A laminated sign points to the screening centre at National Centre for Infectious Diseases (NCID) at Tan Tock Seng hospital. (Photo: AndersSlagaLarson)
This article will not add to the emotionally fraught debate over the situation of foreign workers (FW) during the COVID-19 crisis in Singapore. Instead, we share our thoughts about how this evolving pandemic, exacerbated by the unfortunate clustering in foreign workers’ dormitories (FWD), have and will impact our work as specialists in public hospitals.
In dealing with COVID-19, Singapore’s healthcare sector had the advantage of preparedness that resulted from the SARS epidemic in 2003 and subsequently, H1N1 and MERS-COV. The lead time we had afforded little comfort but added greater urgency as a result of instantaneous media reporting of situations abroad, first in China, then Italy, UK and US. In many hard-hit countries, an unprecedented numbers of infected patients admitted to hospitals overwhelmed health services. It also thrust into the spotlight the plight of healthcare workers who faced the dual nightmares of taking indescribable personal risks as a result of a shortage of personal protective equipment (PPE) as well as their inability to offer potentially life-saving treatment to critically ill patients from a shortage of ventilators.
The outbreak amongst foreign workers (FW) living in dormitories across Singapore is undoubtedly a massive and unprecedented public health, infection control and epidemiological predicament acutely thrust upon the healthcare sector. The scale of the problem is highlighted by the sheer number of residents in these dormitories – about 300 000 of them with various stages of the disease: infected with no or mild symptoms, coexisting with the healthy, thereby posing a threat of infecting these uninfected dormitory mates.
The nation’s health services’ preparedness and capacity in terms of manpower, medical equipment, drugs, laboratory facilities, hospital beds and isolation facilities are currently put to the test with the daily tally of infections. The stressed vital health resources meant for the country’s nationals have been diverted, in no small measure, to care for this sizeable group of residents.
Managing hospital resources during COVID-19
As health service providers, we can confidently state that our healthcare sector, under the leadership of the Ministry of Health, is well prepared to manage the COVID-19 infections on all fronts, despite mounting strain from the new outbreaks.
The activation of DORSCON Orange in early February had resulted in a well-rehearsed implementation of workflows, namely workforce segregation, to ensure continuity in the event some staff needed to be quarantined or worse, were infected. This is vital for the survival of the entire health services sector because of the potential devastation to manpower.
In the operating theatres where we work as anaesthetists, routine surgery is being curtailed, except for time-sensitive surgery such as cancer work and emergencies. This allowed for staff to help in areas of greater needs, such as in the Emergency Department (ED) where suspected patients (and contacts of infected patients) come in droves to ascertain disease status. The corresponding reduction in routine laboratory tests that would otherwise be needed for elective surgery also allow the laboratories to focus on COVID-19 testing.
Importantly, the whittling down of electives reduces consumption of N95 respirators, gowns, gloves and masks, of which the world is facing a shortage. These are needed for frontline staff manning Intensive Care Units (ICU), COVID-19 wards, ED, and now, being involved in dormitory work. Curtailing elective surgery help conserve drugs needed for ICU patients. This is in the light of availability of drugs already showing signs of strain due to the global shutdown of factories and logistics. However, our less visible but absolutely essential purchasers, procurers and pharmacists work ceaselessly to secure adequate supplies.
With the extended ‘circuit breaker’ put in place till 1 June 2020, more elective surgery will be delayed, but we are confident Singaporeans will have no ungenerous thoughts that this is consequent to the ongoing cases in FDW dormitories.
Clinical and epidemiological studies have shown that about 5% or more, of infected patients may require ICU care and ventilator support. Hence, with increasing numbers infected, we are prepared for a corresponding increase in patients needing ICU care.
We see the fruition of years of contingency planning that detailed workflows and mapped out capacity and importantly, evaluating and procuring suitable ventilator models. All this give us the confidence and assurance of being able to render quality and appropriate care.
The battle for scarce resources
Our surge planning and experiences with our leadership allay any concerns that we may need scarves or trash bags to protect ourselves, or worse, deny any patient life-saving therapy from a lack of life-sustaining equipment.
However, if such rationing was needed, which approach would be optimal: an egalitarian approach where every patient has an equal chance to limited resources, or an utilitarian approach where scarce resources go to patients with the best chances of good outcomes or with more future years? This may need to be battled over.
The same approach will be required with the rationing of extracorporeal membrane oxygentation (ECMO) when ventilation fails, dialysis machines as well as decisions about withdrawing care for those patients who are unlikely to survive, so that resources can benefit other patients.
These are not battles new to intensivists. They are fought daily as ICU beds are scarce. Intensivists prioritise care based on needs, not who the patients are or where they are from. These decisions are transparent, consistent and guidelines-driven so that patients receive fair and proportionate treatment.
Moreover, in these exceptional times, we trust we will be further guided by well-argued statutory and clinical directives that will remove any distress over rationing decisions so that we can focus on our beleagued ICU.
Dormitories: the new COVID-19 frontline in Singapore
The frontline against COVID-19 has moved. Once confined to the ED, ICU and COVID-19 wards, this has now shifted to dormitories and temporary accommodations housing FW. Here, the hospital’s comforting sense of familiarity is noticeably absent. Work in these locations include handling cough and sneeze-inducing COVID-19 swabs that put procedurists at risk, performing blood tests and caring for the residents. Care here are of the same standards accorded to any other patients. This is the spirit of medicine at its best, exemplified by inclusiveness and indifference to who the patients are.
Health personnel safety is vital, enabled by the reassuring availability of PPE, though misuse is understandably frowned upon. These mobile teams work under sometimes sweltering conditions, dressed in stifling PPE. This has not dampened the availability and indomitable spirit of many volunteers who converge in teams to help the containment effort, demonstrating an overwhelming sense of duty.
As long as there are resources available for us, our healthcare workforce will forge on, resolved to see us through this pandemic, and certainly not at the expense of a Pyrrhic victory.
This sense of appropriate bravado is not groundless. The confidence is grounded in transparency, disclosure and doing the right thing, at all levels. The daily routine instructions sent out to each staff are distilled from decision-making by teams of leaders and they invariably include clear instructions on self-care and personal protection. Access to our CEO and department heads is unfettered. If we falter, we know we will be supported. This unifies our common purpose despite our disparate roles, some of which are invisible to the public but yet so indispensible for the functioning of our entire health ecosystem.
Finally, we posit that especially under these current adverse circumstances, Beauchamp and Childress’ pillars of medical ethics (autonomy, beneficence, non-maleficence and justice) have never stood out clearer as beacons to guide health providers in our medical decisions.