CHAN YIN LAM, NATALIE

• Our group (of 4) embarked on a 3-week long attachment at Tan Tock Seng Hospital, under the mentorship of Dr Endean Tan who is a Consultant, Head of Department of General Medicine and founder of the Acute Internal Medicine Service in Tan Tock Seng Hospital.
• During our attachment in the hospital, we managed to acquire medical knowledge and jargon mainly pertaining to different types of diseases, methods of diagnosis, as well as management strategies. We also made many observations and deductions regarding the processes occurring within major hospitals and how they operate. We shadowed not just Dr Endean, but also his team (which included Nurses, House Officers, Medical Officers and Senior Residents who work in AIMS wards).
• The “standard” schedule/outline in the mornings for each day (which does not vary much), is as such:
  1. 8-9: Morning Discussion
  2. 9-10: “Coffee Break” OR 9-11.30: Lecture
  3. 11.30-2: Lunch
• For the Morning Discussion, we would observe the group of nurses, doctors and medical students (4 of the 5 were in their final year of medical school, here for their rotational attachment as part of their curriculum for experiential learning) conducting case presentations, delivered in accordance to the CCA (Comprehensive Case Analysis) documentation format. They would discuss about the History, Diagnosis, as well as Management strategies of the respective cases. From these cases, Dr Endean, who would assume the role of a Consultant and head these discussions, would teach us about medical conditions related to a specific organ system.
• During “Coffee Breaks” and lectures, we would listen to the medical students/Nurses and Dr Endean engage in lively conversations regarding highlighted issues/topics that were brought up earlier but required a more lecture-based setting to further explain and analyse.
• In the afternoons, which are more flexible in terms of series of activities lined up for us, we either had time to ourselves for group work, or would follow Dr Endean on his ward rounds. There was once we sat in on a Medical Jeopardy session.
• Medical Hierarchy System/Career Progression Trajectory: Medical Student (usually 5 years of medical education in local and overseas universities) → House Officer → Medical Officer → Senior Resident → Consultant (route to specialisation) OR Medical Student → House Officer → General Practitioner → Family Physician

2. Background information of organisation

Tan Tock Seng Hospital (TTSH) is one of Singapore's largest public multidisciplinary hospitals, with 16 specialist centres as well 45 clinical and allied health departments.

The 15-storied hospital makes use of vertical expansion to facilitate surveillance and extensive observation of all areas within the hospital. TTSH is part of the National Healthcare Group and is the principal teaching hospital for the NTU Lee Kong Chian School of Medicine.

Geographically, TTSH is located near Ang Mo Kio and Toa Payoh districts and is the most central public hospital. Hence, its location, coupled with its purpose as a major hospital (which is on the frontline of health emergencies and epidemics) makes it attractive for many patients, and has a large patient intake.

Acute Internal Medicine Service (AIMS), a sub-department in TTSH, headed by Senior Consultant and Professor Dr Endean Tan, is a unit established in 2016. It takes care of patients with acute medical conditions that do not require active surgery. AIMS has a strong emphasis on interdisciplinary care and collaboration. In this department, staff are utilised to their fullest potential. Unlike a typical ward where doctors present cases to the consultant, nurses can do so as well. This improves efficiency, such that the turnover rate remains high.

Due to the issue of unnecessary hospitalisation, identified as certain patients' 1-day hospital stay, there has been a worrying occupancy rate of 99%. As such, we (the 4 of us) decided to delve and probe deeper into the issue of the criteria for hospitalistion, as well as the factors contributing to the low threshold of discharge and propose a screening tool for Influenza A patients specifically. We chose Influenza A as our viral infection/disease of interest because of how pertinent these seasonal flu outbreaks area, coupled with the fact that Influenza A is the most commonly-spread strain because influenza A strains infect both animals and humans, increasing the number of vectors for transmission.

3. Background information of the project

Our project examined the issue of unnecessary hospitalisation among Influenza A patients. In addition, we aimed to develop a screening tool based on a scoring system to determine if Influenza A patients should be hospitalised.

Singapore hospitals have been faced with the issue of overcrowding with an average daily bed occupancy rates for public hospitals is at 85%. In particular, Tan Tock Seng Hospital had the longest waiting time at around 4.5 hours during the time of study and had the second highest bed occupancy rate of 95% among 6 public hospitals surveyed. This is especially concerning considering the increasing healthcare demands due to the ageing population locally and the possibility of a huge spike in demand should epidemics occur.

Influenza, commonly known as "the flu,'' is an infectious disease caused by an influenza virus and is mainly transmitted through respiratory droplets. Symptoms of Influenza range greatly in severity, from sore throat to possible pneumonia. There are 4 main strains of Influenza, namely Influenza A, B, C and D. We chose to focus on Influenza A as it is the most common form of influenza that humans are infected with.

Through this project, we hope to reduce the number of unnecessary hospitalisations. With the guidance of our mentor, Dr Endean Tan, we analyzed data regarding Influenza A patients admitted to Tan Tock Seng Hospital from __ to ___. From this, we could then determine symptoms that indicated that patients required hospitalisation. In addition, we compared differences in the threshold of discharge of Influenza A patients between the General wards and Acute Internal Medicine Service (AIMS) at Tan Tock Seng Hospital.

With this knowledge, we then developed a scoring system to act as a screening tool that determines when patients can be discharged. There has been increasing reliance on medical scoring systems as these scoring systems are more objective and can be used to gauge the severity of the condition. The utilisation of this tool would standardize the threshold for discharge, thus reducing unnecessary hospitalisations.

4. Elaboration of activities done

Our project examined the issue of unnecessary hospitalisation among Influenza A patients. In addition, we aimed to develop a screening tool based on a scoring system to determine if Influenza A patients should be hospitalised.

Singapore hospitals have been faced with the issue of overcrowding with an average daily bed occupancy rates for public hospitals is at 85%. In particular, Tan Tock Seng Hospital had the longest waiting time at around 4.5 hours during the time of study and had the second highest bed occupancy rate of 95% among 6 public hospitals surveyed. This is especially concerning considering the increasing healthcare demands due to the ageing population locally and the possibility of a huge spike in demand should epidemics occur.

Influenza, commonly known as "the flu,'' is an infectious disease caused by an influenza virus and is mainly transmitted through respiratory droplets. Symptoms of Influenza range greatly in severity, from sore throat to possible pneumonia. There are 4 main strains of Influenza, namely Influenza A, B, C and D. We chose to focus on Influenza A as it is the most common form of influenza that humans are infected with.

Through this project, we hope to reduce the number of unnecessary hospitalisations. With the guidance of our mentor, Dr Endean Tan, we analyzed data regarding Influenza A patients admitted to Tan Tock Seng Hospital from November 2019 to January this year. From this, we could then determine symptoms that indicated that patients required hospitalisation. In addition, we compared differences in the threshold of discharge of Influenza A patients between the General wards and Acute Internal Medicine Service (AIMS) at Tan Tock Seng Hospital.

With this knowledge, we then developed a scoring system to act as a screening tool that determines when patients can be discharged. There has been increasing reliance on medical scoring systems as these scoring systems are more objective and can be used to gauge the severity of the condition. The utilisation of this tool would standardize the threshold for discharge, thus reducing unnecessary hospitalisations.

As findings are confidential, they will not be published here.

5. 3 Content knowledge learnt

1. Sepsis

Sepsis is the body's response to an infection, which involves releasing chemicals into the bloodstream to fight an infection. When these chemicals are out of balance, the patient is septic and may have damaged organ systems. This can progress to septic shock (a life-threatening condition in which blood pressure drops dramatically).

Q-SOFA score can be used to calculate the risk of sepsis and early treatment for this includes antibiotics and large amounts of intravenous fluids.

To be diagnosed with sepsis, one must have a probable or confirmed infection and all of the following signs:

(i) Change in mental status

(ii) Systolic pressure less than or equal to 100mm Hg

(iii) Respiratory rate higher than or equal to 22 breaths a minute.

If the patient experiences septic shock, he/she will have unrecovered hypotension (abnormally low blood pressure, <90 for the measure of systolic pressure and despite adequate fluid replacement, and <60 for diastolic pressure) thus requiring medication required to maintain blood pressure greater than or equal to 65 mm Hg.

Risk factors for sepsis include: Young or old age, people with compromised immune system, patients with chronic illnesses of invasive diseases and people with open wounds or injuries, patients who have previously received antibiotics or corticosteroids.

2. Gait analysis

Gait is a translatory progression of the body as a whole produced by coordinated, rotatory movements of body segments. Clinical gait analysis is the process by which quantitative information is collected, through the use of technology (e.g. specialized video cameras), to aid in the understanding of gait abnormalities and in treatment decision-making.

Normal gait is a rhythmic and characterized by alternating propulsive and retropulsive motions of the lower extremities. Gait has 2 main phases: the stance phase (comprising of the heel strike phase, foot flat, mid-stance, push-off), the swing phase (comprising of acceleration phase, mid-swing, deceleration).

Gait abnormality rating scale (GARS) is used as a screening tool to evaluate a patient’s risk of injury from falling. Patients are assessed on 16 different aspects and patients with a score above 9 are at risk for falling. Conditions associated with gait abnormality may include foot drop, ataxia and limp.

3. Case Presentation (With reference to a video sent by our mentor)

When meeting a new patient, a doctor should classify the breadth (medical, functional and social issues) and depth (justifications for the differentials and for the decisions made) of case.

The doctor should then write the Comprehensive Case Analysis (CCA). This is written in the SOAP format (subjective, objective, active issues and passive issues). Active issues refer to issues that are receiving or have received treatment, have new evaluation and management. Active issues are anchored on presenting complaints with corresponding plan (s). Passive issues refer to issues that have no new evaluations and are receiving ongoing treatment. Passive issues are presented after active issues with single-line entry and no plan(s).

Before going on ward rounds, the doctor would refresh himself/herself on the patient’s case through reading the detailed version of the CCA. The doctor would also review overnight events and results and check the parameters. Afterwards, the doctor would speak to the patient and conduct a focused physical evaluation. The information obtained should be documented in the SOAP format and list the daily active medical problems concisely, justifying them if appropriate.

During the ward round (once in morning, next in late afternoon), cases would be presented in the following format:

New Case

Existing Case

• Demographics & pre-morbid status
• Past medical history
• Present complaints
• Detailed history of current illness
• Vitals & physical findings
• Investigations
• Active issues & management
• Analysis & discussion
• Functional issues
• Social issues
• Demographics & brief history
• Present status & investigations
• Medical issues & management
• Functional issues
• Social issues

6. 1 Skill learnt

Since the TTSH attachment involved mainly teachings, lectures and morning discussions that included medical knowledge and technical jargon, we did not learn much hands-on/applicable practical skills.

However, one notable skill we observed during one of our morning discussions would be (physiological) speech and stress testing. We observed a final year medical student (who was also interning at TTSH, under Dr Endean, as part of a clinical rotation/the curriculum) performing these tests.

Speech testing is carried out if there are any interferences in speech detected, and may be due to cognitive impairment, to find out of this problem is a sign of an underlying medical condition. If it is a motor or reception problem which causes unclear speech. The sequence of testing would be to first test for the individual's reception skills, because impairment of his reception ability would mean that it would be difficult to test for his motor skills., and then tpo test for his motor skills.

Firstly, to test for his reception skills, the doctor or the clinician in question will get the patient to obey a 3-step command without giving them visual cues so as to prevent them from relying on their visual ability to imitate the 3-step action.

Secondly, to test for his motor skills, the doctor will ask the patient a question, such as "Can you tell me what you did yesterday?" or "Can you tell me about your family?". This is to test to see if the patient is able to speak and articulate himself coherently such that he can be understood.

Stress testing is carried out to increase the heart rate from normal- 60/70 to high- >150, so that the heart is overloaded and "stressed" into pumping faster. In order to carry put stress testing, two methods can be employed. The first would be physical, which is using the treadmill to increase the patient's heart rate.

The other would be through pharmaceutical means. Inotropes such as dobutamine stress the heart directly by increasing contractility. Vasodilators, which are medications that dilate and widen blood vessels so as to allow for smoother and easier blood flow, such as dipyridamole stress the heart indirectly by increasing vasodilation of the blood vessels.

7. 2 Interesting aspects of my learning experience

The 1st interesting aspect of my learning experience during the TTSH attachment was on: Different Diseases (affecting the various organ systems). Organ systems are a group of organs working together to perform a particular function and contribute to the organism’s survival. Examples of organ systems include muscular, skeletal, nervous, circulatory, lymphatic, respiratory, endocrine, urinary/excretory, reproductive and digestive systems.

1. Renal diseases (diseases affecting the renal system/urinary tract- kidneys, ureters, bladder, and the urethra):
   • AKI (Acute Kidney Injury) is the first stage of kidney disease, characterised by a reversible acute increase in nitrogenous waste products in the urine, with sudden episode(s) of kidney failure or kidney damage.
   • CKD (Chronic Kidney Disease) is the second stage of kidney disease, occurring when the kidneys are damaged and cannot function normally to filter blood.
   • ESRD (End Stage Renal Disease) is the final, permanent and most serious stage of kidney disease, occurring when the kidney function has dropped to around 10-15%.
   1. Aetiologies (causes):
      1. Pre-renal (deceased renal perfusion: decreased effective blood flow to kidney, resulting in a subsequent decrease in GFR [Glomerular Filtration Rate]): ATN (Acute Tubular Necrosis, which is a medical condition involving the death of tubular epithelial cells forming the renal tubules of kidneys), vasodilators
      2. Renal: AIN (Acute Interstitial Nephritis)
      3. Post-renal (inadequate drainage of urine distal to the kidneys): obstructive uropathy (urine backs up into the kidney, causing it to become swollen, such that urine cannot grain through the urinary tract)
   2. Diagnosis of AKI: Evolved from the 2004 Risk, Injury, Failure, Loss, End-stage (RIFLE) criteria to the 2007 AKI Network (AKIN) classification
      • Urine output measurements- measuring volume of urine each day
      • Urine tests- urinalysis (Urine analysis) can reveal abnormalities in renal function. Warning signs/ Abnormalities include a rise in serum creatinine and/or fall in urine output.
      • Blood tests- blood sample analysis can reveal abnormal levels of creatinine and urea, two substances that are used as a measurement of renal function.
      • Imaging tests- ultrasounds (imaging method that uses high-frequency sound waves) can be used to screen patients’ kidneys
      • Renal biopsy- procedure where a small piece of kidney tissue is extracted from the patient for examination under a microscope to observe signs of damage or disease.
   3. Complications:
      • Fluid buildup- shortness of breath presents itself as a symptom of AKI, due to the buildup of fluid in the lungs
      • Chest pain- occurs when the pericardium (lining of heart) becomes inflamed
      • Permanent kidney damage- occurs when the patient’s condition worsens and develops into CKD or even ESRD
      • Mortality- due to dwindling levels of renal function
   4. Treatment/ Management strategies: RRP (Renal Replacement Therapy):
      • Hemodialysis (i.e. HD) involves the usage of a dialysis machine and a special filter that fulfils the function of a kidney, called a dialyser used to clean patients’ blood for creation of direct access to the patient’s bloodstream. A catheter is inserted.
      • Peritoneal Dialysis (i.e. PD) is a treatment using the patient’s peritoneum (lining of abdomen) as a filter, and a dialysate to absorb wastes and fluid from the patients’ blood. It is needle-free and is less expensive than HD
2. Diseases affecting the circulatory system
   1. DVT (Deep Vein Thrombosis) refers to a blood clot that forms in the deep vein of a person’s body
      1. Aetiologies (causes):
         • Inability of blood to circulate or clot normally (e.g. limited movement due to long haul flights, injury to a vein, surgery, certain medications)
         • May Thurner’s Syndrome (MTS) occurs when the left iliac vein is compressed by the right iliac artery, which increases the risk of deep vein thrombosis (DVT) in the left extremity
         • Most people do not know they have MTS, but it is identified when they present with symptoms of DVT
      2. Complications:
         • Pulmonary Embolism (PE) is a serious complication that can result from DVT. This associated complication occurs when a part of the clot breaks off and travels through the bloodstream to the lungs, causing a blockage called a PE

The second interesting aspect would be to see how social concerns are handled from a medical professional’s point of view

1. Concordance vs. Compliance/Adherence
   • Concordance refers to the nature of the interaction between clinician and patient, and does not refer to how closely a patient follows his medicine-taking regimen. It is underpinned by the notion that consultations between clinicians and patients are a negotiation between equals, and is patient-centric care in essence. “Concordance” is achieved when the value ascribed to the risks and benefits of certain medications is relatively similar and both parties have similar opinions and sentiments regarding the management strategies, when an agreement has been established. When a patient is non-concordant, there is a disconnect between the patient and the doctor’s ideologies. He does not agree with the follow-up actions that his doctor proposes and since “concordance” respects the right of the patient as well, another proposition that is accepted and the patient is willing to adhere to has to be made.
   • Compliance insinuates that there is a tacit or even pronounced expectation that the patient is at the receiving end of the doctor’s commands and has no right to reject any management strategies that the doctor proposes. This is not characteristic of Western ideals of respecting the individual and self, and is not compatible with the ideals that underlay Singaporean society.

2. Morbidity & Mortality (attending to the death of a patient)

• Steps:

Arouse patient by name calling and gentle tactile stimuli.

Listen to heart sounds and respiration.

Check for pupillary light and vital sounds.

If all are absent, pronounce official death and note the time of death.

Make a record of death with the following information in C-docs...

• exam findings
• relevant events leading to the death
• time and date of death
• assessment of the cause of death

The same should also be reflected in the discharge summary.

Fill in the CCOD. (not guesswork, and cause of death must be a pathological medical condition)

8. 1 Takeaway for life

Through this WOW! attachment at TTSH, I have truly understood the life lesson that passion is what drives you. Your inherent motivation to stay resilient and tenacious in the face of threat and adversity is fueled by your passion in it. It gives you purpose and the strength to push on.

This is evident from Dr Endean's attitude towards his job- Consultant and Professor. Despite holding a high position that encompasses a wide array of responsibilities and being in a sterile environment constantly filled with stress, he never ceases to be upbeat and enthusiastic about his job.

Indeed, his countless duties and obligations are viewed as psychological and mental burden for many, but his passion for teaching and in the field of medicine serves as his driving force to overcome these mental hurdles. He has managed to strike his own version and permutation of a work-life balance, one that does not take the conventional form of incorporating "trivial temporal joys" of life on one end of the spectrum with his main source of income on the other end of the spectrum, but rather makes his professional career his life. and truly loves what he does.