01 Jan 2012
By: TAN HUI YEE
As a general rule, most fractures don’t stretch the medical profession, but try telling that to Patient A, who turned up at the Singapore General Hospital (SGH) seeking help earlier last year.
The foreign construction worker had fractured the middle finger of his left hand at work and was treated by his company-appointed private doctor on the same day.
But he was not given medical leave, went back to work and, within three weeks, had to leg it to the public hospital as he still could not move his finger.
An X-ray revealed a disturbing sight: Three tiny screws used by the doctor to attach a metal plate to his fractured bone were wedged in his finger joint, effectively immobilising it.
And one of the screws inserted in his bone was so long that it had exited on the other end and was probably impaling a tendon.
It was a startling case of sub- standard treatment but far from unique.
Similar cases have surfaced recently at SGH, the National University Hospital (NUH) and Tan Tock Seng Hospital.
Each year, the three hospitals treat more than 15 cases of foreign workers whose hand injuries are not treated properly, or who were not given adequate therapy.
They turn up with stiff, painful fingers, sometimes crossed or bent at awkward angles.
In some cases, the wires and screws used to fix fractured bones were misaligned, inflaming the tissue and infecting the bones. In others, patients were put through unnecessary operations.
In one particularly disturbing case, a private surgeon overlooked the fact that part of a nerve in the patient’s hand had been severed, and left it unattended.
The number of such cases has been noticeable enough in the last three years for doctors in these public hospitals to start keeping count.
Typically, these workers have no independent means to pay for medical treatment and are sent by their companies to private hospitals after getting injured. But they surface at public hospitals alone a few weeks later, desperate for help.
Medical standards may be high in Singapore, but migrant worker support groups note that these labourers, with their paltry savings and limited command of English, usually have no say over how or where their injuries are treated.
Employers are required to bear the cost of their foreign workers’ medical treatment, which in public hospitals attract the higher-tier fees reserved for private patients.
Hand, wrist or finger surgery which does not require hospitalisation can cost anything from $1,000 upwards, so it makes financial sense for some large companies to simply whisk injured workers to appointed private hospitals where they may be treated faster.
But it appears that some workers are not getting treated by doctors who are skilled enough to tackle their injuries, or prescribe the right kind of therapy.
SGH hand surgeon Andrew Yam told The Sunday Times that some foreign workers turned to public hospitals as they were not given medical leave from the doctors who initially treated them, despite having stiff and painful fingers.
“Some of them come because they realise that something is not quite right,” he said.
They usually have few or no medical records to show because such documents are retained by their employers or the doctors who initially treated them.
The head of NUH’s department of hand and reconstructive microsurgery, Dr Peng Yeong Pin, told The Sunday Times: “A lot of times, the workers who come feel they have been abandoned, that no one is looking after their interests.”
This seemed to be the case with Patient A. After the reason for his stiff and painful finger was identified, SGH recommended corrective surgery.
But as this was considered an elective procedure, the hospital required his employer to guarantee payment for the operation.
The letter of guarantee did not arrive and Patient A never showed up again.
Knowing their limits
These are not cases of quack doctors at work. Hand surgeons at these public hospitals declined to name where the patients were originally treated, but it is understood that the problematic surgery was conducted by registered doctors.
What is not clear though, is whether the operations were mishandled because they were rushed, done on the cheap or simply because the private doctors involved had overstretched the limits of their expertise.
The doctors interviewed for this article stressed that they had no wish to pit surgeons in the public sector against those in the private sector.
“It doesn’t matter who treats the patients,” said Dr Andrew Chin, who heads the SGH department of hand surgery. “However, if it is a complex injury, it should be treated by doctors who are appropriately trained to handle the level of complexity.”
The three major public hospitals all have dedicated hand surgery units which attend to a few thousand cases requiring operations every year.
Technically, any doctor can operate on a hand, but hand surgery is a specialisation in Singapore with a training programme lasting at least three years. There were 22 hand surgeons in Singapore as of December 2010, with 17 in the public sector.
Given Singapore’s compact size and wealth of medical facilities, there is no reason for the patients to be denied specialist attention, said private hand surgeon Jonathan Lee, who operates out of Mount Elizabeth Medical Centre.
Hand surgeons, he said, “are registered and easily accessible both in public and private hospitals in Singapore”.
Yet, botched cases of hand surgery keep popping up.
Last February, Patient B, a 33-year-old Filipino shipyard worker, was treated by a private doctor after the top half of his right thumb was crushed in an accident.
A month later, he turned up at NUH complaining of a rigid and painful thumb. An X-ray revealed that he had gone through unnecessary surgery.
Surgeons commonly insert a stainless steel Kirschner wire into fractured bones to stabilise them during recovery. In Patient B’s case, the doctor who first treated him had used the wire even though the bone was so shattered it would have been as useless as skewering soft tofu.
To make things worse, one end of the wire was jabbing painfully at the man’s tendon.
The hospital removed the wire from his thumb and gave him a splint.
It’s about therapy too
The Ministry of Manpower (MOM) told The Sunday Times that it would “take stern action against employers who are found to be colluding with any institution or medical professional to short-change a worker with work injuries of his medical care and rest”.
It added: “MOM will not hesitate to blacklist these employers and debar them from hiring foreign workers.”
In the past two years, the ministry received an average of 30 cases a month involving foreign workers seeking help over employers who did not give them medical treatment. But MOM has not penalised any employer so far.
All employers, its spokesman said, met their work injury compensation and medical treatment obligations after intervention by the ministry.
The Singapore Medical Council stressed that its ethical guidelines require a doctor to “practise within the limits of his competence” and refer complex cases they cannot handle to a more skilled colleague. Those who fail to do so may face disciplinary proceedings.
Doctors said proper therapy is also needed to ensure that cases do not become problematic.
This includes regular exercises to desensitise a patient to the severe pain that he may feel after a crushing injury.
In theory, “light duty” can help a patient with an injured hand recover faster by getting him up and about and keeping him positive about his prospects of returning to work.
But the arrangement was subject to some controversy four months ago, after migrant worker advocacy group Humanitarian Organisation for Migration Economics (Home) lodged complaints with the Singapore Medical Council on behalf of workers who claimed that some private doctors did not explain their conditions to them, or certified them fit for light duty, instead of giving them medical leave.
Home’s executive director Jolovan Wham asked if the private doctors were giving these workers fewer days of medical leave than appropriate so that employers need not report the accidents to MOM, thus keeping their safety records clean.
Meanwhile, some workers have been known to be assigned to routine manual work while being on light duty.
Hence, NUH will not certify a worker fit for light duty if it is not confident that his company will give him generally sedentary tasks.
Its light-duty arrangement, said Dr Peng, “applies only to companies that we know will take care of their workers”.
“If we are not sure that the workers’ welfare will be looked after, we will issue medical certificates,” he said.
Rapid recovery possible
Yet, the results can be nothing short of remarkable if doctors and employers work closely with the patient.
Dr Peng cited the case of Patient C, a 28-year-old shipyard worker from India whose left hand was crushed by a heavy machine in March last year.
The accident left his little finger mangled, his ring finger severed and middle finger split open. NUH doctors could do nothing about his ring finger but managed to reconstruct his middle and little fingers.
His recovery, said Dr Peng, was “rapid”. After just over two months of medical leave, he was put on light duty for the next four months and then returned to his normal work routine.
He added that this success story was possible because Patient C was motivated to return to work, and his employer worked closely with his doctor to track his progress.
In the same vein, SGH’s Dr Chin urged more employers to develop a “robust programme” to help injured workers heal and slowly re-enter the workplace.
He said: “Ideally, they should communicate with the doctor every step of the way, including what kind of light duties the workers will be assigned to.”
Given that there are more than 10,000 workplace injuries in Singapore every year, this is one call that begs to be heeded.
Email: tanhy@sph.com.sg
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