At Ground Zero: First-line Defenders at TTSH-NCID's COVID-19 Screening Centre

​The Straits Times (24 May 2020) 

For those manning the Covid-19 screening centre at TTSH-NCID, going eight hours without a loo break, playing agony aunt and facing down their fears are all in a day's work

On the first day of Chinese New Year in January, Dr Ang Hou cooked, as he usually did, for his extended family who came to visit.

But his mind was not on the claypot rice he was making - his attention distracted by the constant WhatsApp messages coming through on his phone.

"I'd usually cook more, and make sio bak," he says, referring to Chinese roast pork. "But I was in no mood; in fact, I was a bit antisocial that day," says the head of the emergency department (ED) at Tan Tock Seng Hospital (TTSH).

And understandably so, because he knew he had a big battle on his hands, with a coronavirus causing a disease which the world now knows as Covid-19. The enemy had, at that time, already pummelled Wuhan, bringing the Chinese city to its knees, and was starting to assault other parts of China and the rest of the world.

Two days before, on Jan 23, the first case of Covid-19 was confirmed in Singapore: a 66-year-old Chinese national from Wuhan who flew in from Guangzhou. The following day, two more cases surfaced. Dr Ang knew the numbers would grow. Having experienced Sars and H1N1, the authorities moved fast and turned the National Centre For Infectious Diseases (NCID) - which last year took over the functions of TTSH's former Communicable Disease Centre - into ground zero for Singapore's response to this new virus.

Dr Ang and his ED staff were tasked with setting up and running a daily 24-hour screening centre, with additional manpower support from TTSH.

On top of leading the charge in fighting the virus, they still have to run TTSH's ED, the busiest ED among all the hospitals in Singapore. On a typical day, they handle at least 400 medical emergencies, ranging from heart attacks, strokes and severe infections to accidents and emerging infectious diseases.

First-line defenders

Dr Ang and company were chosen to be first-line defenders for a reason. They are professionals used to crisis management, and trained to multitask, work under pressure and remain calm amid chaos.

The ED, after all, is the entry point to other areas of medical care.

Set up in just two days, the screening centre was up and running on Jan 29. Initially designed and equipped to test more than 100 patients a day, it can now accommodate - with the addition of two tents - more than 280 people.

Nearly 400 nurses, allied health workers and operations personnel from other departments in TTSH have been deployed here until the pandemic is over. On the medical side, an extra 51 doctors from the surgery division are also attached here - at any given time - to help the 20 to 25 ED doctors on daily duty.

Before the screening centre was set up, suspected Covid-19 cases were tested in a fever room which could accommodate only 29 people, seated 2m apart.

"It's the nature of the ED to move fast," says Dr Ang who has been working in the department since 2002 and took over as head in 2018.

"We're always on the lookout for things happening in the world, like outbreaks of diseases. So we're on a year-round surveillance for TTSH," says the father of three who first heard of the virus last December while on holiday with his family.
The likelihood of a pandemic like Covid-19 erupting was never in doubt. It was a question of when, not if, says Dr Ang.

"We were setting up the screening centre even before we got the official go-ahead from the Ministry of Health. You don't know the scale but you have to be ready," says the doctor who has donned his personal protective equipment (PPE) each time Singapore was threatened by a virus, from Sars to Mers to H1N1.

As it turned out, Covid-19 is, in more ways than one, a show-stopper. Globally, it has already infected more than five million people and claimed more than 330,00 lives. In comparison, there were only about 8,000 cases of Sars worldwide and 774 deaths.

In Singapore, the number of Covid-19 infections has gone past 30,000, with 23 deaths.

Like Dr Ang, many of the first-line defenders at the screening centre are battle veterans. Dr Charmaine Manauis, the leading infectious disease consultant at TTSH's emergency department, not only took charge of setting up the centre but also established the protocol as well as trained the doctors deployed from other departments.

"They come from all departments including pathology, radiology and neuroscience. Even heads of department come and they work like medical officers here. We have to be role models for our juniors. Many of them volunteer to do repeat stints," says Dr Manauis who has worked at TTSH for 14 years.

Hers is a stressful job, made even more difficult by the crafty virus. The mother of a nine-year-old boy has had to refine safety and work protocols multiple times because of new information and discoveries about Covid-19.

"Clinical protocol is now version 68, work instructions version 79, foreign worker protocol version 46 and the recovering/recovered Covid protocol version 2," she says.

She often takes her work home, sometimes getting by on just two or three hours of sleep.
The 42-year-old recalls one "terrible Monday" when more than 500 people arrived to be tested. Even the tentage outside had to remain open until 3am.

That was the day before Singapore closed its borders to tourists and short-term visitors. By then, many Singaporeans had also returned home as they fled the disease in other parts of the world where they were working, studying or living.
"When the volume is high and everyone is busy, there is no time for breaks. It's hard to go to the toilet because you need to degown," she says, referring to the full PPE suit that medical staff at the screening centre have to wear. "Our bladders are trained. I can hold mine for an eight-hour shift," she quips.

FEELING OF UNITY

What amazes me is seeing a culture being built up so quickly... When you’re in crisis, you fight together. There is no drama, social alienation. Everybody is just so united.

- Senior Nurse Manager James Ang

Senior nurse manager Atiqah Tanty, 44, says: "When you're busy, you forget you need to pee. You just focus on the work at hand."

Her colleague, senior nurse clinician Christina Xie Fang, agrees: "You just drink less water."

Both of them - who train nurses from other departments deployed to the screening centre - have been with the ED for two decades and have also fought Sars and H1N1 on the front lines.

"When Sars happened, we just focused on Sars. This time around, we handle Covid-19 on top of our usual ED work," says Madam Xie, 40. "The other difference with Covid-19 is the transmissibility is so high."

This makes their job riskier.

A patient who is brought to the hospital after collapsing from trauma could, for instance, also be infected with the virus. "That's why in the resuscitation area, we also wear a full PPE suit," she adds.

Nurse manager Sundramalar Mathiaparanam, 44, helped to manage the first three resuscitation cases which came through the screening centre.

"There's no time to be afraid. You just have to be calm and stabilise them before transferring them to the wards," says Madam Sundramalar who, like Madam Atiqah and Madam Xie, is part of a team of ED nursing officers who have been actively preparing for large-scale infectious disease (ID) outbreaks since H1N1.

Because they are so busy, most medical staff keep their PPE suits on for the duration of their shifts of between seven and 10 hours. Their cheeks are lined with deep furrows when they take off N95 masks after their day is done. Dr Ang says: "I don't see TTSH as not ever being at the front line of any outbreaks. During Sars, some of our colleagues got infected and died.

"Although it has risks, this is our job and our responsibility is to do it well so that we can protect our friends and our colleagues. My family is supportive of what I do," says the amiable man who is married to a homemaker.

Like Dr Ang, many of these front-liners have supportive families. Interestingly, quite a few of them have spouses who are front-line health workers too.

Dr Manauis' husband is an ED doctor, so is Madam Xie's husband.

Madam Atiqah, meanwhile, is married to a paramedic.

"He's even more careful than me. When he comes home, he doesn't want to touch anyone. He'll put his specs in front of the doorstep and then he'll shower. After that he'll take his specs to the balcony and start cleaning them. Only then will he talk," says Madam Atiqah, who has three children aged between seven and 17.

Because of the pandemic, she doesn't get to spend much time with her family.

"Sometimes, my weekends are also spent at work. But they understand why. Before home-based learning, I made it a point to take my children to school every morning to make up for the little time I have with them."

There are other sacrifices.

Madam Ilayaraja Bhuvana, 41, has volunteered to be on the permanent night shift at the screening centre. Married to a pharmaceutical executive, the clinical instructor feels that night shifts help to balance her time with her family.

Her two children, aged eight and nine, are asleep while she is at work. She also gets to spend time with them and prepare meals for the family before she heads for the screening centre in the evening.

To minimise physical contact, she has been sleeping in a separate room since she started working at the centre.

"I need to protect this house. I need my family to be safe so that I can go out and protect others," says Madam Ilayaraja who has been with TTSH for 12 years.

Co-ordinator Jamaluddin Kasa, who provides operational support for the ED, has not seen his wife and 13-year-old son, who live in Malaysia, since January.

His role involves procuring equipment and supplies for the screening centre. The former coordinator in the construction industry took a pay cut to work in the hospital because he was grateful to medical staff who helped to look after his late mother when she was ill.

Despite undergoing heart surgery barely two years ago, he has been putting in extra hours at the screening centre over the last few months. "Once there is teamwork, nothing is difficult," says Mr Jamaluddin.

Senior nurse manager James Ang, 37, agrees. "What amazes me is seeing a culture being built up so quickly. Although these people come from all over the hierarchy from different departments, I have never experienced such a high level of teamwork.
"When you're in crisis, you fight together. There is no drama, social alienation. Everybody is just so united," says Mr Ang who has documented the camaraderie of his colleagues in comic strips.

He has seen many of them coming back to work on their days off, and beavering away way after their shifts are over.

Paying it forward

They are even paying it forward. Many of the doctors and nurses pooled money to buy NTUC vouchers for housekeepers and porters working alongside them.

The concern and solidarity are also extended to the migrant workers who now make up 80 per cent of the 200 or so people who now turn up daily to get tested.

Dr Manauis says: "Aside from screening them, we have to make sure they are transported back to dorms that can separate them."

Because migrant workers can't isolate themselves, the hospital holds them for about eight to 10 hours after they have been given the swab test.

Mr Ang says: "You can see the fear in their eyes while they are waiting for their results. There is a lot of tension because 70 or 80 per cent of them will test positive."

Many front-liners have stepped up to allay these fears.

In the beginning, many contributed to a fund which was used to buy hot meals of curry and rice for these migrant workers who were not used to the biscuits or porridge served. Based on their feedback, the TTSH kitchen now serves hot meals more suited to the palates of these workers.

There were other initiatives: recliners so that the migrant workers could rest while waiting for their test results, videos to ease their anxiety, and morning exercises for those who have to wait overnight.

There's even a tea trolley offering snacks and beverages which makes the rounds once every two hours in the screening centre.

"Some of my colleagues even initiated a flash card system to ask them if they have a cough or other symptoms since many do not speak English," says Madam Ilayaraja.

Often, they play agony aunt too.

Madam Sundramalar says: "It's obvious from their faces they are worried. They're worried about their jobs, whether they will be paid because they are breadwinners in their families, so I do my best to reassure them."

Madam Atiqah says: "Over the years, Singapore has relied on these foreign workers. They live here and are equally threatened by any disease. It's our duty to look after them to the best of our abilities. In nursing and medicine, there are no boundaries."

Although the number of people going to the screening centre has decreased, the work is still intense.

"The upside of being close to five months into the pandemic is that I can now tahan the PPE and N95 mask for the whole shift without going for a break. Before this, I'd feel faint after two to three hours," says Dr Manauis, using the Malay word for tolerate.

Meanwhile, the battle continues, around the clock.

Fear? Mr Jamaluddin sums it up best: "I have no fear. I have a lot of doctors around and I know they will help me. If you do good, God will never forget it."