Drs Talk About NHG

Treating the Small Kids

Nothing is more apt than for me to write this article while I’m on duty, being inspired by the environment, my colleagues and my patients. Don’t worry, there’s no patient in the queue now, or is there? I’m currently in NUH Children Emergency (CE), which is part of NUH Paediatrics. It is not easy for a ‘baby’ MO to be in the emergency department given our limited experience, but with the guidance and patience of my seniors, I managed to grow clinically and also in terms of knowledge. In CE, we work in shifts: 8am – 5pm, 4pm – 11pm, 10pm – 8am (weekdays) and 8pm-8am (weekends). Even though these timings may be anti-social, it has actually allowed me to have more free time to myself. As my off-days tend to fall on weekdays, it has allowed me to roam the shopping centers while gloating that the rest of the Singaporeans are slogging away.

In CE, we get to see the bread and butter of paediatrics, which is good for both Paeds trainees/ trainees-to-be or GPs-to-be. We have also GP trainees with us on 3-month-long rotation. The cases that I’m exposed to in CE are varied. For medical cases, the most common presentation is fever. In CE, unlike the adult counterpart, we tend to manage a lot of fever cases for various reasons. The most common infections we deal with include viral fever, respiratory infection, gastroenteritis, urinary tract infection and recently, Dengue infection. The 2 main things that we must establish at the end of the consultation include what the source of the fever is, and whether the child can be managed at home or in hospital. Besides an unwell child, the other reason that we admit a child is when the parents are not confident in managing him or her at home. In CE, a lot of time is spent on educating and reassuring parents. Education includes fever control, the need to encourage fluids and also to monitor fever trend. Communication is definitely essential and a frequently, genuine concern helps.

Minor trauma makes up the bulk of non-medical cases. For eg, stable head injury, lacerations, fractures, foreign bodies in the ear/nose/throat/gastrointestinal tract. When in doubt, we seek help from our friendly orthopedic, ENT, dental or surgical colleagues. In not so common times, we see surgical emergencies like appendicitis, intussusception, suspected torsion of testes, etc. In CE, I’ve learnt simple procedures like putting on a backslab, repair of laceration – which include suture, glue or steristrip. One of my proudest moment was when I sutured a really long heel laceration, and all my nurses kept praising me; even the child’s guardian felt so proud of me!

With hundreds of kids you see each month, you’ll learn to recognize a sick child when you see one. In between the mundane cases we see, we also receive high priority patients, though not as many as our adult counterpart. We are prepped for this with weekly mockcodes, but nothing beats handling it yourself. I had a stand-by case once when I was on night shift – a 3-month old baby found unresponsive. It helped that I just had an exact mockcode few days ago, so I knew exactly what to do. I called my senior, went over to the adult’s P1 area, wrote down all the doses of drugs on the board based on estimated weight, prepare the intubation set, etc. When the child arrived, my senior and I were already at the bedside, waiting to pounce onto him. Intubation, CPR, IV access, flush and in the end we had to let him go. Another memorable case was this 4-year old girl who came in post-fit. Although we had a lot of children who came in for febrile fit, we must always think of other causes of fit at the back of our minds. The worrying thing about her was that her fever wasn’t very high at the time of fit, and her post-ictal period was very prolonged. In the end, we sent her to ICU as she’s probably in status epilepticus secondary to encephalitis. Her CT brain showed multiple infarcts and she didn’t make it in the end.

This article would not be complete if I didn’t mention PR (public relations) problems. I was just mentioning to my registrar that I haven’t seen many difficult parents these days and BOOM I had 2 today. (*word of warning – NEVER EVER say things like “what a quiet morning”, “never seen many difficult parents these days”, “wish I could see a SVT”). There are definitely difficult parents to handle and many a time, our seniors will come rescue us. Even during my Paediatrics interview, my interviewer asked me how I would handle difficult parents. My answer... CALL FOR HELP!! I guess it comes with experience, but you must not lose your cool, act firm and no matter what, always think for the child.

by Dr Yvonne Lim
Medical Officer
NUH Paediatrics
National Healthcare Group

My work as a Family Doctor at NHG Polyclinics (NHGP)

I graduated from NUS in 1999, and did all my Housemanship postings in SGH. I subsequently did 2 general surgical postings, 1 emergency medicine posting and several busy medical postings in various hospitals. I subsequently did 6 months of palliative care posting at Dover Park Hospice and Hospice Care Association. Following that, I did Polyclinic Postings for about 18 months and am currently happily working as a Family Doctor at NHG Polyclinics (NHGP) - Clementi.

I can say without any doubt that I am quite happy working at NHGP. I say this for various reasons.

Firstly, as part of a forward-looking team with no stifling restrictions on style of practicing, including prescribing non-standard drugs when indicated, I find my work very satisfying. There are a slew of initiatives that are being gradually introduced, like Electronic Medical Records and Chronic Disease Management Database, which convinced me that I am part of one of the most progressive primary healthcare system in the world. I am able to offer my patients lab tests with stat results, eg ECG, fungal smear, full blood counts, and Radiography, which few General Practitioners can. I don’t have to be worried about my overheads while being confident that my patients are getting these tests at an affordable cost. Moreover, I have with me a strong support network of nurses, MSW, dietitians, pharmacists, etc who provide a much more extensive and up-to-date service than is possible by a lone practitioner. All this is immensely satisfying.

Secondly, I am able to practise evidence-based medicine based on Ministry of Health (MOH) guidelines rather than being tempted to practice “state-of-the-art medicine” by using the newest available drugs. This is probably made possible by working in a group practice with constant peer review and decoupling of my compensation from the cost of my prescriptions to my patients.

Thirdly, there is a wider range of services that I can provide to my patients which would not be possible in a private setting. These services include minor surgical procedures such as H & L injections, small lumps removal, I & D of chalazions, IUCD insertion, ear syringing, FB removal, T & S, developmental assessment, childhood and adult immunization, travel advice, smoking cessation service, weight management program, marriage counseling, general and statutory health screening, etc. This is made possible by the constant learning environment and support service network made available to at NHGP.

Just recently, I have secured sponsorship for the GDFM course from NHGP. I hope to carry on completing the M Med (Family Medicine) and am sure that NHGP will be supportive in that too. I found out just recently that there is a very structured career path for Family Physicians which includes Health Manpower Development Plan (HMDP), opportunities for teaching and research and healthcare administration while still practising as a physician. All this makes me more convinced than ever that there is a bright future ahead for Family Doctors and Family Physicians in NHG Polyclinics.

by Dr Anuj Gupta
Family Doctor
NHG Polyclinics - Clementi
National Healthcare Group

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