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Lessons from SARS Articles Written by Prof Chee Yam Cheng and Published in SMA News 2003/2004 6 Personally Speaking

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Lessons from SARS Articles Written by Prof Chee Yam Cheng and Published in SMA News 2003/2004 6 Personally Speaking Lessons from SARS Articles written by Prof Chee Yam Cheng and published in SMA News 2003/2004 6 Personally Speaking SARS (and Me) (Part 1) By Prof Chee Yam Cheng, Editorial Board Member This article is a diary, my diary, of events. Editorial Note: cases as SARS was noted to be highly airborne. This has huge implications The following article was submitted on contagious. At that time, Tan Tock Seng on the protection of our staff. 31 March 2003. Contents are accurate and current as at this date. Part 2 will be published Hospital continued to function as it Therefore, for those dealing with suspect in the next issue of SMA News. always did – as a general hospital. or probable cases (the difference being Patients were still admitted through the latter has CXR infiltrates), protection UK BOUND – THE HK CONNECTION Emergency Department (Tan Tock Seng of self meant the wearing of the 3M On the night of Sunday 9 March 2003, Hospital ED is the busiest ED in Singapore), N95 mask, properly fitted, and with I left Singapore for London on Singapore and elective operations were ongoing. gloves and gown. Airlines. I was headed for Glasgow ICU beds were in demand. Patients were in 3 categories: and arrived safely there on Monday That meeting gave me the first for observation, suspect SARS and morning. I was there for some medical inkling of the pulse of our staff. Yes, probable SARS. It was essential that meetings of the Royal College of there was fear. Yes, nobody would there be a history of contact with a Physicians. The meetings proceeded volunteer to manage the cases. All SARS patient, or history of recent travel as planned and on Friday evening, quite natural reactions. We were not to the 3 countries mentioned earlier. I was on the night flight of Singapore fully aware of what SARS was about, Of course, patients could still be febrile Airlines. I arrived in Singapore on at that time. Nonetheless, once the from URTI, UTI, cellulitis, and so on, Saturday 15 March evening. While in decision was taken to allocate certain but in such cases, they were treated Glasgow, the TV programmes were resources (staff, equipment, wards, as non-SARS, in the usual manner. about Tony Blair and his war efforts. ICU, etc.) to manage SARS patients, Most cases were admitted to the CDC He was being taken to task by his own everyone did their best and showed low lying wards with lots of fresh air, MPs and members of the public. He their commitment to their professional open ventilation, sunshine and green was accused of being reckless. Also on standing and ethical standards. grassland pleasing to the eyes. If they TV was European football. Arsenal, What did we tell them? These were deteriorated and became breathless, Liverpool, Celtic and Real Madrid. There our assumptions: CXR with infiltrates, then they were was nothing about SARS, Hong Kong, SARS is Severe Acute Respiratory moved over to Tan Tock Seng Hospital’s Guangdong or Hanoi. Syndrome. As its name implies, the main building, and isolated in single However, on CNN, there was mention severely ill ones suffer respiratory rooms in certain wards on certain of SARS. SoSARS I asked my Hong Kong doctor failure from ARDS. It is acute. Usually, levels. Segregation of SARS and non- friend, also present at the same meetings, by the third day of illness (first day SARS patients in main Tan Tock Seng about the SARS situation in Hong Kong. defined as when the fever starts), lower Hospital had begun. Likewise, staff It was not rosy. He promised to send me respiratory tract involvement begins. were divided into the SARS and non- updates on our return home. The chest X-ray starts to white out, SARS teams. the PaO2 falls, and supplementary Remember at this stage that Tan HOME AGAIN oxygen is mandatory to maintain life. Tock Seng Hospital was still operating It was Monday 17 March when I Further deterioration means assisted as per usual. We are a large hospital returned to Tan Tock Seng Hospital. ventilation. Of course, some do not with over 1,000 beds and the busiest As usual, I ran my clinic at KKWCH go that far and after oxygen therapy ED in Singapore. that morning. I was aware that there for a few days, start to improve, fever were already SARS cases in the ICU. settles, and appetite returns. MBBS EXAM – THE HK CONNECTION That afternoon, I was present at the The cause is viral. Which virus – Then came Tuesday 18 March. I had my meeting chaired by an anesthetist, initially thought to be paramyxovirus reply from my Professor HK doctor with nurses and doctors discussing (as are measles, mumps and RSV and whom I met in Glasgow. His e-mail said how best to deal with the resources Nipah) – but now, it may be the corona the situation was bad. I then asked for available in our ICUs. As you are all virus (as is influenza). the medical protocol they were using aware, Tan Tock Seng Hospital has 4 The next critical assumption is that in HK. This came a day later. It consisted different ICUs – Neuro, Cardio, Surgical the spread, contagious as it is, is by of several antibiotics plus the usual and Medical. The advice was to cohort close contact and droplet. It is not management for ARDS. This day, I was Page 7 SMA News March 2003 Vol 35 (3) 7 Page 6 – SARS (and Me) (Part 1) were being ordered. Press conferences At the meeting, some questions Examiner for the Final MBBS held at were being held. were asked. Is it true that Singapore SGH (and I was to be involved for the Saturday 22 March started off for is now in the WHO list of countries whole week). There, I met the External us at 8am, at the Lecture Theatre of with SARS together with Hong Kong, Examiner for Medicine who happened Tan Tock Seng Hospital. I was chairing Vietnam and Guangdong? If yes, to be from HK. So I asked him about a seminar on “SARS – All you need to what does this mean? What are his perspective, the situation, the know”. All the senior staff were present. the implications for our people, our treatment, and the success stories. The theatre was full. Staff were interested. doctors, and our airlines? Can MOH He is a hepatologist but he told me A reporter tried to sneak in but was give some guidance to our doctors they tried ribavirin and steroids, turned away. What did I say? SARS is who are asked to certify fitness to travel and these seemed to work. So a viral illness. Today it is thought to be abroad? I will leave it at that, as it is henceforth, we considered the same, a paramyxovirus in the same family another story. but found in Singapore that we as measles, mumps, RSV and Nipah The next week from 24 March had thousands of tablets but little virus. It is spread by close contact. unfolded with the finding that some intravenous ribavirin. TODAY newspaper reported the of our TTSH staff had fallen ill, seen On Wednesday, the Minister of deadly sneeze of the Beijing Professor a GP or polyclinic doctor, and were Health visited Tan Tock Seng Hospital who stayed at the Metropole Hotel at home on medical leave. We at in the afternoon. (This he said in HK, resulting in Singapore’s first 3 TTSH worried they might have SARS. himself in one of his subsequent press index cases contracting the disease. So we had to do daily roll calls on all conferences.) It was good that he saw At this stage, I was interrupted by a staff to ensure they were healthy. for himself the situation, met, and senior doctor saying rhinorrhoea and And if they were ill, to verify that spoke with some staff and some sneezing are not common symptoms they did not have SARS, and a staff patients. He visited the ICU where the (less than 25%). clinic was set up purposely for this seriously ill were. Precautions at that Our doctors presented the reason. Meanwhile, patients by stage for visitors were that SARS epidemiology and clinical features. themselves, or referred by GPs, were patients were allowed one visitor for Management protocol was shown. being screened at Ward 72 CDC. 10 minutes only, and under the Precautions were re-emphasised for From these 2 sources, SARS-related supervision of our staff ensuring their all staff. Then, the CEO took the stage patients were warded and the masks were properly worn. to give out policy statements regarding numbers rose. At ED itself, although Thursday was fine and sunny in how the hospital was dealing with it was supposedly closed, patients Singapore. The ultimatum given to the SARS outbreak as it affected staff still came and had to be seen. If they Mr Saddam Hussein was due to expire morale (many taken ill were healthcare were serious enough to warrant at 9.15am. The MBBS medicine clinical workers). MOH was standing solidly admission and were not SARS, they examination, scheduled to be held at behind Tan Tock Seng Hospital in this were transported to the other hospitals. Tan Tock Seng Hospital, was relocated war against SARS. On Wednesday 26 March, came back to SGH,SARS and there in the Examiner’s the decision that all schools (from room, the TV set was on. CNN was WHO LIST pre-schools up to Junior College, but on telecast. Soon after, the war started.
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