48 hours in the life of a Malaysian truck driver: From Cameron Highlands...

Getting old and paying for healthcare is an increasing worry for many people around the world, but the elderly in Singapore could be forgiven for thinking their problems would be sorted.

After all, the Republic's healthcare system ranks among the best in the world, delivering basic, affordable treatment for those who qualify. And this is not all on the taxpayer - individuals pay an initial amount and then a national health insurance scheme kicks in.

The compulsory health insurance scheme, MediShield Life, was introduced in 2015 to help with the needs of a rapidly ageing population, as families worried about the large medical bills that can arise when a loved one becomes frail.

But the recent case of 84-year-old Seow Ban Yam revealed that for some, the worry had not gone away.

He was shocked when he received a medical bill of thousands of dollars from the Singapore National Eye Centre (SNEC), and for which he received only $4.50 in insurance payment.

The normally mild-mannered Mr Seow took it upon himself to challenge the bill, writing to the hospital authorities and insurance administrators to get to the bottom of why he was being charged so much.

The explanation that everything was in order merely confused him further. He did not understand why a public institution would charge him $3,664, after government subsidies, when the maximum amount he could claim under MediShield Life for his surgery was $2,800.

Wondering if he had got his sums wrong, Mr Seow wrote a letter to The Straits Times, saying: "Hopefully, you can find my case worth looking into, not only for myself, but also for the sake of the many people like me who otherwise are not aware of what a MediShield Life claim entails.

What The Straits Times discovered, as a result of Mr Seow's case, shocked even those in the upper echelons of the Ministry of Health (MOH) - that at least one public health institution had raised fees to levels much higher than those covered by the national health insurance scheme."We all think that MediShield Life is to subsidise large hospital bills. It is only when one goes through some kind of operation will one know it may not be true."

In Mr Seow's case, the subsidised bill from the SNEC was 50 per cent higher than the claim limit for that procedure.

The wider implication was that thousands of patients in Singapore were probably in the same boat as Mr Seow, getting bills from public institutions which exceeded the claim limits set by MediShield Life.

s a result, the issue was raised in Parliament in January and the Government decided to review national health insurance claim limits every three years instead of five.

There was more good news for those who need the system to deliver basic, affordable healthcare. In March, the SNEC cut its fees for 20 procedures by between 15 per cent and 32 per cent. This could reduce the bill for 14,500 procedures done each year at the centre.

WHY IT MATTERED

What got Mr Seow so riled up and made the issue such a talking point was that when MediShield Life was introduced, the Government made a promise that lower-income people need never fear having to foot big medical bills entirely by themselves for treatment at public hospitals.

The aim was to cover 90 per cent of the bill for 90 per cent of patients beyond the initial deductible and co-payment over that.

Mr Seow's complaint led to the discovery that, in the years since MediShield Life was launched, full coverage had in fact dropped to 80 per cent of patients with large, fully subsidised bills.

This affected patients who need a helping hand - about a third of four million Singapore residents rely entirely on MediShield Life for their health insurance.

HOW THE PROBLEM CAME TO LIGHT

So how did Mr Seow, a retiree who lives in a subsidised government apartment, end up being a healthcare hero for the needy?

It began in 2017 when he went to the SNEC for two operations to unblock the tear ducts in both eyes, in preparation for cataract surgery.

Mr Seow knew he would have to pay 10 per cent of the bill after the deductible, which is capped at $3,000 a year for those over 80, so he expected to pay a total of $3,148.

But he ended up paying $4,472.30 instead, as the bill exceeded the claim limit by $1,472, including fees for room and board, as well as the operation.

The latter alone was limited to $2,800. This capped amount is stated in MOH's table for surgical procedures, though there is no explanation for how the amount is derived.

Said Mr Seow: "The whole idea of MediShield Life is to meet heavy bills. I don't understand why it is limited to $2,800 when the bill is more than $4,000. This defeats the purpose of insurance."

MediShield Life determined it could pay out $3,005, but there was just $5 to take care of after Mr Seow paid the deductible. Of that, MediShield Life paid $4.50, minus his co-payment of 10 per cent.

Fortunately, Mr Seow did not need to take out a bank loan for the overall bill - he could pay the amount from a long-established national scheme where workers pay into designated savings accounts, including one for healthcare called Medisave.

John Q:I am not guna bury my son, my son is guna bury me!

As Neil Parker dragged his broken body along an isolated Australian bush track, thinking he would likely die out there, he channelled his mind on reconnecting with his estranged son living in New Zealand.

The seasoned bushwalker, 54, had broken his leg and wrist after he fell six metres from a waterfall while hiking alone at Mount Nebo, north-west of Brisbane, on Sunday.

His mobile phone was drenched and unusable after he plunged into the water, and he had given his personal alert device to his ex-wife.

Speaking from his hospital bed on Wednesday, the day after he was airlifted to safety, Parker said he knew his only chance of survival was to fasten a splint from his walking poles and drag himself to safety.

"I caught myself the first time as I started to slide but I had too much momentum and over I went.

"I started sliding down the face of the rock and I slid about 20 foot, cartwheeled then slammed into the rock then landed into the creek at the bottom.

"Straight away I thought, 'Now I am in a lot of trouble, nobody knows where I am, I don't have a personal location beacon'."

Parker had spent seven years as an SES volunteer and had worked on several rescues himself.

"I knew where I was located, there was going to be no way they could find me," he said.

"Inch by inch" he began to drag himself along the three-kilometre track to a clearing where he thought helicopters would be able to spot him.

"My left foot, the bottom, just above the ankle - clean snap in half - so the whole bottom of my leg came loose," he said.

"Legs are very heavy when they aren't connected to anything and trying to pick it up over rocks ... I would get about a metre, metre-and-a-half each time before I would have to stop and take a break.

"What took me 40 minutes to walk up, took me two days to crawl down."

With just a handful of nuts, a protein bar and some liquorice to eat, Parker spent two nights out in the bush.

"At night-time I was sleeping on rock, I had been crawling on rock all day - everything was hard so most of the pain I was going through was constantly being on hard rock.

He said he did not actually get much sleep thanks to his broken leg continuing to spasm in the cold.

"I think I have a very high [pain] tolerance, I had no issues with pain while I was crawling around, I didn't feel any discomfort or that while I was crawling but that could have just well and truly been adrenalin pumping."

The relief finally kicked in after he was spotted by a rescue helicopter on Tuesday afternoon.

"I had had enough of laying on rocks and I just started imaging nice fluffy pillows," he said.

As to what kept him going, he said it was sheer determination to see his sisters, children and ex-wife.

"The family connection, wanting to get back and let them all know I was OK kept driving me," he said.

"[My sister] rang my kids in New Zealand and my son said he would fly over next week.

"I have been disassociated with him for the last two years, so I only just came back together with him four or five weeks ago," he said, tearing up.

"Gee, I wanted to talk to him.

"So that was the main reason, I wanted to get home to my kids."

He was airlifted to the Princess Alexandra Hospital and credits his survival to his preparedness and the rescue mission mounted by his family with the support of the Brisbane Bushwalkers community, whose members set out on Monday to find him.

Orthopaedic surgeon Nicola Ward said Parker would remain in hospital for at least the next two weeks and was expected to go into surgery on Wednesday afternoon.

true or lies?

The way Dr Sean Ng Yung Chuan treated a patient who died following total knee replacement "goes beyond mere human error", said the coroner at the conclusion of a seven-day hearing.

State Coroner Kamala Ponnampalam said on Monday (Sept 16) that a coroner "does not make a determination of guilt or negligence or attribute legal or moral culpability".

Nevertheless, she flagged Dr Ng's behaviour which "demonstrated a clear departure from the standards expected of a physician who had primary care of a post-surgery patient".

She criticised the doctor for failing to make detailed notes or to hand the patient over to another specialist when he had planned to travel after operating on her. If he had done so, the other specialist might have noticed tell-tale signs that something was wrong, and taken action earlier.

Dr Ng, who has been a practising orthopaedic surgeon since 2011, said he had told Mrs Yuen about the conference in Tokyo and had suggested performing the surgery upon his return.

“According to Dr Sean Ng, Mrs Yuen was quite insistent on having the surgery done before his departure but did not say why,” the coroner recorded.

Dr Ng said that prior to his departure, he had checked how Mrs Yuen was progressing and was told “everything was fine”. He said it was not mentioned to him that her lower left limb was cold.

Dr Ng said that while he was in Tokyo, ward nurses told him Mrs Yuen complained of leg numbness and he called the anesthetist who assisted him on the knee replacement surgery Dr Adrian Ng to review her. Dr Adrian Ng told him to continue with his trip, Dr Ng said.

When the elderly woman’s condition worsened, the surgeon said he cut his trip short and returned to Singapore on Nov 5, 2016.

“Dr Sean Ng stated that he did not hand over care of Mrs Yuen to another specialist during his absence because there were no post-surgical complications prior to his departure and her progress was acceptable,” the coroner wrote in her findings.

“He added that he was unable to comment if there would have been a significant difference to life and death if the vascular damage had been identified and managed intra-operatively.”

In addition, Ms Ponnampalam found that Dr Ng had documented his reviews of Mrs Yuen's condition retrospectively in the case notes, instead of at the time of the reviews on Nov 1, 2016 and Nov 2, 2016.

"The making of retrospective case notes is a clear contravention of SMC guidelines," the coroner wrote.

According to the coroner’s report, the hospital also had concerns about the nurses who cared for the patient, with one being given a “verbal warning” for having documented circulation as normal in the care pathway chart when she did not personally assess the patient.

In her conclusion, Ms Ponnampalam said the evidence showed that an artery and vein were likely transected during the initial knee replacement operation conducted by Dr Ng, and that although a “relatively rare complication”, it was a known risk and should have been accounted for during the surgical approach.

Ms Ponnampalam also said: “Dr Sean Ng leaving the country on post-operative day two after performing a major surgery with a failure to hand over the patient’s care to an appropriate specialist was injudicious and may have resulted in the delayed recognition of the ischaemic limb.”

“The decision not to arrange for a covering specialist during his absence was short-sighted,” she said.

The coroner also said that the documentation of Mrs Yuen’s post-surgery care was “less than ideal” and “found to be unreliable” by the medical expert.

There was a “dire lack of details” in Dr Ng’s notes and that the retrospective entries days after were “unhelpful” as the patient’s condition had “severely deteriorated”.

The nurses’ notes were also “brief and in some instances, inaccurate”, and one nurse had relied on Dr Ng’s observations instead of making independent checks.

Ms Ponnampalam noted that an inquiry is not meant to make a determination of guilt or negligence, but it does assess "if an act has fallen short of reasonable standards".  

She said there was no basis to suspect foul play.

A scan found that severed blood vessels had caused an ischaemic limb, which is a lack of blood flow to a limb.

An emergency operation was conducted successfully but Mrs Yuen continued to deteriorate. Dr Chin decided on emergency high above knee amputation to save her life but post-surgery, Mrs Yuen went into cardiac arrest and developed multi-organ failure.

How Nurse Helps Chinatown's Ailing Elderly Stay Out Of Hospital

When Richard Chew woke up one Thursday morning feeling “a weakness” on the right side of his body, he didn't think it was anything out of the ordinary.

“I tried to grab onto my bed but I slipped to the floor,” the 57-year-old retiree recalled.

“So I told my wife, I think I'm still quite okay,” Mr Chew said matter-of-factly. “Then she said, okay you take care, and went on to work.

“I was thinking, for whatever reason, I have this weakness and it may go away at night.”

But when his wife came home from work that evening, she noticed that the features on the right side of his face “were twisted”, and his speech had become slurred.

These were the typical signs of a stroke.

“We didn't know how to react to this," said Mr Chew. "Of course, the first thing is to go to the hospital. But should we go straight?”

Eventually, they decided to go to Singapore General Hospital’s accident and emergency department (A&E), but in their own car, driven by Mrs Chew.

When they reached the hospital, they had to register and go through triage, before the A&E nurse found out that Mr Chew has had a stroke and immediately activated the acute stroke team.

By the time the team attended to Mr Chew, more than 12 hours had passed since the time he woke up with that tell-tale "weakness".

Due to the delay, the team couldn't administer treatments which would have helped him if they were administered within six hours after onset of the symptoms. He was sent to the stroke unit for monitoring to prevent further complications. 

Fast forward three months, Mr Chew is now wheelchair-bound and unable to use cutlery with his right hand.

It was only after his experience that he realised that he had made two mistakes - not going to the hospital immediately, and going to the A&E by car.

While more patients are arriving at the hospital "early enough" for timely treatment since the first Spot Stroke campaign in 2016, only around 50 to 60 per cent came in by ambulance

72-year-old Tan Mong Huat was luckier than Mr Chew.

Last year, the former Grab driver was ferrying a passenger from Jurong to Labrador Park when his vehicle crashed into a lamp post.

"At first I thought my car tyre was punctured," said Mr Tan. "But luckily my customer was alert and saw that I might have (had) a stroke. He asked me not to move and immediately called the ambulance."

SCDF paramedics arrived within 10 minutes and he was sent to National University Hospital where he was given the clot-busting medication.

As a result of that timely intervention, he suffers no side-effects or disability from the stroke. 

When asked what he would have done if he were alone, Mr Tan replied: "I would not know, that was the first time I suffered a stroke and I don't know the symptoms."

"I want to express my heartfelt gratitude towards the passenger who called 995, the SCDF paramedics and the hospital’s acute stroke team. Their actions had contributed to a better outcome for me and my condition would have been more serious without their prompt response."

"TIME IS BRAIN"

​​A stroke occurs when a part of the brain gets damaged due to an interruption in its blood supply. When brain cells die because they do not receive oxygen from blood, it is irreversible.

Stroke remains the fourth leading cause of death in Singapore and one of the top contributors of adult disability.

In the treatment of acute stroke, the team’s priority is to save the brain tissue that hasn’t died, which in turn saves body function and the patient's quality of life in the long run.

“If you ask me, the better term is time is brain," said Dr De Silva. 

The more time we lose, the more brain we're losing.

For the team, the clock starts ticking not when the patients passed through the doors of the hospital, but when they first experienced the symptoms.

The most common signs of a stroke are sudden drooping of one side of the face, weakness of one side of the body and difficulty speaking or understanding speech.

There's a bit of “detective work” involved in pinpointing when the symptoms first appeared, said NNI Advance Practice Nurse Il Fan.

“The patient’s history is the most important thing that we want to find out when they arrive," said Il Fan. "Sometimes if patients come in unable to talk, we go to the extent of checking their phone to trace their last conversations and find out (the last time) they were well.”

"If the SCDF (paramedics) can actually give us a lot of information then it will be helpful, because sometimes even though passers-by witness it, they don’t come together with the patient to the emergency department.”

“When we receive a notification that there is a stroke case (inbound), we will go down to the emergency department,” said Il Fan as she quickened her pace to the basement where the resuscitation area is located.

Just because the Singapore Medical Council (SMC) is the professional watchdog does not mean that it can act with "absolute impunity", the Court of Three Judges ruled on Wednesday (Sept 4) when it upheld a disciplinary tribunal's decision to make the SMC pay the legal costs of a high-profile plastic surgeon.

The SMC had charged him for using a patient's pictures and medical information without her consent, but the disciplinary tribunal, in finding him innocent, said the complaints were "vexatious and baseless" and told the SMC to pay the surgeon's costs for the hearing.

The SMC did not dispute his acquittal, but appealed to the Court of Three Judges against having to pay the surgeon's legal costs. It now also has to pay $20,000 to cover his costs for the appeal.

The plastic surgeon was not named in the judgment.

The surgeon, who runs his own clinic, had successfully treated the woman with Botox for enlarged parotid glands from 2008 to 2013.

In 2014, she filed a complaint against him for using her "unanonymised photographs" in a chapter of a book and in at least two medical presentations.

The surgeon told the SMC's Complaints Committee that he had obtained her written permission for the use of the materials.

Almost two and a half years later, the SMC informed the surgeon it was bringing charges against him.

But, satisfied that the surgeon's conduct met approved standards, the disciplinary tribunal acquitted him of all charges. It also faulted the SMC for its lack of documentary evidence to back up the patient's claims.

The Appellate Court noted that the SMC was aware that the patient had signed a written statement allowing the use of her photos and to describe her case in medical/scientific publications.

The surgeon told The Straits Times that he used them in a technical book and was not paid for his contribution.

The SMC's case rested on the patient, her husband and one expert witness who did not have the professional experience to back his opinions. The court said the SMC should, "at the very least", scrutinise if its expert had the relevant expertise.

It noted that the tribunal saw fit to "express its strongest condemnation" against the patient and said: "This is by no means a common finding and not one that a court of a tribunal would make lightly."

The tribunal found that not only were her allegations false, but the patient and her husband had also lied in other areas. She had claimed to be a naive homemaker but the tribunal found her "a sophisticated, capable and highly educated professional with a mind of her own".

The surgeon told The Straits Times the case had been "a most unpleasant experience".

He added: "But the judgment by the disciplinary tribunal and the High Court has given me great faith in the disciplinary process and in our legal system."