Need To Go To The Hospital But Not Urgent Enough To Be Priority? Try Urgent Care.

Hospital emergency rooms are infamous for being overcrowded. Instead of waiting for hours in the hospitals where ambulances constantly bring in sicker patients, people who need care urgently can consider treatment at urgent care clinics, according to Cheah Si Oon, an Emergency Specialist at Urgent Care Clinic International. We discussed with Cheah on what is urgent care, when patients should choose urgent care clinics over hospital emergency rooms and why making an Advance Care Plan is important.

Name: Cheah Si Oon

Company: Urgent Care Clinic International

Medical Specialization: Emergency Care

Base Country: Singapore

Service Style: Efficient, personalized, compassionate

Anything Interesting: Avid scuba diver who finds joy in reading children’s books

Clinic Location: Parkroyal on Kitchener Road, 181 Kitchener Road, #01-01, Singapore 208533 (Central Singapore CDC)

Q: Can you tell us more about yourself? Why did you decide to be a doctor?

Cheah: My story is very typical. I wanted to be a doctor because I wanted to help people. I ended up specializing in emergency care and working in the hospital’s Accident & Emergency (A&E) department for more than 10 years because I like to multi-task and handle different kinds of challenges.

Q: Is A&E in real-life similar to what you see in the movies?

Cheah: Yes! You might remember the US television drama, ER, which came out around the same time as when I started in A&E. We get different kinds of cases every day and just deal with whatever life throws at us. It’s never boring there. We are constantly in motion and everything looks messy to the eye but it’s our kind of “organized” mess. All the doctors and nurses know where everything is, and we know exactly what our roles are.

Q: What is the most significant incident that you still remember till this day?

Cheah: We get to see many different cases, but the ones that we find it difficult to forget are the traumatic incidents with tragic outcomes, sometimes involving multiple casualties.

The recent most memorable incident for me happened in 2017. A pregnant woman was knocked down by a truck when she was crossing the road. She collapsed on arrival at the A&E and we had to perform a perimortem cesarean section (the delivery of a fetus during or near the time of death of the mother) to save the baby.

We tried to save both the mother and the baby, but in the end, we only managed to save the premature baby, who is miraculously doing very well today. Even though we couldn’t save the mother, it still feels very rewarding to be able to do what we did.

Q: Do you get immune to death after dealing with so many cases?

Cheah: No, I think it’s very hard to be immune, or even get immune at all. You just learn how to deal with your emotions through time. It’s always going to be difficult when it comes to death.

As a senior doctor, we are like the captain of a boat. We have to quickly make sure all our junior doctors and nurses are okay emotionally, because most of the time before anyone can fully recover from one case, new cases will appear.

We see patients with sudden cardiac arrests from accidents or heart attacks on a regular basis. It is devastating to break the news to the family. Typically, we don’t break the news over the phone, because we don’t know how the family will take the news. We don’t know what ages the family members are or whether they will faint when they hear the news, so we wait for them to come to the hospital and then slowly break the news to them. That’s the least we can do.

Q: You are now running your own clinic focusing on “urgent care”. What exactly is urgent care and what made you start your own clinic?

Cheah: Urgent care is for people whose conditions are urgent enough to need to see a doctor urgently, but not for emergency life-threatening cases. Instead of waiting for hours in hospitals, where ambulances constantly bring in sicker patients, people who need care urgently can be treated in a non-hospital setting like my clinic.

If you are sick, there are generally two places that you would go to - your neighborhood clinic that does general practice or if it’s urgent, you would go to the hospital’s A&E. But something is missing in between. Not everyone who needs to be treated urgently will require hospital admission. Only about 30% of the urgent cases end up with an admission. My co-founders and I realized that there’s this gap where a lot of urgent patients can actually be treated quickly and discharged home.

Me and my other two co-founders are all Emergency Specialists. We understand the frustration of waiting at the A&E for 5-6 hours to be seen by a doctor. We started to think of ways on how we can decongest A&E and reduce patient waiting time in Singapore, and that’s how our clinic came about.

Urgent Care Concept

Urgent care is not a new concept. Some countries, like the United States (US), already have urgent care to help decongest A&E. Urgent care is a sub-specialization in the US, and I’ve been observing its development. I believe that if 10% of the A&E patients can be brought to clinics that provide urgent care, this will help significantly decongest A&Es in Singapore.

Another reason why I decided to leave A&E and start my own clinic is because I want to know my patients better and have closer relationships with them and their family. At A&E, we have very little time to interact with patients and family. Over time, I felt like there wasn’t really a close doctor-patient relationship where I could follow-up with their recovery.

Q: How is your clinic different compared to public and private hospitals and other clinics?

Cheah: Even though we are a clinic, we’re slightly different from other clinics as our doctors are all emergency specialists. Some people described us as “super” GPs or jack of all trades, who know a little bit of everything and have the skills to perform most of the simple procedures.

Compared to public and private hospitals, our clinic can provide patients with faster care for certain emergencies, and patients can be treated by an Emergency Specialist from the start.

For example, if you have a very bad ankle sprain or a minor fracture, but not to the extent that you need surgery, we can put you on a walking boot instead of a plaster cast. You will be able to avoid multiple visits to the hospital for change of plaster cast and cast removal. You will still be able to maintain your mobility and save time and money as well.

House Visits For Elderly Patients

We do house visits as well, where we would go to patient's homes to see them instead of them visiting a hospital’s A&E.

For example, if you have stomach pain, but you’re not sure whether it is food poisoning, a problem with your gallbladder or something else, we can go to your home much like a mobile A&E doctor. We can perform blood tests by the bedside and we can also use a portable ultrasound machine to look for gallstones and gallbladder infection. We can provide intravenous (IV - a medical technique that administers medication or fluids directly into a person’s vein) antibiotics for infection as well as IV fluids for rehydration at your home.

This may be a good option for elderly patients with dementia who are more comfortable in their own home as they often get disoriented by unfamiliar places like hospitals.

Another difference between us and the hospitals is our charges. We charge slightly higher than public hospitals’ A&Es but are more affordable than private hospitals. Public hospitals are heavily subsidized by the government and thus the cheaper charges.

Q: What is a typical patient for you?

Cheah: We treat patients with any minor accidents which do not need immediate surgeries such as falls, fractures, cuts, bruises, and dislocations. We also treat patients with mild infections, for example, skin infections such as cellulitis, boils and bacterial infections such as urinary tract infection, food poisoning and dengue infection, who may need some IV hydration.

We are not able to follow through life-threatening emergencies, such as heart attacks and strokes which require big scanners for diagnosis, or surgeries, such as perforated appendixes.

Q: How does someone know when to call your clinic or an ambulance for emergencies?

Cheah: If you have life-threatening symptoms such as severe or crushing chest pain, where you suspect it’s a heart attack, you should call an ambulance. The ambulance would know which hospital has a 24/7 cardiologist that can perform urgent medical procedures on you. If you were in an accident which resulted in massive bleeding and fractures with bone jutting out of your skin, you would definitely need surgery, so you should call an ambulance as well.

If you are able to make your way to the A&E on your own with minor symptoms, you may be a suitable patient for urgent care. If you are not sure whether you should come to us or whether someone like an elderly patient is suitable for a house visit, you can give us a call or send in a photo of your injury and we will evaluate and advise what’s the best course of action for you.

We have this concierge-like service because we think the public is unsure about the medical system, so we want to provide a bit of guidance on what they should do for different emergencies.

Q: What services do you provide in the last mile of life space?

Cheah: We help people do Advance Medical Directive (AMD), Lasting Power of Attorney (LPA), Advance Care Planning (ACP), and death certification.

A lot of people, especially elderlies who are nearing their end of life, either from cancer, old age or other reasons, actually want to die at the comfort of their home. Many patients, who are on palliative care (specialized medical care that helps people relieve pain and other symptoms because of serious or life-threatening illnesses, such as cancer or heart failure), still have mental capacity and want to be taken care of in a certain way.

One way to achieve what these patients want is through ACP.

Q: What is your ACP procedure?

Cheah: If you already know what you want to do, that’s great, you can just get us to sign off your ACP document. But if you don’t know what you want to do, then you will have to consult us first.

During the consultation, we will determine if you are still mentally capable of making your own decisions. Once we have established that you are still mentally capable, we can assess your medical history and details and the medications you have taken through the National Electronic Health Records (NEHR) database.

Next, we will have an open discussion with you because the details that go into ACP are very in depth. Let’s say you are a patient diagnosed with end-stage colon cancer, we will ask what care would you want and to what extent.

Detailing Your Healthcare Preferences

If there are symptoms relating to your cancer but are not immediately fatal, such as slow bleeding in your body, what do you want medical professionals to do? Do you want us to still provide you with intermittent blood transfusion (medical procedure that transfers one person’s blood to you to replace lost blood)?

If you developed medical issues that are unrelated to your cancer and are reversible such as fever and pneumonia, would you want to be treated and be put on antibiotics?

What if it’s a sudden medical catastrophe that is so great that your heart stops? Do you want medical professionals to do cardiopulmonary resuscitation (CPR - a lifesaving emergency procedure to restore blood circulation and breathing when your breathing or heart stops), put a tube down your throat and then put you on an artificial ventilation machine (equipment that helps you breathe when you can’t breathe on your own)?

What if your cancer is causing you to feel so sick that the cancer cells have spread to your brain and you can no longer eat, do you want to be put on an artificial feeding tube?

Consider Doing Your Advance Care Plan

If your answer is no to certain things, you would rather not suffer than to get those procedures performed on you, we’ll put that wish on your document.

After you have decided that you want to do your ACP and made sure that your wishes are documented, we will sign off the document for you.

We highly advise that your children or family members are made aware of your decision when you are doing your ACP. If you have many children or family members, pre-select a primary healthcare spokesperson that will speak on your behalf for when you lose mental capacity, because that would make things easier for medical professionals when they only need to talk to one person to make certain decisions.

(Want to get started on your ACP but find it too difficult? Reach out to providers who can help you with your ACP here)

Q: How does an ACP get activated?

Cheah: For instance, a cancer patient could have signed his ACP to allow pain medications to be given for his cancer to alleviate his pain but not further surgery, chemotherapy or radiotherapy to remove or shrink his tumor. So when this patient is suffering from pain, medical professionals like us can follow his ACP instructions and make him more comfortable. He may not need hospitalization for further scans and surgical procedures, because we understand what his wishes are.

There was a case where one of our patients had signed her ACP. And in her ACP, she stated that she doesn’t want surgery, transfusion, artificial tubes or any life support procedures for her illness and only wants to treat issues that are reversible. One day, she developed symptoms of confusion and is not eating well.

At first we thought it’s her illness causing these symptoms, and since her ACP says she doesn’t want to be fed by artificial tubes, we followed her ACP instructions and didn’t proceed to force her to go to the hospital. We later found out it was actually her chronic medications (medications that are taken on a regular basis for long-lasting illnesses) that caused her sodium level to be lower than average. This is a treatable issue so we immediately took action and corrected her sodium level. After a short period of IV fluid treatment, she recovered from her confusion.

Q: What are some of the common issues that people face when they do or have done their ACP?

Cheah: When it comes to ACP, one of the common issues that people face is when they have never had prior discussion about end-of-life planning before they come in to sign their ACP.

ACP is something that you can discuss with your family before you decide to sign the document. There are available brochures to assist you to start the difficult conversation with your family.

Another thing that most people don’t know is that ACP is reversible. A lot of patients and family members are not comfortable signing the document because they think it is permanent. They are also afraid that they will not receive care when they need it nearing their end of life.

For details about the extent of care, which can sometimes be too technical, we can provide you with more information and examples to help you with your decision. You can have a discussion with your family first and then come back when you are ready. It’s good to have your family around when you do your ACP so they are aware of your wishes.

Difficult For Caregivers To Be Bystanders

The other issue is that it’s often very hard for caregivers to be bystanders in situations where they have to witness the patients’ pains and sufferings. In many cases, they will inevitably bring patients to the hospital and patients have to die in the hospital. But this is exactly the sort of thing that the elderlies are trying to avoid.

At the end of the day, everyone wants to have a comfortable last day in life. Everyone wants to leave this world peacefully with no suffering. A lot of what we do is advise dying patients of what to expect and prepare, and make them as comfortable as possible. In turn, caregivers can also be mentally prepared and won’t be too traumatized when the day comes.

Q: What are your interests or hobbies?

Cheah: My ‘real’ full time job is taking care of my three kids who are all under 12 (laughs)! Currently I’m discovering my second childhood and being introduced to books that 11-year-olds enjoy reading. Remember the time when Harry Potter was hugely popular? Now there are many more books and series about dragons and magic.

When the kids are old enough, I want to go back to scuba diving. I used to dive with my husband. It's something that we both find very therapeutic.

This interview has been edited for length.

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What is urgent care?

Urgent care is a medical service that provides care for people whose conditions require treatment by a doctor urgently, but are not life-threatening.

Should you call an ambulance or a clinic that provides urgent care when there is an emergency?

If you can make your way to the A&E on your own with minor symptoms, a clinic with urgent care services may be able to treat you. For more severe emergencies, you should call an ambulance.

Should I discuss my Advance Care Planning (ACP) decisions with my family members?

You can and should discuss your ACP with your family members before signing the document so that your family members are made aware of your decision/wishes. You can also pre-select a primary healthcare spokesperson that will speak on your behalf for when you lose mental capacity, which would make things easier for medical professionals when they only need to talk to one person to make certain decisions.

If I have done my Advance Care Planning (ACP), when will it get activated?

Medical professionals can carry out your healthcare preferences that is indicated in your signed ACP in the event that you lose mental capacity.

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