Vol. 47 No.10 October 2015 MCI (P) 154/01/2015

MEDICAL Optimisation For OUr ARMED FORCES 4 28

Editorial Opinion SEEK, save, serve Celebrating 80 Dr Tan Yia Swam and Batches of MO Dr Jipson Quah Cadets in SG50 Vol. 47 No. 10 2015 MAJ (Dr) Joachim Yau

EDITORIAL BOARD Editor 5 9 29 Dr Tan Yia Swam feature president’s forum OPINION Deputy Editors Dr Tina Tan Military Medicine The NS Experience Reminiscing on Dr Tan Tze Lee and Singapore Dr Wong Tien Hua National Service Editorial Advisors Interview with COL (Dr) Dr Jipson Quah A/Prof Daniel Fung Tang Kong Choong A/Prof Cuthbert Teo Dr Toh Han Chong Members Dr Jayant V Iyer Dr Natalie Koh 12 30 Dr Leong Choon Kit Dr Jipson Quah INSIGHT FROM THE HEART Dr Jonathan Tan Beyond the Call of Duty Not for Fame nor Dr Jimmy Teo SLTC (Dr) Ng Yih Yng, LTC (Dr) Vernon Lee, for Glory COL (Dr) Poon Beng Hoong, COL (Dr) Gan Wee Hoe, LTC (Dr) Adrian Tan EX-OFFICIOS SLTC (Dr) Chow Weien and SLTC (Dr) Lim Hou-Boon Dr Wong Tien Hua Dr Daniel Lee Hsien Chieh

EDITORIAL OFFICE Senior Manager 18 20 33 Sarah Lim INSIGHT OPINION EXEC SERIES Editorial Executives Military Psychiatry Maximising Deputy Applications Sylvia Thay MAJ (Dr) Soh Teck Hwee Performance under the Mental Donna Cheong and Safety Capacity Act — ADVERTISING AND LTC (Dr) Jeremiah Chng, Writing the PARTNERSHIP MAJ (Dr) Noreffendy Medical Report Li Li Loy Bin Ali and MAJ (Dr) Lim Hui Min Denise Jia Magdalene Lee Tel: (65) 6223 1264 Email: [email protected] 22 23 36 OPINION Opinion Calendar Publisher Singapore Medical Dual-tracked The Case for SAF SMA Events Association Career Regular Surgical Nov – dec 2015 2 College Road MAJ (Dr) Kwan Kah Wai Specialists Level 2, Alumni Medical Clarence Centre LTC (Dr) Shalini Singapore 169850 Arulanandam Tel: (65) 6223 1264 Fax: (65) 6224 7827 Email: [email protected] URL: http://www.sma.org.sg UEN No.: S61SS0168E

DESIGN agency 24 38 Oxygen Studio Designs Pte Ltd OPINION AIC SAYS

PRINTER Top Knife: Aviation Education for Sun Rise Printing & Medicine in Action Better Eldercare Supplies Pte Ltd LTC (Dr) Benjamin Tan

Opinions expressed in SMA News reflect the views of the individual authors, and do not necessarily represent those of the editorial board of SMA News or the Singapore Medical Association (SMA), unless this is clearly specified. SMA does not, and cannot, accept any responsibility for the veracity, accuracy or completeness of any statement, opinion or advice contained in the text or advertisements published in SMA News. Advertisements of products and services that appear in SMA News do not imply endorsement for the products and services by SMA. All material appearing in SMA News may not be reproduced on any platform including electronic or in print, or transmitted by any means, in whole or in part, without the prior written permission of the Editor of SMA News. Requests for reproduction should be directed to the SMA News editorial office. Written permission must also be obtained before any part of SMA News is stored in any retrieval system of any nature. 4 editorial

am very pleased and honoured to I’ve had the good fortune to work with present this special collaboration male colleagues who are SAF regulars issue, which was almost a year in the (eg, Hong Yee, Leonard, Joachim and Dr Tan Yia making. It started in August 2014 as Alvin, to name but a few) and have Swam is an an idea to celebrate doctors in service, always been impressed by their strong associate consultant but as discussions with colleagues in sense of duty and efficiency in getting at the Breast the Singapore Armed Forces (SAF) things done. That set me wondering Department of took place, it gradually grew into about “Army doctors” and what they do on a day-to-day basis. KK Women’s and a full issue to happen this year in Children’s Hospital. She continues conjunction with SG50! Do remember that I’ve never served to juggle the commitments of being National Service (NS), unless you a doctor, a mother, a wife and the Special thanks to Dr Jipson Quah and count having children as NS, and I do increased duties of SMA News Editor. MAJ (Dr) Tan Mian Yi, my personal have a vested interest in knowing more She also tries to keep time aside friends, for their effort in getting this for the sake of my two sons who will for herself and friends, both old collection of articles together. Much serve NS one day. I hope this insight and new. thought was given to ensure that we into the myriad responsibilities and cover as many aspects of the SAF abilities of the SAF Medical Corps will as we could, given the time and be as inspiring and assuring to you as Yia SwamEditor physical constraints. it is to me.

hat a year it has been for Like a hospital, the SAF Medical Singapore! We celebrated Corps has a chief, ably assisted th Dr Jipson Quah is our nation’s 50 birthday, hosted a by various service chiefs (akin to a medical officer splendid SEA Games, and mourned heads of departments). Within each who has recently the passing of our nation’s founding department, there are specialist father, Mr Lee Kuan Yew. Throughout completed his consultants, registrars, MOs and National Service these momentous events, a constant medics, all working in teams to and is currently pillar of strength was working tirelessly attached to the Department behind the scenes to ensure mission serve the patient population of the of Pathology at Singapore General success — the SAF. In this issue, we SAF. Visiting national servicemen Hospital. He enjoys music-making, celebrate the contributions of our consultants also frequently lend their fitness-related activities and medical colleagues working in the SAF expertise and volunteer their services editorial work in his free time. Medical Corps, a true heavyweight to the SAF. In addition, there are in the national healthcare landscape. public health, dental, physiotherapy Having just completed my NS as a and civil defence services provided to medical officer (MO), this issue holds the general public. With the breadth Jipson Guest Quah Editor great significance on a personal level. and scope of medical practice and services provided, it is indeed a SMA News has put together an SAF- themed issue to share more about national healthcare juggernaut. the practice of military medicine in Singapore. As the healthcare The SMA News Editorial Board “Our nation called as need arose landscape changes and the medical extends our thanks to Chief of For stations in the field fraternity become more populous, Medical Corps, COL (Dr) Tang Kong To treat our fallen brothers all it is necessary to highlight this key Choong, for agreeing to this SMA- medical establishment, which provides The wounded and the ill SAF collaboration and Head of excellent medical services outside Our pioneers rallied to this call General Staff, MAJ (Dr) Tan Mian Yi, the conventional medical/clinical for helming it. Also, special thanks to Then thousands joined this band practice. These include humanitarian/ MAJ Chin Kok Yee, who aided us by disaster relief missions, aero/naval And soon a new cry could be heard providing content for the issue. Lastly, A ringing through the land” medical evacuation and combating of bioterrorism. In this issue, you will we are grateful to all our contributors, read about the variety of roles that the both within and outside of SAF, who Excerpt from the Medical Corps’ Song, have worked under tight deadlines to Medics of the Field SAF Medical Corps play, its specialty tracks and the challenges of practising make this special issue possible. military medicine.

SMA News / OCT 2015 feature 5

An interview with COL (Dr) Tang Kong Choong

COL (Dr) Tang Kong Choong joined the SAF in 1992 when he received the Local Study Award (Medicine). After completing his Bachelor in Medicine and Surgery, he returned to serve the SAF in May 1998. He held several key appointments in the Navy Medical Service and Headquarters Medical Corps before taking on the positions of Chief Naval Medical Officer (CNMO) and Commander Force Medical Protection Command in 2011. In May 2015, COL (Dr) Tang was appointed as Chief of SAF Medical Corps.

COL (Dr) Tang was responsible for planning the naval medical support for Operation Flying Eagle in the aftermath of the Boxing Day tsunami in Dec 2004. In 2008, he was sent on a recce mission to Afghanistan, in preparation for SAF’s first medical deployment, codenamed Operation Blue Ridge. During his clinical posting at The Alfred, Melbourne in 2009, he contributed towards the disaster management effort of the devastating Victorian bush fires.

COL (Dr) Tang Kong Choong (TKC) holds a Masters of Medicine in Anaesthesiology from National University of Singapore. He is a consultant anaesthetist with Tan Tock Seng Hospital and a consultant in Diving and Hyperbaric Medicine with the Singapore General Hospital Hyperbaric and Diving Medicine Centre, and is also a board member in the Agri-Food & Veterinary Authority.

OCT 2015 / SMA News 6 feature

relief deployment to Nepal by SAF. We also collaborate with the Changi PROFILE Though Nepal is not our immediate General Hospital Sports Medicine geographic neighbour, Singapore has Centre to strengthen knowledge on had a long history of the Gurkhas treatment of sports injuries, thus deployed in Singapore. Hence, there contributing to the sports medicine was a compelling need to respond community in Singapore. and provide humanitarian assistance. The Medical Corps maintains the The medical fraternity often question capability and readiness to respond how the civilian doctor population Interview by to any disaster in the region. We have can play a role in the NS institution. medical personnel who are always on So how do we, as a profession, work standby and they form the first line of Dr Jipson Quah together for the best interests of the response. We also depend on both our patient-soldier? in-house regulars and Operationally- Guest Editor Ready National Servicemen (NSmen) TKC: From the SAF standpoint, we specialists if the need for a surgical rely on the national healthcare system team deployment arises. For the Nepal Introduction to the SAF to take care of our servicemen so I relief mission, I was heartened to see Dr Tang, how have your roles and feel that the best thing our civilian how numerous NSmen specialists responsibilities evolved since your colleagues can do is to continue new appointment as the Chief of volunteered to be on standby and were prepared to deploy if the need arose. to provide good medical care to Medical Corps (CMC)? our servicemen and maintain their professionalism in the management of TKC: Compared to my previous role Military medicine SAF personnel when they are seen in as CNMO, my new appointment in the national the local hospitals or clinics. Based on requires a deeper understanding health landscape the diagnosis, we will seek to deploy and consideration of issues at the How is military medicine currently the serviceman appropriately in the organisational and strategic level. being practised in the SAF and military context. The disposition of the For the SAF, maintaining strong how does it differ from soldier in a military setting eventually public support for National Service conventional specialties? remains the responsibility of the SAF. (NS) is crucial for the defence of our nation. To this end, the Medical Corps TCK: Traditionally, military medicine is committed to providing quality comprises aviation and hyperbaric Another way that civilian doctors healthcare and emergency medical medicine, field surgery and sports can contribute is through their care should an incident occur within medicine. However, with the SAF participation in SAF advisory panels the SAF. It begins by first ensuring that Medical Corps running 32 primary and boards as visiting consultants, our servicemen are properly classified. healthcare clinics, specialists and as well as by lending their specialist Secondly, when they are ill or they dental clinics and ancillary services expertise and opinion to help us get injured, we ensure that the best like physiotherapy, we are like another improve on the classification and resources are available for their care. healthcare cluster in Singapore. deployment of soldiers. Without responsive medical support The practice of military medicine and quality healthcare, confidence in the SAF is hence very broad and Recently, Dr Janil Puthucheary, a in the NS institution can easily be includes public health, occupational senior consultant in paediatrics and eroded. Therefore, my role as CMC medicine, family medicine and even a Member of Parliament, volunteered is to coordinate and improve the emergency medicine. as a security trooper under the newly SAF medical system and to provide launched Volunteer Corps scheme. comprehensive and excellent support What are the volunteer roles that to the SAF. Of course, the SAF leads in the practice of aviation and hyperbaric medicine. our colleagues can play in the SAF Our air force doctors and staff on Medical Corps? The SAF Medical Corps not only duty are always on standby for search has a role in defence and protecting and rescue operations. This service TKC: We welcome doctors, nurses, full-time National Servicemen (NSF) extends to the whole of Singapore radiographers and laboratory and regulars, but is also involved in and our nearby waters. If a ship out at technicians, among others, to medical diplomacy. How are these sea runs into an emergency, the SAF volunteer their expertise in the SAF. different roles performed? will respond to its call for help. At the Having expertise in these fields is Singapore General Hospital Hyperbaric useful in reinforcing our training TKC: In medical diplomacy, it is Diving Medicine Centre, which caters to programmes in the SAF Medical about how we continue to strengthen regional commercial and recreational Training Institute. Many of our NSmen relationships with our regional divers, we provide a 24-hour standby medics, who may not be in the neighbours and other countries. service for injured divers who require medical profession, need regular skills A case in point was the recent disaster treatment for decompression sickness. refresher training. They will benefit

SMA News / OCT 2015 feature 7 tremendously from the experience and in Tan Tock Seng Hospital (TTSH) to blend of work that the SAF offered — expertise of these volunteers who will maintain my practice. I really enjoy the both clinical and policy-making. work alongside our regular medical time there because I get to interact trainers. I would like to highlight that with patients, residents and medical Would you encourage more medical the SAF Medical Corps has a long officers (MOs). Occasionally, when the students and doctors to join the history of working with medical workload varies, I calibrate my clinical SAF Medical Corps, since there volunteers. From the early 1970s, commitments accordingly. I attend is a scholarship? we had many doctors and nurses continuing medical education (CME) volunteering their services in the newly activities regularly and whenever the TKC: That’s a very good question. I formed Combat Support Hospitals. opportunity arises, I try to acquire new think we can do with more medical Today we have esteemed colleagues skills such as the use of ultrasound for students and doctors because there like Prof Low Cheng Hock who has regional anaesthesia. Although I am a is more we can do to improve the been involved in our Advanced Trauma consultant, I recognise my limitations medical system in the SAF. However, Life Support programme for a long and seek the advice of other senior every doctor we bring into the armed time; A/Prof Kenneth Mak, A/Prof consultants whenever I encounter forces is one doctor we take out of Aymeric Lim and Dr Nelson Chua, who complex cases. the local healthcare sector. I know have gone over and beyond their call how short of staff our hospitals are of duty to contribute in the SAF. I think my decision to join the SAF and so that is something we’re very is quite interesting because back in careful about. Human resource is What was the SAF Medical Corps’ 1992 when I was a recruit, I had a the only resource that Singapore role in the SG50 SEA Games negative experience at the medical has, so we need to manage this and events? centre. I remember asking myself, precious resource of doctors in “Why did this doctor treat me that public service very judiciously. TKC: The SAF Medical Corps provided way?” Then it struck me that I could The good thing is that when our medical support for the Opening and do something about it rather than doctors leave the SAF, they bring Closing Ceremonies (OCC) as well accept the situation. That year, I was with them added skillsets that will as for all the competition venues one of six scholars offered the Local throughout the 28th SEA Games 2015 Study Award in medicine. When that (SEAG15), held in Singapore from opportunity presented itself, I saw the 5th to 16th June 2015. More than potential to do something 200 SAF medical personnel were different and it also deployed across 19 medical posts for helped that the award the SEAG15 OCC, and more than 100 would provide some SAF medics augmented the medical financial assistance support at all SEAG15 competition for my studies. As my and training venues. In addition, career progressed and the SAF Medical Corps conducted I rose through the ranks, professional training for approximately I decided to stay 500 Volunteer Paramedic Assistants, on, as I enjoy who assisted in medical coverage the unique throughout SEAG15.

On a medical career with SAF Tell us more about your SAF career and anaesthesia practice. What led you to decide to join the SAF Medical Corps?

TKC: As CMC, I take my appointment and responsibilities very seriously, and so naturally, most of my time is spent in the SAF. Most of my time in the SAF is spent meeting my staff and SAF leadership, visiting different medical units in the SAF and also establishing linkages and opportunities for the Medical Corps both in Singapore and internationally. As an anaesthetist, I try to spend about two sessions per week 8 feature

a lot of inertia and even resistance have many consultant supervisors and because this would take up extra time one must clock all their cases, hours and could disrupt residency training. of training and CME. Fortunately, we had the strong support from MOH, especially In the larger conversation that we from Prof Satku, then Director must have with MOH/ACGME is of Medical Services at MOH, whether it is even possible to consider who saw the need to train our this. One potential issue is that we doctors before they serve NS. have very differing job scopes for NSFs. One can be a battalion MO, Through this initiative, we staff officer, or medical centre MO have been able to help in different services. So how do we MOs develop competency meaningfully accredit the training and consolidate it into a single residency? and confidence to manage It’s a good idea, but I think it will be P1 emergency cases. This is quite challenging. evident in some of the recent cases where resuscitation and evacuation were required. It has really Personally speaking made a difference, as our MOs felt What are some of your hobbies confident in managing these cases outside of SAF and TTSH? allow them to add value in the public on their own. I am confident that sector. I think the challenge with this initiative will continue to make a TKC: Being in the SAF, I make it a recruitment lies in the fact that most positive difference and enhance the point to keep fit. I do this by making 19-year-olds who apply to study care we provide to our NS boys. time to go to the gym, run around medicine will be very focused on my estate and swim laps when having a conventional clinical career. my children go for their swimming It will not be easy to convince them As for the placement of SAF MOs lessons. We spend Saturdays as a that they will need to devote time at selected hospital EDs, ED staff family and attend church on Sundays. for medical administration if they certainly welcomed the presence of I also enjoy reading and am currently join the SAF. To this end, we do SAF MOs to manage SAF servicemen reading a book on food production and have the provision for our doctors to who seek medical care at the EDs. Our food security called The End of Food specialise and also spend time in MOs have also given good feedback, by Paul Roberts. It’s an interesting the hospital every week while they as they get to manage a mix of P1 and commentary on the fragility of the are in SAF to maintain their clinical P2 cases with the ED staff, in addition global food industry including a very skills and competencies. to SAF personnel who present at the scathing analysis of how large food ED. This helps to give more breadth manufacturers are driving up costs and depth to their clinical practice for consumers! On SAF collaboration with within the SAF. Of course, we are still emergency departments studying the long term sustainability In recent years, there has been two Any last thoughts for our readers? of this initiative as we need to ensure large collaborations between SAF that the operational demands of the TKC: Throughout my career, I have and Ministry of Health (MOH) — SAF are not compromised. appreciated the fact that most of firstly, to rotate pre-enlisted MOs in our SAF doctors have been viewed emergency departments (EDs) and favourably as clinicians. Personally, secondly, to position SAF MOs in the Do you think NS can be formalised I am appreciative that TTSH has department during certain hours. into a military medicine residency? appointed me as a consultant in the Can you tell us more about how these department, as they value me as a initiatives have fared? TKC: I think the question is whether fellow colleague and clinician, not just NS can first be considered an elective as a soldier. Our hospital colleagues TKC: The idea of rotating pre-enlistees posting that can count towards their also recognise the different roles for anaesthesia or emergency residency training. What you have that we play in humanitarian, relief medicine postings came about suggested is quite interesting, but and rescue operations. As clinician- because we received feedback from not easy to work out because to get administrators, we are here to provide MOs who had no prior postings it accredited as an elective and count the best healthcare in the SAF and to in acute or emergency medicine. towards residency, we will need to develop policies that will benefit the They expressed their concern about subject the SAF posting to the entire national population. And should our facing their first collapse case while Accreditation Council for Graduate services be called upon by the people serving their NS. When we raised this Medical Education (ACGME) system. of Singapore, we are always ready possibility, we knew we would face To fulfil these requirements, you must to respond.

SMA News / OCT 2015 president’s forum 9 10 president’s forum

I remember my first day of not much knowledge available to crackling and cackling kept us up enlistment quite clearly. It was a prepare one for what lay ahead in for the better part of the night, and it humid Monday morning in March basic military training. Recruits were felt like we could be hit by a swinging when I trudged up the hill at literally “blur like sotong” because creature any moment. At about 3 am Dempsey Road, where the former most had no clue what was required in the morning, our camp was Central Manpower Base (CMPB) of them. There was no blog to read overrun by a swarm of army ants. was located. In a single-storey about the experience of others, no At 4 am, as I lay in my hammock building next to the small circular forum to discuss army preparation shivering after a rainstorm, with my driveway, where Huber’s Butchery and no YouTube to watch Ah Boys bottom gently swaying barely two & Bistro is currently located, I took to Men. It was not until I was on inches off the forest floor and the my SAF oath in a room packed with the RPL watching the shoreline of sound of ants rustling underneath, Singaporeans from all walks of life. Singapore receding that reality hit I stared into the forest and saw the At the quadrangle, we boarded a home; there was no escape. I cannot dark vegetation magically illuminated three-tonner truck, which whisked say that I enjoyed my three months by two bands of light. The night sky us off to some distant location to in Pulau Tekong — it was physically lit up in a purplish glow above us, collect our gear. demanding and emotionally tough, while the forest floor glowed in green especially for an 18-year-old. phosphorescence. It looked as if the The journey in the truck was rocky, entire jungle was sandwiched and hot and sticky. Amid the roar of the Six years later, I returned to embark floating in a band of twilight. engine and hissing of the brakes, on the medical officer cadet course there was an uncomfortable silence. (MOCC), a six-month training After MOCC, I was posted back I was among strangers embarking on programme for our cohort of to Dempsey Road camp. By that an unknown journey, leaving behind male doctors who had completed time, CMPB had moved to Depot the comforts of home and family. At housemanship. This time, things were Road, leaving the Headquarters the army supply depot, we were led very different. I remember that first Medical Corps (HQMC) and the down a large hallway and hurriedly day of re-enlistment very well too. We SAF Band behind. I was assigned fitted with equipment. Each of us were in a similar army truck, but this as a staff officer to Col (Dr) Lionel was issued four sets of uniforms, time, instead of an uncomfortable Lee, then Chief of Medical Corps. thick cotton green t-shirts and socks, silence, there was much bantering HQMC, consisting of a cluster a pair of stiff heavy leather boots, and cautious laughter as we returned of separate small buildings set water canteens, mess tins, and other to the military with our medical among shady banyan trees, was a strange-looking equipment unfamiliar school classmates. We knew what to very serene and peaceful camp to to me at that time. The helmet was expect and many of us had physically work in. Staff officers would have a heavyset steel tin-can that looked conditioned ourselves for the training meals at the canteen, which is like it came from the Vietnam War ahead. We were more mature after the site now occupied by PS.Cafe. era and the black running shoes surviving housemanship (which was, Administrative work was not a skill had thin rubber soles. Apparently, arguably, more gruelling than army taught in medical school; we had to arch support and midsoles had not training!) and could rely on each other learn how to draft meeting minutes, been invented then. Everything was for moral support. We were among write official correspondences and stuffed into a voluminous “Ali Baba” friends. I would not have guessed organise events on the job. Those bag made of thick green canvas, so then that among us were the future were the early days of office intranet, named because one could possibly Chief of Medical Corps and Chief Air dial-up modems and work plan stow one of the 40 thieves in it. We Force Medical Officer. presentations done using frames of were then taken to the commando developed film cast on a white screen jetty where a landing ship, the ramped One experience that stood out during by slide projectors. powered lighter (RPL), was waiting to MOCC was the jungle training in transport us to Pulau Tekong. Brunei. Our section of cadets (Wee, My third and longest phase of Wong, Wong, Wu and Yap), having army life was my assignment to an In those days, most of the difficulty lost our checkpoint, had set up armoured medical company and and hardship that one suffered camp to pass the night. The jungle being called back as an Operationally- could be attributed to the lack of quite literally sprang to life after dark Ready National Serviceman (NSman). information. It was the era before and was filled with a cacophony of My first high key training took place the internet and smartphones, with noises. The swooping, swishing, more than ten years ago and I have

SMA News / OCT 2015 president’s forum 11

PROFILE

Text by Dr Wong Tien Hua

Dr Wong Tien Hua is President of the 56th oy SMA Council. He is a family medicine evin L

K physician practising r in Sengkang. Dr Wong has an interest in primary care, patient communication and

Illustration: D medical ethics. been called back almost every year appreciate these unless one has evening was cool and a dry wind since. Being posted to a unit helped had the experience of donning the was sweeping across the open field. me forge new friendships, as people old equipment. Try running around As my eyes adjusted to the night, from different backgrounds bonded in a heavy steel helmet in tropical shimmering blades of tall grass with one another in training from year heat and one would immediately swaying gently came gradually into to year. Camaraderie goes beyond appreciate the vast reduction in focus under the silvery light of the the annual two weeks of training, weight afforded by Kevlar. Cookhouse moon. With no light pollution in the as many NSmen gather on social food has improved to the point that Australian outback, I was able to gaze occasions and celebrate important I found myself looking forward to up at a crystal clear sky filled to the life events. Many of my army buddies meals during In-Camp Training. brim with billions of stars and distant have come to me for medical Above all, the training methodology galaxies. That was truly breathtaking! consultation, for they consider me has evolved with the times; now, there to be someone they could trust, a is a strong emphasis on ownership I do not think my NS experience feeling that is mutual. It was these of training among NSmen and was particularly special, as many in strong bonds that convinced me commanders can decide how the our medical profession have gone to extend my National Service (NS) yearly training should be conducted. through the same training and commitment so that I could go would have their individual stories to through the battalion assessment The one experience that stood tell. However, the NS experience is exercise with these men. out during my training was the unique to Singaporeans because few opportunity to take part in Exercise countries afford their doctors such an I have witnessed the gradual Wallaby in Australia. We had spent opportunity away from mainstream transformation of the SAF from four days in the open terrain and medical practice. the time of my first enlistment. were preparing for the final push to Lightweight Kevlar helmets, our exercise objective. It was past NS training is tough — it demands waterproof Gore-Tex boots and proper midnight as I was returning to my one’s time and necessitates sacrifice running shoes are some of the big medical company on completing my away from work and family, but it is improvements that have benefited briefing and planning at the battalion unquestionably an experience unlike the soldiers. One will not be able to headquarters. The November any other.

OCT 2015 / SMA News 12 insight

The SAF Medical Corps plays a crucial role in maintaining the health of our soldiers and optimising their combat performance. Beyond that, it also renders medical assistance to our neighbouring countries in need and helps to spearhead regional medical initiatives. Six senior commanders of the SAF Medical Corps, each outstanding specialists in their own field, from the Civil Defence Force, Biodefence Centre, Army, Air Force, Navy and Military Medicine Institute (MMI) share how their respective services respond to the call of duty to seek excellence, save lives and serve the SAF.

coordinated Ministry of Health (MOH)- PROFILE Singapore Civil Ministry of Home Affairs Emergency Medical Services (EMS) masterplan. Defence Force The last three years have seen the introduction of new equipment and All SAF medical officers (MOs) have drugs, such as intraosseous needles, unconventional careers compared to their peers. I have had the unique professional grade defibrillators experience of working in military that transmit ECG wirelessly preventive medicine, although I am by 3G connectivity, tramadol, text BY an emergency physician by training. I Penthrox inhalers and faster class III have “toured” Timor Leste as a United ambulances, in our efforts to upgrade SLTC (Dr) Nations peacekeeper for three months, SCDF’s capabilities. organised the Boxing Day tsunami Ng Yih Yng epidemiological surveillance, managed The use of systems thinking, a chain of over 30 SAF primary acquired from SAF staff processes, SLTC (Dr) Ng Yih Yng care clinics as Deputy Commander has also helped me to holistically is an SAF emergency of MMI and coordinated with the review our EMS system, leading physician and holds US Armed Forces to send our SAF to the strengthening of medical a Master in Public medical personnel, including National leadership structures, improved Health and Business Servicemen (NSmen) doctors, to run a paramedic education and workforce Administration from surgical team in Afghanistan. transformation by cross-deploying Johns Hopkins firefighters as emergency University. He holds In addition to my training in medical technicians. the rank of COL emergency medicine and public as the CMO in the health, the military leadership Finally, to benchmark our EMS, development and training in medical SCDF. He is actively we’ve compared our efforts against administration I have received in SAF, involved in EMS some of the best EMS systems provided a valuable foundation for research in Asia and in Arizona, Milwaukee, Seattle, my secondment as the Chief Medical is also the Vice- Tokyo, Taipei and Seoul, leading to Chairman of the Officer (CMO) of the Singapore Civil Defence Force (SCDF) in 2012. transformative initiatives that have Asian EMS Council. doubled bystander cardiopulmonary As the CMO of SCDF, I have had the resuscitation rates from 22% (2012) privilege to drive and implement a to 47% (2014) nationally.

SMA News / OCT 2015 insight 13

to 2012, and have since been actively Biodefence Centre shaping international health policies. PROFILE

SAF’s contributions to infectious These opportunities for secondment diseases prevention extend beyond were also extended to other SAF Singapore to the wider regional and personnel. During the 2014 MERS- global scientific community. The CoV outbreak in the Middle East, SAF has built upon existing scientific Ms Christine Gao, Head Epidemiology research in infectious diseases Section of SAF Biodefence Centre, prevention and control. For example, was sent to WHO to assist with the text BY its seminal study1 on the efficacy response. These secondments serve of ring chemoprophylaxis with to enhance the professional exposure oseltamivir in the 2009 H1N1 and training of our personnel and LTC (Dr) influenza has significantly advanced at the same time, benefit the SAF Vernon Lee the understanding of medical through the networks established with protection measures. international biodefence experts. LTC (Dr) Vernon Lee The SAF has since developed The fight against emerging infectious is Head of the SAF expertise in biodefence matters and diseases (EIDs) is not something that Biodefence Centre. participated in international military SAF can undertake on its own due He is in charge and scientific meetings. In addition, to the global nature of EIDs and the of preparedness, SAF staff has also been seconded to global health security concerns. surveillance the World Health Organization (WHO) and response to — a clear recognition of the quality The SAF builds on its strong infectious diseases and expertise of SAF personnel. biodefence framework by leveraging in the Singapore on both local and international military. He is Notably, at the height of the H5N1 partners. Locally, the SAF collaborates also an associate avian influenza outbreak in 2007, I with agencies and institutions such professor at Saw was given the opportunity to assist as the Defence Science Organisation, Swee Hock School the WHO office in Indonesia. Being MOH, National Environment Agency, of Public Health and trained and qualified as a preventive Agri-Veterinary Authority of Singapore, the Deputy Director medicine physician and infectious Saw Swee Hock School of Public for Communicable diseases epidemiologist, I was Health and local hospitals to build Diseases in MOH, the necessary linkages for exchange intimately involved in the development spearheading public of information and expertise. of the avian influenza pandemic health policies, preparedness and response plan Internationally, the SAF has also disease response, for the country. Subsequently, I established collaborations with our and research activities. was appointed as advisor to the regional and international military Assistant Director General for Health counterparts to optimise research Security and Environment at the WHO efforts and to ensure timely exchange References headquarters in Geneva from 2010 of information on EIDs. 1. Lee VJ, Yap J, Cook AR, et al. Oseltamivir ring prophylaxis for 1 containment of 2009 H1N1 influenza outbreaks.N Engl J Med. 2010; 362:2166-74.

Legend 1. LTC (Dr) Vernon Lee works closely with his counterparts in the WHO.

OCT 2015 / SMA News 14 insight

vocationalists and units (including the PROFILE Army Medical Combat Support Hospitals), manages medical matters of the ground units, Services provides injury rehabilitation to maximise soldier performance, and Through National Service (NS), the ensures operational readiness to Army conscripts the Singapore male respond to Humanitarian Assistance population every year to train them and Disaster Relief (HADR) operations as soldiers and to form fighting units. when called upon. Upon completion of full-time NS, they text BY will continue to serve in their NS units Through the SAF Medical Training to ensure the operational readiness Institute (SMTI), medics, paramedics, COL (Dr) of the Army. Every cohort comprises nurses and MOs are trained to Poon Beng Hoong males from all walks of life with deliver the best care validated by different aptitudes and capacity for evidence and international best physical activities. They are expected practices. Effective team training COL (Dr) Poon to carry heavy loads and perform of the medical units and Combat Beng Hoong holds strenuous tasks in our tropical climate. Support Hospitals ensures that, in the appointments military operations, they will take on of Chief Army Besides training for battle, the Army is crucial roles to treat combat injuries Medical Officer also regularly called upon to organise and perform life-saving surgeries. and Commander, large-scale complex national events All our MOs are trained and certified SMTI. He is a such as the annual National Day to provide Advance Trauma Life family physician Parade. It is also tasked to respond to Support, while the surgical teams by training and natural disasters in our neighbouring also undergo more advanced training also holds an MBA countries and to provide support and in trauma management. with specialisation relief to those affected. in healthcare The Soldier Performance Centre management. The Army Medical Services (AMS) in the AMS works closely with the plays an important role in supporting local sports medicine fraternity to the mission of the Army. To ensure the utilise the latest medical evidence to Legend safety and well-being of our soldiers reduce injuries and to optimise the 1. The inaugural joint during training and operations, the performance of our soldiers through medical socio-civic mission medical support in both peacetime regular improvements to the Army’s between the Vietnam and operations needs to be robust training policy and physical equipment. People’s Army and the and of high exacting standards. SAF to locals at Vinh Phuc province, Hanoi, from 15 to Over the years, the AMS has Through the headquarters and 18 April 2015. participated in numerous socio-civic subunits, the AMS oversees missions and HADR operations such the training of all the medical as the 2004 Indian Ocean tsunami and the 2015 Nepal earthquake. 1 We have constantly maintained a high level of readiness of our personnel and equipment for swift deployment. Lessons learnt from these deployments are incorporated into the development of the Army’s surgical capabilities.

In summary, the AMS oversees a wide span of responsibilities. It is through the dedication and professionalism of its people that the AMS has grown from strength to strength over the years.

SMA News / OCT 2015 insight 15

Centre (ARMC). Inaugurated in 1982, Republic of ARMC has developed into a centre of PROFILE excellence in aviation medicine after Singapore Air Force more than 30 years of operations. Medical Service ARMC is a one-stop specialist centre that provides a comprehensive range The medical service of the Republic of of aviation medicine services for all Singapore Air Force (RSAF) traces its RSAF airmen. ARMC focuses on roots back to 1968, when it began as aircrew health, medical selection, a medical centre providing support to aviation physiology training and text BY the (previously known as) Singapore human performance programmes Air Defence Command. through four main specialist domains: COL (Dr) (1) Clinical Aviation Medicine; Since then, the RSAF Medical (2) Aviation Psychology; Gan Wee Hoe Service (AFMS) has undergone (3) Aviation Physiology and rapid changes and reorganisations, Crew Safety Enhancement; and COL (Dr) Gan Wee each furthering its ability to support (4) Performance Maximisation. Hoe is concurrently the RSAF in its different stages of the Chief Air Force development and operational needs. In 2009, RSAF commissioned a Medical Officer AFMS is responsible for three main new suite of training equipment that and Assistant areas of medical operations, namely enabled ARMC to conduct third- Chief Medical medical training, medical research generation Aviation Physiology Corps (Capability and capability development. The Training (APT) for RSAF airmen. The Development AFMS headquarters oversees the suite of APT equipment included the and Systems planning and deployment of assets human training centrifuge, spatial Integration). He for operational medical support disorientation trainer, air force night holds dual specialist for all RSAF local and overseas vision integrated laboratory, ejection accreditations activities. This entails developing and seat trainer and altitude (hypobaric) in occupational executing medical support for local chamber (to be upgraded in 2016). medicine and and overseas flying, ground-based air ARMC has also implemented the APT aviation medicine. defence deployments and heliborne e-learning initiative to better educate search-and-rescue missions. In He sits on the Civil airmen about physiological threats in Aviation Medical addition, AFMS is responsible for air operations. providing aeromedical evacuation Board and Chief Medical Informatics (AME) for any injured SAF personnel In 2014, aviation medicine was requiring medical repatriation Officer Council formally accredited as a medical from overseas. This includes the (Ministry of Health), subspecialty in Singapore. ARMC, assessment for fitness-for-flight, and is a member with National University Health the optimal mode of AME platform of the Subspecialty System as the sponsoring institution, (military or commercial platforms), Specialist Training will run a national programme, configuration of medical equipment Committee for known as the Aviation Medicine and deployment of the AME teams aviation medicine. to perform in-flight critical care. Subspecialty Training Programme, to train aspiring aviation medicine The AFMS has a specialist centre physicians in Singapore. Legend known as the RSAF Aeromedical 1. A group photo of AFMS personnel during the SAF Medical Corps Workplan Seminar.

1

OCT 2015 / SMA News 16 insight

accomplishments. This is a very high 1 accolade indeed.

What motivates us in the NMS is our need to support and defend Singapore’s every day. To this end, our MOs are required to:

1. Possess professional skills and knowledge to support ships that are deployed for prolonged durations during training and operations. More importantly, they are deployed on board ships to safeguard Singapore waters and to ensure maritime security by protecting our vital sea-lanes PROFILE Navy Medical Service of communication. 2. Train “under pressure” in From a humble beginning with just underwater medicine to support two wooden ships, the Republic divers and submariners at the of Singapore Navy (RSN) has Naval Diving Unit and on board the become a modern, versatile and submarine rescue vessel, respected modern force today. The MV Swift Rescue. office of Senior Medical Officer 3. Become “fly docs” as part of the was formed in 1971 to support the RSN naval aviation capability text BY fledgling Navy, and this has since (naval helicopter). transformed into the current Navy SLTC (Dr) Medical Service (NMS). NMS has been deployed for several Chow Weien significant operations such as HADR Generations of full-time National mission in Aceh (Boxing Day tsunami), Servicemen (NSF), NSmen and regular peace support operations in the SLTC (Dr) MOs have come through NMS to serve Northern Arabian Gulf (where we Chow Weien is on board the missile gunboats, missile assisted in post-war reconstruction concurrently corvettes, patrol vessels, mine counter efforts in Iraq), anti-piracy operations the Chief Naval measure vessels, landing ship tanks, in the Gulf of Aden, and search and Medical Officer and submarines and frigates. It is definitely recovery operation for AirAsia QZ8501 Commander Force not a task for the faint-hearted, as our earlier this year. Medical Protection MOs have to work independently in Command. He austere environments for prolonged As we celebrate SG50 and reflect oversees the durations out at sea, away from any on our past achievements, we also SAF Biodefence shore hospital. look ahead with confidence that Centre and Medical the commitment and dedication of Response Force. It is the strength of our NSmen that our people will enable us to achieve He is also a SAF has contributed to the successful greater things for the RSN, so that we cardiologist. development of the RSN naval surgical can continue to defend our waters and capability. The RSN is one of the few protect our every day. Legend navies in the world where surgeries can be conducted on board a ship. I would like to thank every doctor 1. Preparing the Deep Search This capability is regularly exercised and Rescue 6 submarine and medic (past and present) who rescue vessel for action. when we render much needed medical has helped build NMS into a credible and surgical assistance to remote medical force that can support the islands in the region during our socio- wide spectrum of RSN operations. civic missions. Of note, foreign navies We can indeed be proud of what we have commended the RSN for our have achieved.

SMA News / OCT 2015 insight 17

has enabled expeditious access servicemen’s commitment to the Military Medicine to world-class specialist cardiac nation’s defence stems partly from investigations and care, have also their family’s support. Institute integrated MMI with the nation’s larger healthcare ecosystem. Every year, more than 20,000 young The mission of the Military Medicine Singaporean males are enlisted into Institute (MMI) is to sustain and While primary and specialist NS, and they go on to become NSmen enhance the health of the SAF forces, healthcare optimises the health who return for In-Camp Training in peacetime and war, through the and deployability of each soldier, for the next ten or more years. This provision of primary and specialist the provision of swift and robust constantly replenished “captive” healthcare as well as emergency emergency medical care allows for audience represents an excellent medical care. These are delivered tough and realistic training. In this opportunity for health promotion. By through a network of medical area, MMI medical centres are always encouraging healthy lifestyles such centres, dental centres and specialist on standby to respond to medical as eating right, smoking cessation clinics run by NSF, NSmen, Defence emergencies that may arise during and reduction in obesity, MMI’s health Executives, as well as civilian medical rigorous military training. To maintain promotion efforts play a big role in staff. MMI is also the governing the proficiency of medical personnel, the health of a large proportion of body for healthcare policies, medical medical centres conduct frequent Singaporeans. Through imbibing classification and health promotion resuscitation drills and refresher practices that can stay with these in the SAF. training. Modern medical facilities and NSmen for their lifetime, we hope to resuscitation equipment, mirroring reduce the eventual burden of chronic To safeguard the health of our those in government hospital diseases on the nation. soldiers, MMI constantly benchmarks emergency departments, further serve itself against standards in the public to strengthen the trust and confidence healthcare institutions and takes PROFILE of the soldier and the public. alignment with established clinical practice guidelines. MMI employs a In caring for our soldiers, MMI medical governance system that taps faces unique challenges, as well on the expertise and experience of as opportunities. eminent senior doctors in the public sector, in the form of advisory boards and visiting consultants. This ensures Every soldier is a Singaporean son, that MMI delivers the best medical brother, husband or father. Given the text BY care to our soldiers, while keeping up conscript nature of NS, taking care of with the changes in the healthcare the serviceman frequently involves landscape. Other initiatives, such as managing his family as well. This is SLTC (Dr) Lim the Physician Partnership Programme, especially the case with NSF, where Hou-Boon where experienced civilian family anxious parents often ask more physicians are deployed in selected questions than the patient himself. SLTC (Dr) Lim medical centres to provide mentorship Nonetheless, it is in MMI’s interest Hou-Boon holds to NSF MOs, and the SAF Cardiac to reassure all parents that a robust Fitness Centre, where a partnership medical system is in place to take the appointment with National Heart Centre Singapore care of their children, for our of Commander of the MMI. He is an aviation medical 1 officer who joined the SAF in 1995 under the Local Study Award (Medicine) scheme. SLTC (Dr) Lim is also an ophthalmologist who practises at the Singapore National Eye Centre.

Legend 1. Resuscitation and treatment facilities in the new generation medical centres.

OCT 2015 / SMA News 18 insight

The first reaction I often get from conscription system, means that PROFILE people when they hear that I am mental health issues can arise from a military psychiatrist is a look of both healthy people being placed in an scepticism with a healthy dose of unfamiliar environment as well as from wariness. Psychiatrists in general patients with existing mental illness are pretty much used to this look serving NS. Therefore, the mandate regardless of our area of subspecialty. of the military psychiatrist to ensure This is often followed by the two the mental health of the soldiers goes inevitable questions, “Can you read beyond that of simple treatment to my mind?” followed by “So how do one that includes prevention and text BY you diagnose people who keng (Army optimisation. slang for malingering)?” MAJ (Dr) Soh In 1973, LTC (Ret) (Dr) Fong Yeng Teck Hwee This light-hearted dig at Hoi started the psychiatric services myself illustrates some of the in the SAF. He laid the foundation misconceptions that some people of what was to become and still MAJ (Dr) Soh Teck may have about the practice of is one of the hallmarks of military Hwee currently psychiatric practice — a complete psychiatry, especially in the SAF. holds the post of holistic occupational health approach to psychiatry, focusing on not only Deputy Commander There is currently no “official” clinical well-being but also the Military Medicine definition of military psychiatry. development of policies and the Institute (PHS). He It has often been described as the shaping of the military environment is also a military practice of psychiatry in the context psychiatrist who to ensure that our soldiers are able to of the military environment and perform at their best psychologically in derives immense joy the management of mental health the challenging military environment. from helping NSFs issues arising from military service. complete their two Personally, I have found the most apt This approach requires an in-depth years of national description published in a psychiatric understanding of the military service. Between bulletin from the Royal College of environment and the ability to these roles, he is Psychiatry, which describes military contextualise it to the practice of either on the hunt psychiatry as an “occupational psychiatry. The psychiatrist forms a for good food or his service” to maintain the mental health part of the greater SAF mental health next diving vacation. of individuals in the armed forces. ecosystem, which also comprises defence psychologists, counsellors There are distinct differences between and unit commanders. Legend a civilian environment and a military 1. The Psychology Care environment, the latter brings with it Military psychiatry can be broadly Centre family at the a unique set of operating challenges. divided into three categories — Military Medicine Institute This fact, coupled with the nature of clinical healthcare provision, mental National Service (NS) in Singapore, health policies and operational mental which is based on a universal health support.

SMA News / OCT 2015 insight 19

Our colleagues in the national A lesser known aspect of military Thus, the military psychiatrist has two healthcare system and generations psychiatry is its role in shaping the roles — that of a psychiatrist and an of doctors who serve as full-time milieu of the SAF with regard to officer. Although it can sometimes be National Servicemen (NSF) will be well mental health. This is far-ranging and challenging to align therapeutic goals acquainted with the Psychological encompasses policy setting, mental to that of organisational demand, Care Centre (PCC), which provides health screening, guidelines and with sound clinical judgement and clinical treatment to servicemen. PCC standards, as well as mental health an in-depth understanding of the includes the psychological medicine education and promotion. A key area military environment, guided by SAF inpatient centre, more fondly known that the psychiatrist works closely with core values, we can achieve mission as the SAF ward, which used to be the Defence Psychology Department success to ensure the mental well- located in Alexandra Hospital and (DPD) is that of ensuring psychological being of our soldiers. is slated to be relocated in the later well-being and the development of part of the year. The mental health mental resilience. The holy grail of issues treated at PCC range from any clinician is thus not treatment but temporary adjustment difficulties to better prevention of mental illness. psychiatric illness with age of onset in we saw a lot of war early adulthood, such as depression Another major area in military and psychosis. A key component of psychiatry is its role in operations. wounds and trauma the clinical practice not often seen From “shell shock” in the First World in hospital practice is unit liaison, War to post-traumatic stress disorders cases, from gunshot where the clinicians (including from the War on Terror, there are counsellors and psychologists) work recognised psychological costs to wounds to limbs closely with the unit to ensure that military missions. This extends to the serviceman is able to adapt to the peacetime training incidents, even that were blown military environment and to mitigate psychological trauma from being the impact of the environment on the exposed to scenes of carnage and illness and vice versa. The majority disaster during humanitarian missions. off or had to be of my consultations end with a The military psychiatrist works with telephone call or an email to the unit counsellors from the SAF counselling amputated. being in commander. This enables me to get a centre and DPD to develop strategies better understanding of the soldiers’ to mitigate the impact of such deployment imparts situation in camp, explain to the incidents. These include established commander the nature of the illness protocols for incident management, a sense of mission and its effects on the soldier’s screening and follow-up to evidence- ability to perform, as well as discuss based treatment approaches such and realism to your how we can work to help him get as eye movement desensitisation better without compromising reprocessing, stress debriefing and work and it brings mission readiness. cognitive behavioural therapy. home the picture 1 that war is real, and we must be prepared at all times.

— MAJ (Dr) Soh on his personal takeaway as part of the medical team deployed at a field hospital in Afghanistan.

OCT 2015 / SMA News 20 Opinion

need to undergo an intensive two- PROFILE Underwater week underwater medicine course to equip them with the fundamental Medicine skills and knowledge. In fact, we have extended the course to benefit The birth of underwater medicine doctors practising in the public in Singapore can be traced back sector and doctors from the region. to the 1960s when the Republic The course was renamed Singapore of Singapore Navy (RSN) received Hyperbaric and Underwater Medicine her first hyperbaric chamber. Since Course and is conducted once a text BY then, the Navy Medical Service year. It is accredited nationally by (NMS) has regularly sent medical Ministry of Manpower and accredited LTC (Dr) officers (MOs) to the United States, internationally by the Diving Medical Canada and Australia for training in Advisory Committee. Jeremiah Chng diving and hyperbaric medicine. By the end of the 20th century, NMS The development of underwater LTC (Dr) Jeremiah had established a robust medical medicine has expanded tremendously Chng is Head of support system for military diving and since the first RSN submarine, RSS submarine operations, as well as a Naval Underwater Conqueror, started operation in 2000. 24/7 emergency hyperbaric oxygen The RSN now boasts a state-of-the-art Medicine Centre. He treatment capability for all recreational submarine rescue vessel, MV Swift oversees the diving and commercial divers operating Rescue, and NMS operates a full and hyperbaric in Singapore and the region. As the suite of three multi-place hyperbaric medical support for only national resource in hyperbaric chambers, a high dependency all naval underwater medicine, NMS also provided medical ward and a general ward to support operations and consultancy in compressed air works treatment of submariners from drives the research to support projects such as the distressed submarines. and development construction of underground tunnels of underwater for the Mass Rapid Transit projects in The development of deep expertise medicine in the RSN. the 1980s and 1990s. in submarine medicine, as part of underwater medicine, ensures that our He completed his Diving and hyperbaric medicine is MOs are able to support current and Masters in Public a specialised field of medicine that new RSN submarines and to develop Health in 2012 and deals with the physiological effects Singapore as a regional submarine is an occupational of working “under pressure” in the rescue hub. Our close collaboration medicine specialist. underwater environment. Failure with Singapore General Hospital to accurately diagnose and treat Hyperbaric and Diving Medicine diving-related injuries may result in Centre has also enabled NMS to permanent injuries or even death. continue to contribute at national and regional levels by providing essential Till this day, very little of diving and 24/7 emergency treatments to SAF hyperbaric medicine is taught in military divers as well as recreational medical school. Therefore, all our MOs and commercial divers.

SMA News / OCT 2015 Opinion 21

performance maximisation and Military Sports obesity management. PROFILE

Medicine To equip our medical personnel with the appropriate skills and knowledge, Military sports medicine in the SAF the SAF sends regular MOs for started in the early 1980s, with overseas programmes to further the establishment of the Physical their education in this emergent field. Performance Laboratory, which functioned as a centre for exercise Currently, regular MOs who specialise stress testing. Over time, the evolution in sports medicine undergo the text BY and expansion of roles and functions Subspecialty Training Committee’s saw the emergence of physiotherapy Sports Medicine Training Programme. MAJ (Dr) services being provided, and the entity was renamed Soldier Performance SPC has also developed a Military Noreffendy Bin Ali Centre (SPC) in 1988. Today, SPC has Sports Medicine Training Programme expanded to include three sections for all Army regular MOs to equip them MAJ (Dr) Noreffendy — sports medicine, performance with core competencies in the areas of Bin Ali is currently maximisation and occupational health. prevention and management of heat Head of SPC at Army and musculoskeletal injuries in the Medical Services Military sports medicine is important military, and in soldier performance Headquarters. He to the SAF given the physically maximisation. The programme involves also runs clinic demanding nature of military participation in sports medicine, sessions as a training and the varying physical physiotherapy and podiatry clinics, resident physician fitness level of full-time National laboratory-based practicum sessions, at Changi Sports Servicemen prior to enlistment. SPC’s and research projects. Additionally, all Medicine Centre. programmes and initiatives have regular Army MOs attend a six-month contributed significantly to training postgraduate diploma course in sports safety, musculoskeletal and heat and exercise medicine at Queen Mary injury prevention and management, University of London.

annual medical screenings, spatial Aviation Medicine disorientation training and fatigue PROFILE management research work in Aviation medicine has its foundations tandem to ensure the aviator is in the physiology and psychology of medically fit, primed for optimum man in flight. It is the science of how performance and armed with the man affects flight and vice versa. right skills to overcome the specific psychological factors experienced It is omnipresent in the business of in flight. aviation — from the selection of a potential aviator candidate to the text BY optimisation of performance and Additionally, psychological enhancement of aircrew safety, assessment of the mental and MAJ (Dr) down to tailored and elaborate emotional states of pilots is equally Magdalene Lee treatment plans, even for the important. Understandably, it is most common ailments. possible to lose the licence to fly based on the severity of a medical MAJ (Dr) Magdalene Aviation medicine in the military is or psychological condition. Hence, Lee received her aviation medicine like a close sister to sports medicine, there is the unique challenge of training at King’s where the athlete reaches speeds building rapport and trust with College London, greater than the speed of sound in the patient so that open reporting the Royal Air Force a pressurised vessel while enduring becomes a culture. Centre of Aviation G-forces up to nine times his body Medicine and the weight, which threatens to hurl him Aviation medicine, though vast, is Republic of Singapore into unconsciousness. undoubtedly still in its infancy. The Aeromedical Centre. future in space travel ensures the It is the elegant balance of continued growth and development maximising performance and safety of this area of medicine. through monitoring, education and research. Processes such as

OCT 2015 / SMA News 22 Opinion

DUAL-TRACKED CAREER SAF regular medical officers (MOs) patience, attention to details and the undertake a dual-tracked career. When ability to translate esoteric clinical compared to our civilian counterparts, signs into ten differential diagnoses. we are exposed to an exciting range Although the context is different, SAF of responsibilities beyond clinical medico-administrative work utilises medicine, such as healthcare policy- similar qualities, which laid strong making, military exercises and foundations ahead of my return to disaster-relief operations. However, clinical practice. For example, while there is a trade-off, with less clinical establishing an electronic medical PROFILE exposure during the SAF-based records system for the SAF, I sat 1 phases of our career and truncated through hours of meetings with in- post-graduate medical training due to house information technology experts, our military commitment. sifting through the nuances and potential manners of interpreting every Anecdotally, those who have made a contractual clause, to safeguard SAF's transition back into full-time medical interests. Through the day-to-day practice as doctors-in-training have “fortunately” eased into their new roles operations in ensuring the smooth- running of SAF medical centres, text BY without major hiccups, somehow. However, some might wonder if it or devising and executing medical is “unsafe” for us to practise after support plans for military training, I MAJ (Dr) a significant hiatus from clinical was conditioned to think holistically, Kwan Kah Wai medicine. Having completed this pre-empt problems and formulate cross-over recently, I offer my appropriate countermeasures. Clarence perspective on the enabling factors Furthermore, the occasional trouble- beyond this screen of serendipity. shooting of unexpected incidents MAJ (Dr) Kwan Kah provided opportunities to develop Wai Clarence is In my observation, despite the speed problem-solving and decision- currently pursuing of medical advancement, most making qualities under stressful changes are evolutionary rather circumstances. These same skills are full-time post- than revolutionary. In a span of three also frequently required by practising graduate medical years, we have seen new therapeutic clinicians in managing complicated training under modalities come and old ones going cases and patients. the SingHealth out of vogue, but the general principles Gastroenterology of medical management remain the To sum up, SAF regular MOs have to Senior Residency same. Admittedly, I pale in comparison contend with truncations in post- Programme. with my more academically-inclined graduate medical training, as well counterparts who have seemingly as the transition between SAF work internalised every management Note and clinical practice. While this may flowchart in major clinical practice appear daunting to the observer, I 1. For SAF regulars guidelines. However, I still kept abreast am convinced that these challenges specialising in medical of major developments within my are surmountable with a reasonable disciplines, post-graduate chosen subspecialty despite being medical training (residency amount of hard work. Personally, it away from clinical practice, and thus, and senior residency) has also been a pleasant revelation I do eventually arrive at the same typically takes place in two that qualities honed by the SAF treatment regime or management separate three-year blocks could be cross-applied to a great at pre-defined points of plan (albeit slower due to time spent extent in clinical practice, adding SAF careers, straddling double-checking medical references). across a period of full-time confidence that success on both SAF rotation. There are some stereotypic traits SAF and clinical fronts need not associated with physicians, including be mutually exclusive.

SMASMA NewsNews / OCTsep 2015 Opinion 23

The Case for SAF Regular surgical specialists

One might question the rationale was successful in discovering the PROFILE and value of having regular surgeons fuselage of one of them. In the event and anaesthetists in a small armed of a distressed submarine scenario in forces that does not have military the region, the Navy would be able to hospitals, especially when we have mobilise and deploy a large medical a ready pool of National Servicemen team with expertise in critical care (NSmen) surgeons and anaesthetists and diving and hyperbaric medicine, staffing wartime surgical units and at short notice. This is where SAF volunteering for SAF missions. anaesthetists serve an essential and crucial role in the care of casualties text BY Without detracting from the requiring intensive care. contributions of the NSmen, here are LTC (Dr) Shalini some strong and valid reasons for Maintain surgical the SAF to have its own in-house capabilities Arulanandam surgical specialists. War invokes images of blast injuries and mangled limbs, underscoring LTC (Dr) Shalini Develop niche the importance of trauma surgery Arulanandam was surgical services in the field or at sea. Maintaining an the first female for SAF personnel effective surgical wartime capability to take up the Myopia is a serious problem that is a mammoth task even (or perhaps Local Study Award affects 80% of the population. The especially) in a country not at war. SAF (Medicine) in 1998. SAF Vision Performance Centre surgeons and nurses take the lead She joined the offers photorefractive keratectomy in training our National Service units Navy as a medical for personnel who sign up for critical in trauma surgery and conducting officer in 2004 combat vocations such as fighter research into new innovations in pilots, commandos, divers and trauma care. They form the backbone and completed her submariners, whose myopia would of surgical teams that are deployed in surgical training in have otherwise made them ineligible response to natural disasters and as otorhinolaryngology for recruitment. Without SAF’s in- part of peacekeeping efforts. this year. She is house ophthalmologists, it would currently on the not be possible to select, screen and On a personal note, the path to Health Manpower follow-up on the patients involved and becoming a surgeon while being an Development ensure that the servicemen are fit for SAF regular has taken longer than the Programme in their jobs. “civilian” route. At times, the challenge London specialising of juggling military responsibilities in Airway and Voice. Support SAF’s while trying to “keep my hands wet” peacetime roles has had me rushing from a camp at The Republic of Singapore Navy has one end of the country to an operating a world-class submarine support and theatre at the other, and taking on rescue vessel — the MV Swift Rescue. extra on-call duties on weekends and It houses a mini-submarine that public holidays. However, at the end of can dock with a sunken submarine the day, it is satisfying to have fulfilled to rescue its crew, a hyperbaric a personal ambition and to know that chamber complex and an intensive my skills will be of direct service to the care facility. This ship was deployed SAF and the nation. twice in the last two years in search of downed commercial aircraft and

OCT 2015 / SMA News 24 Opinion

Photo: Blair Bunting Photography

Another hill top zips by outside the the intercom in quick succession, canopy, its peak towering above us. “altitude, altitude” — that’s the In flying operations, there Here we are, travelling at 500 knots aircraft’s altitude low warning. The is no room for errors in (that’s roughly about 926 km/h, more bombs are dropped with punctilious communication. To avoid any than twice as fast as the fastest car precision, and the aircraft proceeds to confusion, words used by pilots in the world) and at 500 feet above pull up at 5Gs, with the G-suit doing are succinct and precise. Here the Arizona desert. The roar of the its squeeze again. A customary bank are some of the commonly used engines change slightly as the F-16 is initiated to catch a glimpse of the operational brevity words, also pitches into a 25 degree climb; the bombs landing on target, followed by commonly known as pilot lingo: G-suit, seemingly having a mind of an almost instantaneous jolt back to its own, was starting to do its thing Bandit — An aircraft identified wings-level position. again and squeezing the lower body as an enemy based on theatre uncomfortably like a sausage. This identification criteria. A 4G turn to the left ensues, followed is the pop. by the release of chaff and flares, Bogey — A radar or visual air with the all too familiar female voice contact whose identity A hundred things happen all at once is unknown. as the aircraft levels off, giving the prompting, “chaff, flares”, in case we uplifting feeling of the negative-G for don’t realise they have been released. Friendly — A positively a split second, followed by a right After an interminably long time identified friendly contact. bank to see the ground. I hear the pilot jink-ing around avoiding enemy fire, state with remarkable sangfroid, “tally the aircraft rolls back to wings-level Tally — Sighting (of a target, the target…” and the aircraft begins position at 5,000 feet for us to catch bandit, bogey or enemy to dive. An alien yet paradoxically a breather before setting up for the position). visceral female voice sounds out over next attack run… No Joy — No visual contact (with the target, bandit or 1 landmark). Furball — A turning fight involving multiple aircrafts with known bandits and friendlies mixed. Pop — Starting climb of an air to surface attack. Jink — Directive call to perform an unpredictable manoeuvre to negate a gun tracking solution. Bingo — Fuel state needed for recovery. Scramble — Take off as quickly as possible. Knock it off — Directive call to cease air combat manoeuvres, attacks or activities.

SMA News / OCT 2015 Opinion 25

2 Legend 1. Top Knife II course students. 2. Peace Carvin II, the RSAF detachment in Luke Air Force Base, celebrated its 20th anniversary on 11 Dec 2013.

Photos by Dr Benjamin Tan

It ain’t all glamour To the seasoned fighter pilots, all the States Air Force (USAF), we are all In all honesty, there really isn’t much unpleasantness is part and parcel taught during residency training about a fighter cockpit that’s even of their daily routine. “It’s just not the basic physiology of flight and remotely close to being pleasant. the most comfortable workplace,” how the human body is never The Plexiglas® bubble canopy acts some say. Despite that, they have to really meant for the empyrean. We like a great big glasshouse and the stay focused on the task of the day; know fighter pilots are subjected to cockpit heats up very quickly in the this could be pulling 9Gs to get their numerous physiological stressors Arizona desert. The flying gear is aircraft into position to shoot down such as acceleration force (G), spatial chunky and uncomfortable and the the bandit while avoiding a mid- disorientation, pressure changes helmet hot and heavy. You cannot air collision at 700 knots, or flying and visual illusions. These problems see below nose-level because of the perilously close to the ground in a oxygen mask, so you need to move are further compounded by the high surface attack mission to drop bombs workload in their stressful “offices”. your head a lot more to see things on an enemy target. Every manoeuvre in that new blind spot. Your throat is Knowing the theory is one thing, but a potential catastrophe, every second perpetually dry from the unceasing there is nothing like putting yourself potentially the last. There is only room supply of dry air from the mask. Add in the cockpit to experience the full for perfection in precision. Such is the to that the incommodious cabin, the impact of the fighter pilot’s job. Since stressful “office” of the fighter pilot. rock-hard seat and the smell of jet 1991, the USAF’s Air Education and exhaust and aircraft oil. And there’s Training Command has put together As part of our training to be aviation the ongoing din of the jet engine in a course for flight surgeons to do just medical physicians, or flight surgeons the background, even if you only hear that — be a fighter pilot for two weeks! the sound of your laboured breathing. as they are called in the United

Negative G Spatial disorientation The G Hypogravity due to the G-force acting This often occurs due to erroneous The centrifugal force felt by pilots when in the opposite direction. Pilots get a sensory inputs produced by the making a turn, described as a multiple of rush of blood toward the head and vestibular system, especially with gravitational force. In a 9G turn, the pilots may experience “red out” vision. degraded visual cues or the absence of it. feel the weight of their body multiplied by nine times and blood is aggressively pooled to the lower limbs. The inflation of the G-suit (compressing the lower body) and the anti-G straining manoeuvre are methods to prevent pilots from losing consciousness Physiological stressors encountered while battling in the air. when flying a fighter aircraft

Hypoxia As fighter aircraft cabins are not Pressure changes completely pressurised, hypoxia can Due to air volume expansion on ascent occur due to a reduction in barometric and contraction on descent, pain may pressure and partial pressure of be experienced in the sinuses, Other physiological stressors oxygen. It also explains why fighter abdomen and other air-filled organs Motion sickness, aircraft vibration, noise, pilots need to fly with an oxygen mask. subjected to these pressure changes. night flying visual illusions and many more.

OCT 2015 / SMA News 26 Opinion

Doctors learning to be avoid being shot down by hostile back to flying whenever they are fighter pilots enemy and yet still maintain your afflicted by medical conditions. Great Conducted at Luke Air Force Base, the wits about you to manoeuvre your care is taken to ensure that their premier F-16 training base in the USAF, aircraft in three-dimensional space. full recovery and optimum physical the Top Knife II course purports to Snap decisions must be made conditioning is achieved. However, that teach flight surgeons the essentials of in time frames which are alien to may not be always possible; medical flying and operating the F-16 Fighting most doctors, while keeping a tight conditions which are degenerative or Falcon. Besides revising the “medical watch over fundamental (yet still chronic in nature may persist. This is stuff” of fighter flying such as the Gs, critically important) parameters such when difficult decisions about their spatial disorientation and flying with as fuel state, aircraft attitude and flying disposition have to be carefully night vision goggles, a large portion altitude, air speed, etc. The ability to considered and made after having of the academics involve teaching think at the speed of light, maintain understood the exact requirements the flight surgeons how to operate composure under duress and to plan and demands of their job. The risks the flight controls and radars. Using three to four steps ahead of time are and responsibilities associated with computer aided instruction and flight distinct qualities which have become such Daedalian decisions is the simulators, course students are given synonymous with the best fighter quintessence of aviation medicine. the chance to fly, operate and fight the pilots. “I am humbled by how you guys F-16. The apogee of the course comes train to get here and how you do this With seemingly erudite and industrious in the second week, when students with such consistency every single allies in the form of flight surgeons, are strapped into the back seat of a day,” I said in admiration to the pilot one might expect an alacritous show F-16 to fly with the operational pilots, who flew with me on my last sortie. of warmth and gratitude in return. and perform what they had rigorously “It’s easy when you practise it every “Truth be told, we don’t like doctors.” studied and practised the week prior. day,” he replied. This came curtly from a very senior Graduates from this course will officially and illustrious USAF fighter pilot we be called the Viper Docs. The practice of met on the course. “We cannot believe aviation medicine that there is anyone, other than God Without exception, the experience Indeed, fighter pilots are a rare and ourselves, who can decide our is a massive adrenaline rush for breed. It takes several years and a destiny. We fighter pilots live to fly and all Top Knife II graduates. But fun few million dollars to train a fighter no one should be able to take that aside, the exposure is invaluable pilot — possibly the only profession away from us.” You see, fighter pilots because the experience of operating which eclipses that of a doctor’s. It are a very confident, highly motivated the F-16 aircraft (with its attendant is not surprising that it is harder to and passionate group of professionals, physiological stressors in full train or find a good fighter pilot than who leave nothing to chance. And force) can never be fully taught a good surgeon; for one, fighter pilots because interactions with the doctor nor appreciated through didactic are expected to be at their prime may yield surprises with regard to learning. Workload takes on a whole at a much younger age due to the their fitness to fly, they very seldom new meaning as you are trying to physical demands of the profession. seek medical attention. Therefore, fly the aircraft, work the appropriate In our practice of aviation medicine, unlike most doctors, aviation medicine modes of the radar to find the target, we attempt to put every trained pilot physicians usually face “patients” who significantly downplay their symptoms or deny them outright. 3 Over the years, aviation medicine physicians have learned to hone that special ability to pick up hints during casual conversations, or detect subtle behavioural changes in pilots to identify those who may need medical help. However, identifying a pilot in need is one thing, convincing them to seek medical attention is another.

An important part of our job as aviation medicine physicians, therefore, is to cultivate trust from our clients — the pilots. Only with trust can we convince the pilots that we are there for their best interest, and that we will go out of our way to put them back in the air should they suffer from

SMA News / OCT 2015 Opinion 27

any medical condition. Attending the Top Knife II course is one of many 5 PROFILE steps toward fostering this trust. By experiencing exactly what the pilots go through in the air and learning to understand some of their lingo during the two weeks, the course enhances their confidence in us — that we can make better decisions when it comes to treating their ailments and deciding text BY on their flying disposition. The analogy in the medical aspect would LTC (DR) be to reverse the doctor-patient roles with our patients for two weeks, to Maybe it was pure luck or that I was BENJAMIN TAN experience their daily grind amid their still feeling high from all that flying, but struggle with medical disease, just so somehow I remember spending more LTC (Dr) Benjamin that we can gain their trust. Surely, time asking my patients the simple Tan is a consultant that is an interesting proposition and questions that mattered to them, such in aviation medicine it might just change current mindsets as, “How long was your waiting time?”, with the Republic of about finishing a busy clinic on time “Who looks after you at home?” and Singapore Air Force regardless of the patient’s consultation “How did you get to the hospital — by and is currently experience or to arrange follow-up train, bus or taxi?”. It dawned on me pursuing his second appointments with no consideration that maybe I have started learning clinical specialty in of the patient’s family background and to be a more patient and caring ophthalmology. social support systems. doctor — one who now makes an effort to strengthen communication, Legend Back in the clinic understands their needs and builds the 3. Top Knife Alumni, L to R: Back in a busy clinic in the hospital, ever-important trust with my patients. LTC (Dr) Wilfred Lim, SLTC I had strangely encountered, for the The roar of jet engines and glamour (Dr) Dale Lim, COL (NS)(Dr) third time in a day, a patient thanking of flying F-16s aside, I suddenly realise Chong Chun Hon, COL (NS) (Dr) Robin Low, SLTC (Dr) me for being a “different doctor” — that the most important lesson Wong Sheau Hwa, LTC (Dr) presumably in a positive way and imparted to me through the Top Knife Benjamin Tan and MAJ (Dr) something which eluded me the last II course was simply how to be a Hong DeHan. 13 years of my medical practice. better doctor. 4. Viper Doc in the backseat of a F-16 aircraft. 5. The RSAF detachment, Peace Carvin II flies with 4 the “Black Widows” — RSAF’s F-16s from the 425th Fighter Squadron over the Arizona Desert.

Acknowledgement

This article was written with permission to include excerpts from unpublished writings of COL (NS)(Dr) Robin Low (the first Top Knife II graduate and Viper Doc from Singapore). Like some of the world's greatest ideas, the origins of this article can be traced back to a few pints of beer and a progressively “coherent” exchange of ideas among Viper Docs as the night went on.

OCT 2015 / SMA News 28 Opinion

forget standing at the bedside of a cadet in the hospital’s emergency department and asking him if there was anything I could do for him. His only request was to re-join the course as soon as possible.

Moments like these make me realise that MOCC is essentially a course of self-discovery where young men discover their limits, understand their The Medical Officer Cadet Course strengths and weaknesses, uncover 1 (MOCC) is a pretty “xiong” (Singlish their potential, push their boundaries for difficult) three-month course that and develop their leadership skills. all Singaporean doctors will have to MOCC is also one of those rare times embark on when they return to serve where the batch learns about one their full-time National Service after another — the good, bad and ugly. attaining their medical degrees. The aim is to equip our medical officers I started the course paying more with life-saving skills and instill in them Photo: attention to the weaker, slower and Dr Ou Yang Youheng the necessary qualities needed to quieter ones. However, I was surprised. treat our fallen soldiers and to become The slowest runner at the beginning future leaders of the SAF. PROFILE of the course eventually got Gold for Having gone through MOCC his Individual Physical Proficiency several years ago and as a Course Test, so I have come to accept that Commander now, I can sincerely initial impressions can be deceiving. say that MOCC is indeed a very There is so much an individual can meaningful journey. achieve as long as he sets his mind to it, which leads me to my other key Through the three months, I observation — motivation being an infectious multiplier. Motivation has a text BY have seen young men push themselves to breaking point and way of infecting everyone with a “can MAJ (Dr) pulling through. Quiet gentlemen do” spirit that pushes each individual stepping up to embrace the torch towards personal excellence. Joachim Yau of leadership, commanding respect from their peers. The miraculous As a course commander, I have learnt MAJ (Dr) Joachim physical transformations of pale about humility, the importance of Yau is currently the and pudgy doctors into lean, teamwork, regional and international Course Commander tan and muscular soldiers. issues, and how to nurture the of the 80th Medical next generation of leaders. Most Officers’ Cadet I have witnessed the mettle and importantly, I have learnt much Course and the resilience of young men who refused more about myself — as a doctor, Armour Formation to stay down after each fall. As medical officer, senior, junior and Medical Officer. dramatic as it may sound, I will never as a human being. He is also a senior resident at Tan Tock Seng Hospital. 2

Legend 1. The 72nd MOCC Vanguards. 2. Recently commissioned medical officers — The 80th MOCC Bravehearts.

Photo: Dr Joachim Yau

SMA News / OCT 2015 Opinion 29

After our commissioning, we each One memorable NS experience was went our separate ways, having in dealing with a serviceman afflicted PROFILE been posted to different units with hidradenitis suppurativa (HS). for the remainder of our National He was having a particularly bad Service (NS). In my case, it was for flare, which impaired his ability to one year and five months, almost perform simple tasks. He was thus the equivalent of three postings of viewed negatively and subjected to the medical officers (MOs) posting workplace bullying. Psychologically, exercise! I was put in charge of a it affected him significantly and military medical centre, which meant resulted in poor performance and text BY that I ran an entire medical centre commitment to NS. When I first with the assistance of medics and saw him, I felt that he needed help Dr Jipson Quah support staff. to break out of this vicious cycle. I treated him with appropriate Dr Jipson Quah is As the MO-in-charge, I had to run courses of antibiotics and referred a medical officer clinics every day, and manage and him to the National Skin Centre for who has recently train full-time National Servicemen follow-up. I also sought to change his vocation and workplace such completed his (NSF) medics to ensure the smooth National Service and running of the medical centre. I also that he was allowed minor but helpful concessions for his medical is currently attached picked up useful administrative skills to the Department such as inventory management, condition. His HS flares were reduced significantly and he was of Pathology at event organisation and investigation Singapore General report writing. I realised that the able to continue serving NS in a meaningful fashion. Hospital. He enjoys practice of effective medicine is not music-making, just purely clinical but also requires Having returned to civilian practice, I fitness-related solid administration, infrastructure recognise that the public’s perception activities and and standard operating procedures to of NSF MOs is sometimes a little editorial work in ensure that all objectives are met in a skewed due to what they read on social his free time. holistic fashion. media. But these MOs and residents have deferred their hospital training Legend However, the military MO’s practice and practices to fulfil their duty to the is sometimes a thankless task. 1. My very own batch, the country and to care for their fellow 77th Medical Officer Cadet Servicemen may present with an countrymen. I wish to encourage my Course Centurions! astonishing myriad of problems, and NSF colleagues to never lose heart and it can be challenging to manage these to strive towards even higher standards issues all at once. Servicemen and of medical practice to uphold the their parents are also increasingly institution of NS. demanding on medical management, which adds a tremendous amount of stress on MOs. We also have to 1 assess the servicemen to determine their physical employment status and suitability for training activities. Occasionally, servicemen’s expectations can be far removed from reality and NS requirements. Nevertheless, we try our best to moderate expectations and find an acceptable solution for all Photo: Dr Jonathan Gan parties involved.

OCT 2015 / SMA News 30 from the heart

had fractures and infected wounds. Others suffered from poor sanitation or exposure to the cold. However, the most poignant stories were those about the loss of friends and relatives. Though they said little, we could see the emotions in their eyes, and there was little else we could do except to hold their hands and give them the best medical attention we could.

A medical mission of this scale involves a rigorous timetable. But I had to find time to sit down and reflect on the day in order to find the focus to carry out the mission. This was different from being a clinician in a hospital. On a mission, I had to think and make the right decisions; decisions that could affect the medical operations, our medical supply, and the safety and welfare of the medical team.

Singapore celebrates her 50th birthday Despite the suffering I have witnessed PROFILE this year. We owe much of our success in such medical missions, there is one to our political and economic stability. common thread that runs through — Yet, Singaporeans often forget how we saw goodness in the people who fortunate we are to be sheltered from laboured day and night, at the risk of the natural disasters that befall our their own health and safety, for those neighbours. It is, therefore, important in need. After the Nepal quake, the that Singapore extends her hand in locals showed great courage and friendship and assistance in their resilience, rallying together to assist time of need. their fellow men. TEXT by While the purpose of the military I recall an elderly lady who had been forces is to avert violence and treated by our team. A few days after LTC (DR) ADRIAN TAN destruction, the SAF Medical Corps her treatment, she returned with bags serves to alleviate and mitigate the of food, prepared for us in gratitude. LTC (Dr) Adrian suffering of mankind, whether in Despite her poverty, she gave all Tan holds the war or in peace. that she could, and it humbled us appointment of to accept her gift. While we go on a Head of Army I have had the privilege to serve on mission to render assistance, often, Developmental Force five medical missions with the SAF. the mission leaves us richer from Medical Group. An Most recently, I was the Medical Team the experience. The very people we orthopaedic surgeon Commander of the SAF medical helped also taught us lessons in by training, he has mission to Nepal. When we first set resilience, courage and generosity. a keen interest in eyes on the devastation caused by the medical humanitarian quake, our hearts sank; everywhere, Therefore, we should always be proud missions, having we saw displaced people who had and appreciative of our vocation as being trained by the to camp out in open spaces to avoid medical men and women. We should United Nations in collapsed buildings. We served the also consider ourselves fortunate to disaster assessment injured at our medical post in Gorkana have had the opportunity to undergo and sent out mobile medical teams and coordination. medical training as well as to put to remote villages to reach those who our training and skills to use in the were unable to get help due to the assistance of others. inaccessibility of their villages. We do not seek any other purpose; not The patients recounted stories of for fame nor for glory. falling debris and caving roofs. Some

SMA News / OCT 2015 from the heart 31

1 Legend 1. One of the Humanitarian Assistance and Disaster Relief efforts by the SAF Medical Team in the 1990s. 2. Evacuation during the mishap of Hotel New World. 3. LTC (Dr) Adrian Tan providing medical treatment to a local during Operation Swift Lion (OSL) in Nepal. 4. MAJ (Dr) Jonah Kua treating an Afghan patient with a crush injury to his hand.

2

3 4

OCT 2015 / SMA News 32 from the heart

5

6 7

Legend 5. The SAF and Ministry of Health Teams were received at the reception ceremony after the OSL (Nepal) in 2015. 8 6. LTC (Dr) Adrian Tan, second from left, leading the resuscitation of an Afghan boy, a victim of a bomb blast. 7. BG (then COL) Tan Chuan- Jin led the Humanitarian Assistance Support Group to provide emergency relief to Meulaboh, Aceh in 2004. 8. LTC (Dr) Adrian Tan (right) presenting the symbol of the Singapore team presence to Dutch colleagues in Uruzgan, Afghanistan.

SMA News / OCT 2015 exec series 33 Deputy Applications under the Mental Capacity Act — Writing the Medical Report

Losing mental capacity orders regarding the scope of the A person can lose mental capacity deputy’s powers. A medical report is for various reasons, such as a stroke, needed to assist the court in making head injury or dementia. The person the decision on P’s mental capacity. could have been the sole breadwinner It is a legal requirement for the report and primary decision-maker of the to be exhibited in a doctor’s affidavit household. But now, he is the one that accompanying the deputy application. needs to be taken care of. Consequences of rejection PROFILE In particular, someone needs to be of medical report appointed as his official representative, If the medical report is not adequate, to make decisions on his behalf, in the court will reject the deputy his personal welfare, and property application and ask the deputy to and affairs — as his bills still need to get a further and better medical be paid, his family provided for, and report which fulfils the relevant there may be insurance monies to be requirements. This means that the claimed, properties to be maintained, appointment of the deputy will be etc. If the person (“P”) had made a delayed, which can lead to serious TEXT BY Lasting Power of Attorney (LPA), then consequences for P and his family, he would have nominated one or more as all his assets are frozen and major Lim Hui Min “donees” to do this. However, if he decisions cannot be made for him had not made an LPA, then someone until the deputy is appointed. who is interested to handle P’s affairs Lim Hui Min is may apply to court under the Mental Tips and pointers for presently the Capacity Act (MCA), to be appointed writing medical report Director of the as P’s “deputy”. Legal Aid Bureau. 1. Use the template provided and Any errors and any Deputy application — fill it up completely views expressed are medical report required There is a court-designed entirely the author’s The application to appoint a deputy template to capture the various own. In particular, (“deputy application”) will ask the legal requirements for the medical they do not represent court to: (a) make a declaration that report. Do not use your own the views of the template nor annex your report P lacks the mental capacity to make Bureau or the decisions in matters relating to his written in your own format to the Ministry of Law. personal welfare and/or property template. Fill in every box in the and affairs; (b) make an order for template and do not leave any blank. The template is available the applicant to be appointed as P’s at https://www.mlaw.gov.sg/ deputy for his personal welfare and/ content/lab/en.html. You can or property and affairs; and (c) make

OCT 2015 / SMA News 34 exec series

also ask the lawyer acting for the ii. Details of the doctor- 3.4 Avoid unexplained applicant to send you the patient relationship. medical jargon Word document. Ie, (a) how long the doctor has Your report is going to be read known P (eg, “The patient first by laypersons (lawyers and 2. Type, NOT hand-write, into came to see me in 2010…”); (b) how judges) and not just medical the template regularly P has been seeing the professionals. So you should Doctors’ handwriting can doctor (eg, “The patient has come explain the technical medical terms in the report (eg, sometimes be illegible! In one to me for regular follow-ups, two to “perseveration”, “AMT score of 1/10”, case where the doctor handwrote three times a year, in the past five “dysphasic”) in simple English, his report, the word “impairment” years…”); and (c) the date of the looked like “improvement”, which as if you were explaining things doctor’s last examination of P. ended up causing confusion for to the reasonably educated, both the lawyer and the court. but non-medical, caregiver of a 3.2 Ask questions to establish patient you are treating. 3. Key points P’s mental capacity There are different tests of mental 3.1 How recent should the last Further reading capacity that you can apply. It is examination of P be, counting I hope the tips and pointers above will from the date of the report? up to you to choose which you help you in writing a medical report think is the most appropriate. An that the court finds sufficiently detailed This depends on: example of a common test is the and useful in making a decision on 1 (a) The length and frequency of the Abbreviated Mental Test (AMT). P’s mental capacity. This article is not doctor-patient relationship intended to give, or be a substitute for, As a rule of thumb, and subject In addition, you may also ask any legal advice. You should seek the to P’s condition, for cases where questions related to P’s personal help of a lawyer if you have a specific the doctor has only seen P once welfare and/or property and legal issue on any MCA matter. or twice, there should be a lapse affairs (eg, If P has a flat, what he of no more than two to three would like to do with it; whether P It is beyond the scope of this article months from the date of the last knows what medical conditions to deal with the principles and examination of P to the date of he has and how he would like to procedures of the MCA, but you can the report (“the lapse”). However, be treated). refer to the following links (https:// if the doctor has been seeing P www.familyjusticecourts.gov.sg and regularly over a few years, then a 3.3 Give evidence to support https://www.publicguardian.gov.sg) lapse of five to seven months may your conclusions for further information and reading be acceptable. materials on these matters. If you have a conclusion, (eg, “P could not understand simple (b) Whether P’s condition is Finally, if you would like to see an questions.”; “P made mistakes temporary or permanent example of a filled-in template, you can in simple maths.”; “P does not If P’s condition is permanent (eg, refer to the Legal Aid Bureau’s website demonstrate understanding of dementia), then seven to eight (https://www.mlaw.gov.sg/ content/ months, or a year’s lapse may be information relating to more complex lab/en.html). acceptable. If P’s condition is not decisions such as those requiring permanent (eg, he is recovering a large sum of money.”), you need from a head injury) then a lapse to put down the supporting Acknowledgement of no more than three to six evidence (eg, “P answered ‘I don’t months, or even less, would be know.’ when asked ‘What is your The author is grateful to acceptable, depending on when name?’”; “P could not subtract seven P’s next review is. District Judge Colin Tan for his from ten.”; “P said $10, when asked comments on the draft of this how much his flat was worth.”). Therefore, it is important to state: article, and to Ms Tan Rou’en, You should write down the exact Assistant Director of the Legal i. Whether P’s condition is a questions you asked P and what Aid Bureau, for her help with permanent or temporary one and he said that made you reach your the article. the basis for that opinion. conclusion on P’s mental state. Eg, if P is in a “vegetative state”, If you administered a test, do not you should state whether this just give the test score, but explain References is a permanent condition, ie, a what was asked and what the 1. Ministry of Health. MOH Clinical Practice “persistent vegetative state”. answers were. Guidelines 3/2007. Page 22. Available at: https:// www.moh.gov.sg/content/dam/moh_web/ HPP/Doctors/cpg_medical/current/2007/CPG_ Dementia_Booklet.pdf.

SMA News / OCT 2015 Life in pixels 35 Life in

SMA NEWS PHOTO COMPETITION

Winning Photo July Theme: “Singapore by Night”

Garden city at night Dr Lau Teh Yee

Camera: Lens: Shutter Fuji F2.0 speed: X100 1/30 s

Aperture: ISO: 2500 f/2.8 Judges’ comments “I like the juxtaposition of flowers and rolling meadows in the hub of a bustling city — Our Honourable Garden City.” mention “Nice composition with the ‘flower’ of the Art and Science SG 50. The Museum in the upper left rule Jubilee of thirds. The setting sun with Dr Deshawn Tan the evening lights lit up is a nice backdrop.”

“Nice shot of a fairly new local icon — the ‘lotus leaf’ museum, with projection of a free field and flowers. Juxtaposition of nature in a city describes our city very well.” Nation Building

The September theme for the Life in Pixels SMA News Photo Competition is Nation Building. Send your best photographs along with your name and MCR or matriculation number to [email protected], with the email subject “NATION BUILDING” by 15 November 2015. All photographs submitted must be in JPEG format and sized to at least 2,480 x 3,508 pixels. The winning entry will be featured in SMA News, and the winner will receive $50 in CapitaVouchers, a Crumpler camera bag and a Canon Digital Ixus lanyard with 16GB thumbdrive.

This photo competition is open to SMA members in good standing only. Visit https://www.sma.org.sg/lifeinpixels to check out the rules prior to submission. 36 Calendar SMA EVENTS NOV – DEC 2015 DATE EVENT VENUE CME POINTS WHO SHOULD ATTEND? CONTACT CME Activities

2 November Sheraton Towers Family Medicine and Margaret Chan 6223 1264 Mastering Your Risk 2 Monday Singapore All Specialties [email protected]

7 November SMA Lecture 2015: Medicine Doctors and Healthcare Carina Lee 6223 1264 One Farrer Hotel & Spa 2 Saturday & Diplomacy Professionals [email protected]

11 November Sheraton Towers Family Medicine and Margaret Chan 6223 1264 Mastering Your Risk 2 Wednesday Singapore All Specialties [email protected]

15 November Family Medicine and Lin Shirong 6223 1264 BCLS Course Alumni Medical Centre TBC Sunday All Specialties [email protected]

17 November Mastering Shared Family Medicine and Margaret Chan 6223 1264 Holiday Inn Atrium 2 Wednesday Decision Making All Specialties [email protected]

18 November Sheraton Towers Family Medicine and Margaret Chan 6223 1264 Mastering Your Risk 2 Wednesday Singapore All Specialties [email protected]

24 November Mastering Professional Sheraton Towers Family Medicine and Margaret Chan 6223 1264 2 Tuesday Interactions Singapore All Specialties [email protected]

20 December Family Medicine and Lin Shirong 6223 1264 BCLS Course Alumni Medical Centre TBC Sunday All Specialties [email protected] Non-CME Activities

5 December SMA Intermediate Food HY California (Marina SMA Members Mellissa Ang 6223 1264 NA Saturday Photography Course Bay Sands) and Guests [email protected]

SMA Members' Appreciation Nite 17 December SMA Members Rita 6223 1264 (Star Wars: Episode VII — The Shaw Theatres Balestier NA Thursday and Guests [email protected] Force Awakens) SMA EVENTS NOV – DEC 2015 38 aic says EDUCATION FOR BETTER ELDERCARE BY AGENCY FOR INTEGRATED CARE

To meet the needs of Singapore’s ageing population, As part of the award, GPs get to collaborate with and a substantial increase in capacity is being planned support their sponsoring Community Care institutions, and implemented for the Community Care sector, using what they have learnt. GPs and Community Care especially since there is an increasing number of institutions are then able to forge closer links, thus patients being discharged from public hospitals to seeding and strengthening a longer-term relationship. nursing homes who have higher levels of medical GPs can also apply their newfound knowledge and and nursing needs. Managing these patients skills to meaningful causes outside their practice and requires a greater level of care from doctors, and the connect with other groups of patients who need help. Graduate Diploma in Palliative Medicine (GDPM), Graduate Diploma in Geriatric Medicine (GDGM) The Community Care–GP Partnership Training Award and Graduate Diploma in Family Medicine (GDFM) is administered by AIC, who is working with the sector can equip doctors with the necessary skills and and linking up interested GPs and Community Care knowledge to care for such elderly patients. institutions. If you are interested to find out more, email us today at [email protected]. The Agency for Integrated Care (AIC) and Ministry of Health (MOH) are pleased to announce that the THE COMMUNITY CARE–GP PARTNERSHIP Community Care–GP Partnership Training Award is TRAINING AWARD AT A GLANCE now open for application. This award will fund the course fees for general practitioners (GPs) taking the GDPM, GDGM and GDFM — programmes that The study award funds 70% of course fees for GPs are relevant to the needs of the Community Care who are enrolled in one of these courses and are sector. MOH will co-fund 70% of the course fees sponsored by an eligible Community Care institution: under this award, while Community Care institutions that qualify for the Community Silver Trust may tap • Graduate Diploma in Palliative Medicine (GDPM) on this grant to sponsor the remaining 30%. • Graduate Diploma in Geriatric Medicine (GDGM) • Graduate Diploma in Family Medicine (GDFM) The Community Care–GP Partnership Training Award is designed to support GPs who would like to GPs who have gained admission or are currently step forward to serve the Community Care sector. enrolled in the above programmes are still Armed with new knowledge and skills, GPs will be in a better position to manage complex cases eligible to apply for the training award through and practise at a higher level of medicine, thus their sponsoring Community Care institution complementing hospital medicine, and benefiting before 31 December 2015. more patients.

Community Care GP-Partnership Training Award is now open for application. Register now! Email AIC at [email protected] for more details and assistance to enrol in the scheme.

This article was first published in The College Mirror (September 2015)

AIC CFPS 08302015_5FA.indd 1 30/9/15 3:35 pm