My Experience in the Time of COVID-19 in Singapore

Dr Pan Jiun Yit, Senior Consultant Dermatologist National Skin Centre

Background

Singapore has over 300,000 migrant workers who live in foreign worker dormitories. From late March to April 2020, the pattern of COVID-19 cases in Singapore began to shift from mostly imported and community-acquired cases to that of infections in the migrant worker population living in dormitories. This surge of infections resulted in the imposition of mandatory quarantine for all foreign workers living in gazetted isolation areas.

To provide medical cover for our foreign workers in dormitories, Medical Posts were set up in all foreign worker dormitories across the country from 13 April 2020. PCR swabbing operations were organized to facilitate case detection, and measures implemented to improve safe distancing and better infection control in the dormitories. On 21 April, Singapore’s Ministry of Manpower announced that all foreign workers except those in essential services living outside the dormitories were to stop work in order to curb the spread of COVID-19 in the population.

Medical, nursing and operations staff from the National Skin Centre and National University Hospital Dermatology Department were deployed to the foreign worker dormitories, community care facilities located in exhibition centres, hotel isolation facilities, and COVID-19 wards in National Centre for Infectious Diseases (NCID), the Khoo Teck Puat Hospital and National University Hospital.

As of 10th June 2020, there were 38,965 confirmed COVID-19 cases in Singapore, of which 36,627 cases were among foreign workers.

Deployment Experience

I was deployed to and headed a Medical Post in a foreign worker dormitory. This gave me the opportunity to work closely with nursing staff from other National Healthcare Group institutions, the Singapore Armed Forces and Police Force, Ministry of Manpower and Dormitory operators in the national effort to stop the spread of COVID-19 infection and to care for infected persons. We were able to set up the Medical Post promptly and provided primary care to the foreign workers who were under quarantine in our care. Education materials in relevant languages were made available by Health Serve, a voluntary social service agency that works with foreign workers.

Our duties were strenuous at times, we took care of one another’s health by ensuring everyone complied with strict PPE standards and had adequate hydration. A dedicated ambulance service was provided to ensure that unwell patients could be promptly evacuated, as well as pharmacy refills for medicines to for underlying medical conditions.

We were able to provide wound dressings, stitch removal and simple surgical procedures. Healthcare manpower was maximised by a roving team system that also covered other nearby dormitories. Professor Steven Thng provided capable leadership in setting up and organizing the string of Dormitory Medical Posts, and subsequently the phlebotomy programme for COVID serological testing.

We also managed a Community Care Facility (CCF) and Community Recovery Facility (CRF) that provided accommodation for stable and recovering COVID-19 patients. These patients were reviewed daily to watch for signs of any deterioration that would require transfer to hospital. Patients were understandably very anxious and needed daily review and reassurance. We brought them daily care-packs and morale boosters like drinks, fruits, bottled water and snacks. Education leaflets about COVID-19 were given and medications they needed were delivered to them. Through these efforts, our patients were reassured that they were well taken care of.

Managing recovering patients in the dorms reduced the need for ambulance transfers and relieved the bed crunch in hospitals and external community care facilities.

Dermatological Conditions

Dermatological conditions were extremely common in this population. We saw a number of patients who had eczema, psoriasis, pityrosporum folliculitis, fungal infections (tinea versicolor, corporis, cruris and pedis), scabies, acne, alopecia areata, callosities and warts, impetigo, cellulitis, folliculitis and furunculosis, as well as lumps and bumps (epidermal cysts, steatocystoma, lipomas etc).

Owing to the difficulty in arranging referrals to specialist care in hospitals during the COVID-19 pandemic, we had to look after workers with new complaints in the dormitories ourselves and had to perform simple procedures at the Medical Post when indicated. With careful attention to proper surgical technique, sterility and follow-up nursing care, good results were achieved even in the less than optimal conditions. We performed incision and drainage of boils and abscesses, excision of ruptured epidermal cysts, paring of warts and callosities, stitch removal, and dressing & bandaging.

Because of the prolonged wearing of N95 mask and full PPE, many of my staff suffered from abrasions, indentations, contact dermatitis, acne and post-inflammatory pigmentation.

We had the opportunity to examine our COVID-19 patients in the dormitory isolation facilities. Most of them did not have any skin issues. However urticaria and a transient exanthematous rash was seen in a handful of the patients, which resolved with antihistamines.

One patient had an eczematous rash of the limbs, another developed a Gianotti-Crosti-like papular rash on the acral extremities at day 12 post-diagnosis. We had one patient with faint bruising of the extremities, but no overt signs of acral ischaemia, petechiae or purpura.

Value-Added Services

Some of the staff were deployed from the physiotherapy department of general hospitals. Due to the prolonged period without work and quarantine in the dormitories, many developed musculoskeletal problems, became deconditioned, overweight or obese, or sustained injuries due to exercising in the bunks. My physiotherapy staff took the initiative to do a thorough assessment for the patients and teach them physiotherapy and stretching exercises. This will help them return to work safely, as their usual jobs may involve heavy manual labour. A fellow ENT specialist brought his own equipment to provide ear toilet, earwax syringing and foreign body removal.

Final Thoughts

Overall, the experience is akin to a well-organized medical mission trip. Although resources were limited, our teams were able to make a big difference. Attrition was minimal as the team was committed to serve and operational safety was maintained on the ground. Communication with patients and workers was often challenging and it was helpful to have Tamil or Bengali translators on hand, or pictorial flashcards.

It has been extremely rewarding to work with colleagues from other organizations in the effort to control and treat COVID-19. The foreign workers were grateful and appreciative for the effort put in by the medical team, and this was the greatest reward, to know that we have made a difference.