As the number of cases continues to rise, it is all hands on deck at Tan Tock Seng Hospital and the National Centre for Infectious Diseases, where doctors, nurses and other healthcare workers screen hundreds of patients daily.

SINGAPORE: At the National Centre for Infectious Diseases (NCID) screening centre, one important part of the defence against the pandemic has been none other than ice cream.

Charmaine Manauis is hardly joking when she says that. She is the lead consultant in infectious diseases at Tan Tock Seng Hospital’s emergency department, which is in charge of the screening effort.



“Ice cream is important; it makes us happy. You see everyone — they have ice cream, they perk up,” the doctor said about her colleagues, and herself.

“Plus, it’s hot inside the personal protective equipment. So they love eating ice cream (in the pantry) during their break.”

She is certainly not kidding about feeling the heat under their yellow gowns, shower caps, gloves, goggles and N95 masks, which they wear throughout their seven- to 10-hour shifts, except during breaks.

In full personal protective equipment.



“When I remove my yellow gown, I’m usually drenched. It’s really hot,” she said. “When I remove (my mask), then I feel as if I can breathe again.”

That is how it has been for the staff running both the TTSH emergency department and the NCID screening centre in the time of the coronavirus.

And it is not just emergency doctors who are seeing to the suspected COVID-19 cases.

While their department used to have about 20 doctors on shift at any time in the day, it has been a whole new ballgame since Chinese New Year.

Hundreds of doctors across different specialities in the hospital — from urology to ENT (ear, nose and throat) to plastic surgery — are being mobilised for training so they can carry out COVID-19 duties too.

Since Singapore’s first confirmed case on Jan 23, more than 400 doctors from the hospital have been rostered to work at the NCID screening centre across the road.

And the one co-ordinating their training is Manauis, the senior consultant leading the screening efforts — as CNA Insider finds out in an inside look at the frontline battle against COVID-19.

GETTING WIND OF THE VIRUS ON HOLIDAY

The 42-year-old as well as her boss — Adjunct Assistant Professor Ang Hou, head of the emergency department — were on holiday in December when they first heard of a mysterious disease in Wuhan.

“I said, ‘Hm, this might be something.’ So when I came back, the department had already started screening,” recounted Manauis. “We started screening for (travellers from) Wuhan on Jan 2.”

Dr Charmaine Manauis.

That was the day Singapore’s Ministry of Health (MOH) announced that it was monitoring the pneumonia outbreak closely, and sent a circular to medical practitioners here.

Whispers of the severe acute respiratory syndrome (SARS) started “floating around” TTSH. “We were SARS central back in 2003, so that’s never left the DNA of the department,” said Ang.

“You can’t help but relive memories that you’ve been through, especially when you know your colleagues and your friends had been affected very deeply.”

The possibility of a second coming did not surprise him, however. “We were always anticipating something like COVID-19 ... We knew that it wouldn’t be a matter of if, but when,” he said.

“We knew that by the time it were to come from Wuhan to Singapore, it would’ve been ... a significant outbreak in the world or at least in this part of the region.”

Dr Ang Hou.

The department started screening for the novel coronavirus (SARS-CoV-2) in a “very small, dedicated space”.

But even “way before” Singapore’s Disease Outbreak Response System Condition alert was raised to orange, the number of people coming every day “was growing to a scale that we had to move out of (that) physical space”, he added.

As the rest of the country wound down for Chinese New Year, furniture had to be moved in, and computers set up, for the NCID screening centre to be activated.

“It was a very busy Chinese New Year for a lot of people, not because we were going around celebrating but because we were preparing for the next phase in screening,” said Ang.

Computers had to be set up on trolleys for the screening centre to be activated.

By Jan 29, the screening centre was up and running round the clock.

FROM SCREENING CENTRE TO TENT

Those first few weeks of the centre’s operations were “really hectic” for Manauis.

“We were on call 24/7. Every Saturday, we’d train (staff). During the week, we’d look at protocols — we’d look at whether our processes were working well, whether we had to manage any choke points in the screening centre,” she recounted.

One of those choke points were the X-ray rooms. “If the screening centre was full, then there’d be a queue for X-rays. And so we’d need more efficiency, more radiographers,” she said.

Based on the travel history and the chest X-ray results, the doctors had to decide whether the patients had to be warded or could be discharged.

Patients must fill in a questionnaire at the screening centre.

For those who needed admission, those were uncertain times. They had many questions. “How long will I stay? What tests will they be doing for me upstairs? How about my family? Do they need to be admitted too?” cited Manauis.

The numbers coming for screening kept rising until the load “became quite difficult at one point”, said Ang.

That came about when the MOH changed the definition of a suspect case, following the transmission of the coronavirus at a health products shop visited by Chinese tourists.

“That led to a lot of patients being referred by their doctors for screening because they’d come into close and frequent contact with travellers from China,” said Ang.

“A lot of people in various industries came in, whether they were taxi drivers, tour bus drivers, people who worked in tourist attractions or hotels, airports and casinos. They were all flooding in.”

Inside the screening centre.

So, after consulting the ministry, TTSH proceeded to swab and discharge these patients, “to conserve beds for patients who were really ill and needed treatment”.

Then there was “a strange point in time”, when the number of people coming for screening and the cases confirmed as positive slowed down, even as the numbers were picking up in the rest of the world.

“We knew that the numbers would go up sooner or later,” said Ang.

“We knew that the screening centre might not be able to cope ... so we made the decision together with the ministry to set up a tentage, to expand the number of places available.”

The tent outside the screening centre.

That ended up being the case. On March 23, the TTSH team screened the highest number of people until now: More than 520. “We call it the most terrible Monday,” said Manauis.

“The patients came in the afternoon and at night. And at night, we have less manpower. We had to open the tentage until 3am, with a lot of patients having to wait a little bit longer. So that was a struggle.”

MIGRANT WORKERS A NEW CHALLENGE

There are still hundreds of patients screened daily, although the challenge as of late is not the numbers but the space needed, as the spike has been among migrant workers, and the tent outside the screening centre is “perennially full”.

“For these foreign workers, we need to wait for swab results before they can be discharged (if they test negative). So we need a bigger waiting area for them,” said Manauis.

“After that, they have to wait for transport also, to bring them back to their dorms. So they can wait for as long as, probably, 18 (to) 20 hours.”

WATCH: An exclusive look inside the NCID screening centre (Dur 5:20)

While there are now Swab Isolation Facilities like the CherryLoft chalets — where the workers can be sent after their nose swabs — these facilities “are quite full” nowadays, she added. The workers are otherwise unable to self-isolate.

"Every day, we’d have to ask whether there’s any vacancy, and then they still need to wait for an ambulance or dedicated transport."

While there is swabbing done at the dormitories now, some of the workers need to go to the screening centre depending on their symptoms.

If they complain of chest pain or have difficulty breathing, for example, then they need an X-ray, a blood test or an electrocardiogram.

An Army Medical Services member taking the blood pressure of a foreign worker at Westlite Toh Guan dormitory. (Photo: Mindef)

As long as they are symptomatic or have had close contact with a positive case of COVID-19, they should be swabbed.

An MOH circular sent on Thursday has also updated the swabbing criteria for everyone. Anosmia — the loss of the sense of smell, either total or partial — is now one of the symptoms to look out for, cited Manauis.

“There were (research) papers that came out, and there were positive cases which presented only with anosmia,” she explained.

The other symptoms still include fever, runny nose, cough, sore throat and gastrointestinal symptoms like diarrhoea or vomiting.

Since she started on TTSH’s clinical protocols and work instructions for COVID-19 screening and infection controls, Manauis has developed 61 versions for the staff to follow.

Manauis has had to change the protocols often.

There is also a workflow for the foreign workers from dormitories, which is at version 17 now.

IN FOR THE LONG HAUL

She has also trained nine batches of doctors from various departments, with as many as 51 physicians in a batch.

They work a 10-day cycle as part of a group of more than 100 people, including nurses and other healthcare workers, running the screening centre.

Most of them, even senior specialists, are volunteers, and some have done more than one rotation, although each department is also supposed to contribute a certain amount of manpower.

Doctors at a voluntary Saturday training session.

“Screening is very different from what they do every day. So it wasn’t a surprise that they were a little bit apprehensive. But they were very willing to help out,” said Manauis.

She is grateful for all the support. At one of the training sessions this month, she told the doctors: “We really need your help on the front line. On behalf of the emergency department, I thank you guys for volunteering.”

The thing is, her department is not only working at the screening centre, but also attending to the usual emergency cases. To do this, the staff have cancelled their leave and reduced their days off.

“You just have to do your work. I go day by day — whatever needs to be done, needs to be done,” she said with a shrug.

“Everyone’s made sacrifices, not only me or not only the doctors ... But we do this willingly because we know that this is our job.”

Their efforts on the front line have not been forgotten.

The emergency cases are tended to in a different zone, although that does not mean the staff necessarily get to dispense with personal protective equipment. The forward screening triage nurses, for example, must wear the full equipment.

“Sometimes walk-in patients ... are close contacts (of a COVID-19 case), so we have to protect our frontline staff,” said Manauis.

To protect the patients as well, one of the changes made is to ensure that they queue at least two metres apart. This, and many of the current arrangements in the emergency department, could be in place for some time.

“For those of us who’ve been here for a while, who’ve gone through other outbreaks, we know that, potentially, it’s going to be long-drawn,” said Ang.

“It could affect some of our own members — that the memories of SARS come back — and I think it might hit those (employees) a little bit harder.”

Patient care goes on in the emergency department.

When asked on Friday about her team’s morale, Manauis, who has been with TTSH for 15 years, gave a cheerful reply.

“We’ll try our best to ... help the nation, especially now that (the number) of positive cases has been increasing,” she said.

“We’re still okay. We still have ice cream, so we’re happy. I mean, you’ll need to try and pace yourself because we know that this is going to stay for a few more months.”