The fact that six Filipino victims of the recent accident at Lucky Plaza were sent to Tan Tock Seng Hospital instead of the nearby Mount Elizabeth Hospital has generated quite a bit of debate among netizens.

In response, the Ministry of Health (MOH) and the Singapore Civil Defence Force (SCDF) explained that while Mount Elizabeth Hospital has a 24-hour walk-in emergency department, it is not equipped or staffed to manage all forms of medical emergencies.

MOH added that most private hospitals in Singapore are not able to provide proper resuscitation and emergency treatment for severe and multiple trauma patients.

In contrast, all public hospitals — except for Alexandra Hospital — have accident and emergency (A&E) departments that can resuscitate and provide initial treatment of acute emergencies for both adults and children as they maintain strict clinical standards in emergency care.

As a doctor who has worked in both public and private hospitals, I would like to shed more light on how the A&E departments of these hospitals are set up differently.

Hopefully, this can help us better understand whether there is scope for ambulances to send more patients needing emergency medical treatment to private hospitals.

First, let’s look at what happens when patients are conveyed to an A&E department at a public hospital.

The patients are first assessed by a triage nurse, who will determine how serious the condition is, before classifying them into priority 1 (P1), P2, and P3.

P1 patients are typically those involved in traffic accidents or who suffered a heart attack or stroke, and will receive immediate medical attention. P2 patients are quite ill and will be attended to when P1 patients are cleared. The conditions of P3 patients are not serious, and they will be handled by a separate team.

For accident victims in a serious condition, the SCDF would likely have alerted the hospital’s A&E department even before they arrive so that it can prepare the appropriate equipment and hospital resources such as an operating theatre and intensive care unit beds.

The A&E department’s medical team comprises at least four doctors, including one senior and one junior emergency specialist, and two or more medical officers.

Should there be a national disaster, or if there is a surge in the number of patients, other A&E department medical staff who are off duty could be recalled.

The A&E team is also backed by the rest of the hospital. There is a stay-in team of doctors and registrars from each major department at all times, and they can be activated to help at the A&E department if needed.

How then does this differ in a private hospital?

First, there are typically only two to three resident medical officers (RMOs) on duty at any time. If there are serious cases or many patients at the A&E, one or two more RMOs from the ward may be activated to help.

Second, unlike public hospitals, A&E doctors at private hospitals are not necessarily emergency medicine specialists.

Emergency medicine is a specialty that requires a minimum of five to six years of postgraduate training before one can sit for an examination to be qualified as an emergency specialist.

According to the Singapore Medical Council’s 2018 annual report, there are 193 emergency specialists in Singapore, of whom 182 (94 per cent) are practising in public hospitals.

To be sure, the RMOs at private hospitals’ A&E departments whom I have worked with are competent in handling emergencies.

But it remains a fact that most of them are not qualified A&E specialists.

Besides, there are no stay-in specialist medical officers or registrars in private hospitals. There is however a call roster for each specialty and the specialists on call have to be contactable.

If say a patient comes in with a leg fracture, the A&E RMO would call the standby orthopaedic consultant, who would return to the hospital to see the patient, usually within 30 to 60 minutes.

The A&E RMO would administer emergency treatment and carry out appropriate investigations, such as an X-ray of the leg. But it is the orthopaedic consultant who decides and carries out the treatment or surgery.

Financially, the A&E departments of public hospitals charge a flat rate of about S$121 for a consultation, which is inclusive of basic investigation and treatment. Charges are kept affordable as they are heavily subsidised by the Government.

Private hospitals do not receive government subsidies. Though A&E RMOs charge about S$130 for a consultation, it does not include any investigation or treatment.

So for a patient with serious injuries such as a leg fracture, the total costs, including charges for laboratory tests, X-rays, specialist consultant charges, plaster, cast and so on, could easily come up to S$1,000.

Costs aside, it is clear that the A&E departments of public hospitals are staffed and equipped differently from private hospitals.

The only exception is Raffles Hospital, whose A&E department meets MOH’s minimum standards for trauma care and can accept ambulance patients not facing life-threatening conditions. These patients could also receive subsidised emergency care at the hospital.

For all other medical emergencies and serious trauma cases, SCDF ambulances would typically convey the patients to public hospitals.

But does that mean that the current system cannot be improved?

Certainly not.

First, there are many different types of trauma cases, ranging from patients with leg fractures to those who had suffered multiple injuries.

At a private hospital, a patient with a leg fracture can first be stabilised and managed by the A&E RMO.

The orthopaedic consultant will be notified immediately, and can give verbal instructions via the phone. It may take him 30 to 60 minutes to return to the hospital to see the patient and plan for an operation, but this 30-60 minute gap is not critical  for the patient.

But to someone with a crushed limb, brain haemorrhage, or liver rupture, immediate attention from a neurosurgeon, general surgeon, and orthopaedic surgeon would be greatly beneficial.

Perhaps SCDF could triage the patients at the scene of the accident. Those with a simple, single injury should be sent to the nearest hospital, including private ones. But those with multiple organ injuries be sent to public hospitals, where there are more doctors on the spot.

SCDF could use communication technology to communicate with the private specialists, and to take instructions from the specialists via phone or video.

MOH could also consider providing some form of subsidised treatments for Singaporeans who were sent to private hospitals’ A&E departments.

There is benefit in having private hospitals’ A&E departments take in less serious trauma cases, as this could help to reduce the load at public hospitals and allow patients to receive medical attention in a more timely manner.

To patients who are seriously injured in an accident, reaching the A&E department 10 to 20 minutes faster may mean the difference between life and death.

Having enough qualified emergency specialists in private hospitals is not a major problem. Private hospitals could either sponsor their A&E RMOs for further training, or they could hire emergency physicians from public hospitals.

Certainly, the current system of SCDF ambulances sending all emergency patients to public hospitals could be improved.

But some actions and adjustments are needed by MOH in terms of financial and subsidy support, by SCDF in terms of triaging patients at the scene of an emergency, and by private hospitals in terms of strengthening the training of emergency physicians.

At the end of the day, a better spread of emergency patients across both private and public hospitals will benefit patients in need of urgent care.

ABOUT THE AUTHOR:

Dr Desmond Wai is a gastroenterologist and hepatologist in private practice.