Presentation Summary

Mr. Melvin See  Partner, Dentons Rodyk

Legal Implications of Telemedicine

There are four aspects of telemedicine from the Ministry of Health's perspective.

The first is Telecollaboration, and this is where healthcare professionals collaborate across time and space, across distances about clinical care. The next is Telemonitoring, which is monitoring a patient's vitals and parameters remotely using the equipment. Telesupport refers to the nonclinical care, education, and admin of patients and their caregivers. Finally, Teleconsult, where a doctor or a health care professional, directly collaborates with the patient using technology.

The current pandemic has increased general interest among people about telemedicine. Telemedicine is well regulated by existing standards. In 2015, the National Telemedicine Guidelines were introduced, and a year later, the Singapore Medical Council (SMC) Ethical Code and Ethical Guidelines (ECEG) were updated. Furthermore, in 2019, the Health Science Authority (HSA) has also issued a regulatory guideline for telehealth products.

Telemedicine clinical standards focus significantly on the duty of care so that the patient fully understands that they are being cared for in the best manner possible. In case of any technical difficulty, the consultation would be terminated and rescheduled. The consent of the patient is necessary to obtain in order to record the conversation. As for the ethical implications, the patients must be made aware of the limitations to the consultation and if they would still like to proceed. Medical prescriptions must only be given on clinical grounds with sufficient information.

Any doctor in Singapore giving teleconsult services must be registered with SMC and comply with the ECEG and the national telemedicine guideline. Foreign teleconsulting service to patients in Singapore is not regulated presently but will be in the future. Singaporean doctors consulting with overseas patients need to comply with both Singapore regulations and any foreign country regulations.

In terms of liability, if anything goes wrong, patients are entitled to seek compensation, even if they are foreign patients. If they are dissatisfied, they can complain. If a patient is harmed, they can lodge a police report as well. However, if a foreign patient suffered harm and decided to lodge a police report, these matters remain to be decided.

Dr. Manish Taneja  Interventional Radiologist

Advances in the Acute Intervention for Strokes

Acute stroke intervention has seen a rapid advancement in the last 23 years, particularly in the last five years. In this talk, Interventional Radiologist Dr. Manish Taneja presents on advances in the acute intervention for strokes.

There are two common causes of stroke. The first is due to blockage of blood supply to brain cells, called ischemic stroke, and the second is due to a burst blood vessel, known as hemorrhagic stroke. The latter is very common in the '90s before we had good control of blood pressure. However, in the last decade, there are more ischemic stroke cases. Stroke is the most common cause of adult disability and is the fourth leading cause of death in Singapore. With an aging population, stroke is one of the more common causes of cognitive impairment like dementia.

The standard management of strokes includes medication and surgical treatments like clot retrieval, stenting, and coiling, which many patients need. IV clot-busting drug is also a solution, but it works in only 1 in 10 patients. It does not work in a large number of patients. It depends on the type of blockage of their blockage and the severity of the blockage.

In finding a clot in the brain, the endovascular route to the brain is to go through the femoral artery and then inject a drug into the clot to melt away the clot. However, it was not effective, and it caused some bleeding. Another way was to physically remove the clot inside the blood vessel in the brain. The third thing which came about was the aspiration of clot. The process can be done as fast as 30 – 45 minutes.

Nowadays, newer and newer technology and devices are coming up to treat strokes better, including the solitaire device, readily available in Singapore. The best results are seen 8 hours after the stroke onset, though the time can vary. Wingspan stents are special stents that help improve blood flow and prevent further strokes.

A brain aneurysm is a ballooning of a blood vessel. It is getting more and more common among young patients. It is less common in Singapore, about 1 in 300 hundred, but it is a common cause of stroke in young people. Surgical clipping used to be the standard of treatment till about 1993. However, many patients did not do well at all with very high morbidity, not even mortality. Then coiling came about in 1995, plugging the aneurysm from groin access. Till 2018, the flow diverter devices are used.

The interventions for acute strokes have rapidly improved, and the progression is such that it is amazing what can be done now compared to what could be done in 1998. Further advances are expected over the next few years.

Dr. Vina Doshi  Consultant Geriatric Physician 

Falls and Fractures – The Next Epidemic

Falls are found to be the second most common symptom in elderlies in emergency departments. Other symptoms like dizziness and acute abdominal pain are potential causes of falls. A study found that 60% of the injuries in the elderly occurred in their own homes, and among those, head and neck injuries are most common, followed by lower limb injuries. In this talk, Dr. Vina Doshi will present about the common falls and fractures that plagues the aging population in Singapore and shares tips on how to prevent them.

One in three of all community-dwelling adults well above the age of 65 are going to experience one fall in a year. This number will go up to 50 percent for all those who are aged 80 and above.

One in three adults above 65 experience one fall per year, and this number increases with age. More worrisome is that half of the first-time fallers are likely to die within a year of the first fall. It is going to become an epidemic because the whole population of Singapore is aging. By the year 2050, we expect 30 to 50 percent of our population to be above the age of 65 years. Fifty percent of these adults are going to have osteoporosis.

Only 60 percent will recover their pre-fracture ability to walk. Half will never get back to their pre-fracture ability to perform basic activities of daily living, and only 25 percent will go on to perform instrumental activities of daily living. These are the higher-end sort of functions of being able to do things outside their homes.

The aging population, coupled with the prevalence of osteoporosis, has led to a rising falls rate over the years, leading to more fractures. There is a small group of severely osteoporotic individuals where even low-impact injuries can result in fractures.

Singapore is building more facilities to cater to the elderly falling, but this epidemic needs to be controlled because the resources will still not be enough at this rate. Fall among the elderly indicates increasing functional decline, which means increasing care needs, more caregivers, more daycare centers, nursing homes, and more hospitals.

The fall prevention program assesses risk by looking at gait balance, strength, bones, muscles and looking at medications and caregiver education to reduce the incidences of falls.

Falls may occur due to an existing impairment and an activity that people should avoid, like using a stool to get something if they have bad knees or trying to multitask. In order to reduce the fall risk, people should increase protein consumption, vitamin D supplementation, do regular exercise, strength and balance training. Patients should also make sure their environment is safe from clutter and that they are wearing the proper footwear and have enough lighting at home.

There is also a need to be opportunistic and find fallers before waiting for them to fall. This can be done by asking them about falls and even training receptionists to check how patients walk into the rooms and stand from chairs to see if they could have gait issues. Caregivers also need to check medication lists to see if anything there could be increasing the fall risk

Dr. Ong Sea Hing  Cardiologist 

Cardiac Emergencies

Acute chest pain is a condition often experienced by many. In this talk, cardiologist Dr. Ong Sea Hing presents a series of case studies on cardiac emergencies and how timely treatment helped increase the chances of survival. Many examples will be provided in this report to help understand the impact of chest pains. First off, a 45-year-old sailor arrived at a hospital after already undergoing 24 hours of chest pain. He suffered from acute anterior territory ST-elevation myocardial infarction and eventually passed away. In these cases, it is crucial to bring the patients to the hospital as early as possible since the ST elevation tells us that the coronary artery is occluded. It also helps with the cost of treatment. The patient mentioned above was in the ICU for three months.

A dose of 300 mg aspirin usually works fast if patients have ST depression or ST elevation. If the patient is already on aspirin, it is probably not useful to give another 300 milligrams. Instead, GTN sublingual tablets or a GTN spray is an option to dilate the coronary arteries. It will not abort the heart attack, but at least it will open up some collaterals and give some pain relief to the patient and hopefully a little bit more perfusion to the myocardium.

If there is ST elevation, give the patients 180 milligrams of Ticagrelor or the brand name is Brilinta, as it does not increase the risk of non-CABG bleeding.

The most common reason for chest pains is musculoskeletal. Moreover, myocarditis is also a severe emergency, along with pneumothorax and pneumomediastinum. CT scans need to be done for patients due to the risk of esophageal pathologies – they give much information about chest pain. A 67-year-old patient had ST elevation and right bundle branch block pathology. These patients will need to think about scar ventricular tachycardia.

Another old lady had a complex escape rhythm, seen through ECG – this means a complete heart block, needing a pacemaker. It is also essential to act on these patients quite fast. Patients with bradycardia syndrome, atrial flutter, and sinus pauses also need pacemakers. A 54-year-old lady came in sickly, drowsy, and the ECG showed accelerated idioventricular rhythm due to hyperkalemia, which needs to be quickly attended to save the patient.

For patients not suited to typical defibrillators, consider using subcutaneously implanted ones. It was once used to save a patient’s life because he had an AV graft in his left arm, allowing no way to insert a typical defibrillator. Lastly, it is vital to pick up on these conditions early so as to have a greater chance of survival.

Dr. Simon Chong  Urologist

Practical Approach to the Management of Urological Emergencies for the Family Physician

In this talk, Urologist Dr. Simon Chong covers common urological emergencies such as ureteric colic, acute urinary retention, testicular torsion, paraphimosis, priapism, penile fracture, and Fournier's gangrene. In the case of ureteric colic, if the stone is closer to the kidney, the pain will be closer to the loin. Once the stone moves lower, so will the pain. Besides causing pain, ureteric colic can also be associated with hematuria. It can be visible hematuria and varying degrees of infection ranging from UTI to pyelonephritis, pyonephrosis, and even sepsis. If the stone is very close to the bladder at the vesicoureteric junction, the patient can experience urinary urgency and frequency in the absence of a UTI.

It is essential to know the patient's hemodynamics stability to keep them from septic shock, and even more important not to get the diagnosis wrong. For investigations, the usual methods are urine and blood tests and x-ray KUB, ultrasound KUB, or a CT KUB, with the lattermost being favorable since it encompasses the whole urinary tract. In terms of pain management, non-steroidal anti-inflammatory drugs tend to be effective, while for uretic stones, alpha-blockers are the way to go, being safe drugs with a low risk of side effects.

For male catheterization, enough lignocaine gel should be administered to relieve pain and facilitate insertion. A pillow should be placed under the buttocks for females to lift the pelvis and make the insertion easier. Once it is connected, a leg bag is a better option than a urine drainage bag.

In the case of testicular torsion, urgent surgical detorsion should be sought. In paraphimosis, the earlier it gets operated on, the better it is, and the patient should get oral analgesia before the operation. As for penile fracture, certain intracavernosal injections can be used, but if there is difficulty passing urine, a catheter can be used. For ischaemic priapism, the patient can try masturbating to see if it goes away or try exercising or taking cold showers. For non-ischaemic priapism, the patient can have a diagnostic angiography to pick up the AFV and then do therapeutic angioembolization. Lastly, Fournier's gangrene requires timely treatment in resuscitation, antibiotic treatment, and surgical debridement.

In all these cases, the patients' history and examination are critical to try and understand the severity of the conditions.

Dr. Joy Chan  Ophthalmologist

Everything You Need to Know About Ocular Emergencies

In this talk, ophthalmologist Dr. Joy Chan presents on the topic of trauma and other ocular emergencies. They include conditions that present with painful red eyes, some conditions with a painless blurring of vision, and chalazion, which are very common and usually seen by general practitioners. In case of trauma, it is essential to know whether the globe is opened or closed to determine the management. An open globe needs to be surgically closed to reduce the chances of infection. The longer the globe remains open, the higher the chance of infection, and if infection or endophthalmitis were to set in, then the odds of a poor visual outcome are much higher. The visual prognosis drops significantly when endophthalmitis is present.

Sometimes patients get intraocular foreign bodies in their eyes due to industrial accidents or due to shattered glass, causing retinal toxicity. They need to be removed very delicately. There are also organic foreign bodies like soil, which can cause fungal infections. When metals go into the eye and get lodged in the retina, they need a vitrectomy to be removed. Sometimes foreign bodies get lodged in the cornea, which calls for a 27-gauge needle or insulin syringe to be used, and usage of eye drops later. In case of abrasion, like from fingernails, copious lubrication is needed, antibiotic eye drops and ointments, as well as bandage contact lenses. Blowing the nose should be avoided in orbital fractures resulting from bar fights or tennis balls, as it forces air through the defect into the orbit.

The lychee test is a quick way of estimating whether a patient has normal intraocular pressure or a significantly raised pressure. Patients with acute anterior uveitis need steroids to half the inflammation. Cornea ulcers can occur due to poor lens hygiene and cause fungal infections. It needs regular antibiotic eye drops. Sometimes the retina gets detached, in which case, urgent surgery is required. Vein occlusions can be ischemic or non-ischemic subtype – for the former, laser photocoagulation is needed, and for the latter, they need monitoring.

In chalazion, meibomian glands get blocked, causing pimples to be formed. The secretions hence accumulate without coming out. In that case, treat the eye with just a warm compress and lid hygiene. In recurrent cases, oral doxycycline is recommended. The main thing is always to be aware of any problems surrounding the eye and get help as soon as possible.

Dr. Paul Mok  Otorhinolaryngologist

The Good, The Bad and The Ugly - Maladies in the Head and Neck

There's a spectrum of severity in several ENT conditions, depending on the mechanism of injury. For instance, facial trauma or laryngeal trauma, or foreign body in the throat. Some ENT conditions are good, which can be treated as outpatient, some are bad, needing inpatient admission, and some are ugly, where there is a danger to life. In this talk, Dr. Paul Mok presents the common ENT emergencies from the good to the bad.

Good ENT emergencies have no real need to panic as these conditions are treated as outpatient. The cases are uncomplicated, such as foreign body (FB) in the throat, a very common emergency. The most common site is in either the tonsil or in the base of the tongue. Using appropriate instruments such as the Tilley forceps will remove these FBs.

Then there is the upper esophageal sphincter which requires surgery. Facial trauma falls in this category, such as injuries that cause bruising and nasal bone fracture, high-velocity injuries like airway compromise, for which top-down systematic examination is urgently required, or septal hematoma may be caused, needing blood drainage quickly.

As for bad conditions, one of such is quinsy, which is an accumulation of pus behind the tonsil. You need to inject a local anesthetic and perform a stab incision to drain the pus. Then there is perichondritis of pinna, which can cause pseudomonas infection, leading to the need for antibiotics till inflammation subsides. If untreated, it can cause cartilage destruction. Furthermore, there is facial cellulitis, which can grow to cavernous sinus thrombosis if not treated early. Again, these patients need admission, IV antibiotics, a CT scan, and incision and drainage if indicated.

Deep neck abscess is one of the most dangerous ugly conditions, causing fever, jaw swelling, breathing problems. These patients require admission, to be kept on nil by mouth, IV antibiotics, and urgent CT scan. Then there is the paradoxical vocal movement where the vocal cords come together, causing episodes of breathlessness. In this case, breathing through pursed lips or straw may abort the attack. Lastly, acute cute supraglottitis and epiglottitis can cause fever, severe sore throat, inability to swallow, drool, and breathing problems. Again, these patients need to be admitted to a high dependency ward and need IV fluids, antibiotics, steroids, and to be kept nil by mouth with a potential emergency airway.

So, in the end, it is crucial to be able to identify the severity of the conditions in patients to accord appropriate accordingly.

Dr. Asok Kurup  Infectious Diseases Consultant

Selected Infectious Disease Emergencies

In this talk, Infectious Diseases Consultant Dr. Asok Kurup presents some of the infectious disease emergencies. The first case is of a 60-year-old male with septic shock and right lower extremities cellulitis and hemorrhaging necrosis. He had aeromonas hydrophila. Such individuals require intravenous penicillin in combination with clindamycin. Group A streptococcus is a common monomicrobial infection, which sees lots of local tissue destruction, requiring early exploratory surgery, aggressive debridement, and antibiotic therapy.

The next case is a 40-year-old woman who had a C-section and had left breast engorgement with erythema and inflammation. She needed inotropic support with face masks, supplemental oxygen; she had renal impairment and organ involvement, including jaundice and DIVC. The necessary treatment here is penicillin and clindamycin. The syndrome is toxic shock syndrome, with management requiring immediate supportive care, fluids, and surgery with empirical antibiotics. Factors that increase the risk of toxic shock are older age, younger age, diabetes, alcoholism, and trauma.

The third case is a 35-year-old male with fever, dry cough, and myalgia, leading to septic shock. He had abdominal surgery following a road accident twelve years prior, which led to anatomic asplenia with overwhelming sepsis. All the patients who have gone for splenectomy were vaccinated. These vaccinations may encounter many, including meningococcal infections as well. In this case, what the patient had was strep pneumonia. Ensure that ceftriaxone is on board. If the patient also had meningitis, then go for vancomycin and if he has penicillin allergies, go for quinolones.

The fourth case is a 22-year-old foreign worker with fever, partial ptosis, facial droop, and ophthalmoplegia through a forehead cut. The diagnosis is cephalic tetanus, and the management is to protect the airway and eliminate reflex spasm with diazepam, maybe magnesium sulfate, then neutralize the toxin with human hyperimmune globulin and surgically debride any infected source tissue. The antibiotic needed is metronidazole.

The last case is a 63-year-old individual with fever, cough, sweatiness, and giddiness. The condition is acute septicemic pulmonary melioidosis, an intracellular gram-negative organism widely distributed in soils in surface water in endemic regions, whose transmission is via percutaneous inoculation during exposure to wet season soil or water. The choice of antibiotics here is ceftazidime and levofloxacin, followed by a prolonged maintenance suppression with Bactrim and doxycycline.