骨髓增 生异常综合征病人设立了独立的互 助小组。 致电6321-4722联系血液病中心的高 级护士长或临床护理导师，转接来 电到相应的小组。 截肢者互助小组 (对新加坡中央医院的病人开放) 护理导师Sivagame 电话：9842-8932 Chew护士长电话：8119-0398 中风俱乐部和早期痴呆症互助 小组 护士Diane 电话：9239-5907 电邮：theng.li.ping@sgh.com.sg 帕金森病互助小组 专科护理师Tan Siok Bee 电话：8125-3543 电邮：tan.siok.bee@sgh.com.sg 大肠癌互助小组 (对所有的大肠癌病人) Carol Loi 电话：6321-3615 电邮：carol.loi@sgh.com.sg 或 ong.choo.eng@sgh.com.sg 肿瘤互助小组 (对新加坡中央医院和新加坡国立 癌症中心的癌症病人开放) Aw Fung Chee 电话： 6321-4480 电邮：aw.fung.chee@sgh.com.sg Lee Teng Teng 电话： 6321-4482 电邮：lee.teng.teng@sgh.com.sg
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2014 年7– 8月刊
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和友谊。很多人都乐意付出。通常在 会议结束后，大家都会留下来继续谈 天、分享、开怀大笑，并安排单独或 小组聚会。” “当有新成员加入时，我们的一些 旧成员就会自发登门拜访。这已成为 一条不成文的规定。新成员常常会情 绪低落，他们需要的是鼓励和资讯。 鼻癌是最容易治疗的癌症之一，但治 疗过程会产生很多副作用，有的还可 能影响终身。因此，我们必须学会如 何照顾自己。与他们分享我们亲身的 经历会带给他们希望、勇气、自信， 更重要的是资讯，这样他们才不会感 到不知所措。”
(左) 互助小组成员赵顺明先生将自己学到的知识与新组员分享。(右) 新加坡国立癌症中心的鼻癌互助小组在2005年成立 时只有20名成员，现在已达到了300名，几乎全部都是幸存者和少数的照护者。
在患癌的初期，讨论的重 点是癌症康复后如何恢复 工作和生活。在晚期阶 段，讨论则多围绕生命的 意义、过程、生活目标和 如何生活的最好。 社会心理治疗师兼新加坡国立癌症中心 社会心理部病患支组联合主席 范锦棠博士
愿意伸出援助之手的成员包括赵顺 明先生。在他患上鼻癌时互助小组还未 成立。他只能在图书馆里孜孜探寻有关 鼻癌的知识。现在的他可以将自己学到 的知识与新组员分享。 “我们必须照顾 好自己，否则就有复发的危险。”他给 新组员的建议是每天清晨中做一些简 单的锻炼、控制饮食和保证充足的休息 和睡眠。 还有一位乐于助人的幸存者是预防 癌症协会的志愿者施宝树先生。他曾
经营一家小型汽车配件店，不过患上 癌症后就退休了。 “现在我的生活很平 静。作为癌症患者，我们践行三个原 则：接受(accept)、适应(adopt)和调 整(adjust)。遵守这三条原则，你就能 克服任何障碍。” 病人的照护者也会参加小组活动， 他们为患者鼓舞士气，并学习如何照顾 患病的家人。同时，他们也建议举办另 一个特别的时段来分享情感与心得，这 个建议正在计划中。 张添才说护理者，尤其是病人的妻 子，往往都会倾向于默默忍受。 “她必 须足够坚强以照顾好病人及子女，甚至 有时突然要承担起家里的经济重担。 她们往往不会向任何人抱怨，而是在浴 室里默默地哭泣。”
从注意营养到克服恐惧心理 在小组的聚会上常常会邀请医生和其 他医务人员来举办讲座。最受欢迎的题 目包括营养和如何克服恐惧和悲伤。
这些问题通常是不会，也没有时间在医 院诊室里进行讨论的。但在这里，医生 们会花上一个小时来讲解，病人还可以 进行发问。 还有一些常见的话题，例如怎样面 对癌症复发和如何应付死亡带来的恐 惧，范锦棠博士介绍说。范博士是一 名社会心理治疗师，也是新加坡国立 癌症中心的社会心理部病患支组的联 合主席。 “在患癌的初期，讨论的重点是癌 症康复后如何恢复工作和生活。在晚 期阶段，讨论则多围绕生命的意义、过 程、生活目标和如何生活的最好。减轻 痛苦的方式也是所有小组共同探讨的 话题。因为要接纳一种终末期疾病并 非易事。有些病人不在乎死亡，但难于 接受痛苦的疗程或残疾的结果。” 范 博士说。 他还指出，每位患者在被确诊的时 刻都面临死亡这个问题。 “在康复后， 此威胁便暂时不存在了。但是他们又会
时刻担心复发的可能。在癌症晚期，死 亡阴影挥之不去。时时刻刻都在谈死亡 的话题，在聚会上、私人谈话时间、与 社会工作者面对面时的交流，这都是宣 泄的方式。” 范博士说，当病人谈到死亡时，通常 会涉及自己的愿望，就好 像是回顾生 活经历。他们想如何死去，如何度过余 生，还没有取得的成就，未实现的愿望 以及令他们抱憾的事情等等。 “那些知道自己时日不多的病人不 愿意数着天数过日子。多数人想尽量把 生活过得最好。很多人能勇敢的面对死 神的到来。病人的家属告诉我们说，与 病人最初被确诊时的情况相比，他们 在这个阶段反而减少了哀伤，过的更开 心。”
欲 知新加 坡国立 癌症中心鼻 咽癌互 助小组的详 情，请上网：www.healthxchange.com.sg/aboutus/ Pages/NPC-Online-Support-Group.aspx
意见箱
为什么账单不一样？ 在入院动手术前，医院给了我 手术估价单。但出院后收到的 账单数目却不一样。为什么最 终结帐单与估计账单出现那么 大的差异？ 竹脚妇幼医院答复： 每一个病 人在住院前都必须接受简短的医药 费辅导。这是所有医院都必须提供 的服务。目的是帮助病人更好地了 解住院收费。 院方会根据病人所需要进行的 手术或疗程给予适当的财务辅导， 告知病人他们所选择的病房等级的 估计住院费用。该信息是以相同情 况或类似程序的账单，取其历史数
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不看医生只买药，可以吗？ 据中的平均数计算出来的。 由于每个病人的情况不同，所 以最后结帐时的数目可能因疗程不 同，用药，以及住院时间的长短各 异而有所区别。 病人应作出谨慎的财务计划，在 衡量自己的经济能力、住院等级、 所需定金和保健储蓄结存或其他保 险配套后，作出适当的选择。
综合诊疗所的医生给我开了 些治疗胃痛和胃抽筋的 药。如今药虽吃完了， 但胃痛仍持续着。我 想索取同样的药，却 又不想花时间去看医 生。反正都是一样的疾 病，为什么非要看了医生 才可以配药？我是否可以凭药物 包装袋直接到药房柜台配药吗？ 新加坡保健服务集团综合诊疗所 答复：与医生会诊是为了重新评估您 的病况，并根据您当前的健康条件， 调整您的治疗计划和药物处方。所以 没有医生处方，我们就无法为病人 配药。 这个程序是依据新加坡医药法规及
道德准则理事会的管制下实行的。然 而，一般的成药还是可以在零售药房 购买，不需要医生处方。 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 会在这个栏目里解答您的问题。
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2014 年7– 8月刊
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