In September 2021, the Ministry of Health (MOH) announced that the home recovery programme (HRP) would be the default mode of management for COVID-19 patients with a few exceptions; eg, children below 12 years old would be eligible only after a physical examination at a children's emergency (CE) department in a hospital. As days and weeks passed, I read news reports of children with COVID-19 trapped at home on quarantine orders; some waiting for more guidance on HRP, others waiting for medical staff to reach out to them as they were unwell. As a paediatrician, I could not ignore the cries for help from the many parents. I brainstormed for days on how a lone paediatrician, who was not directly part of MOH or the Singapore Armed Forces (SAF), could contribute to the newly launched HRP and help keep these sick children safe at home. To me, it was truly ironic how the families were so close (on this small island of Singapore) and yet so far (on quarantine orders and not able to leave their homes).
Humble beginnings
Finally, on the evening of 1 October (which to me is still traditionally Children's Day),a I was determined to do something about it! Children's Day is an annual reminder to me, as a paediatrician and a father, to celebrate the joys of childhood. Instead, children were trapped at home with stressed-out parents, in need of help and assistance. That evening, I managed to reach out to a medical colleague directly involved in HRP and we spent a frantic 20 minutes on the phone, rapidly exchanging ideas on how paediatricians from the community could assist in the HRP. We worked out an idea to augment the HRP telemedicine (TM) workforce with community paediatricians, who would reach out to the children on HRP via TM consults in their time of need. Over the next few days, a flurry of online meetings, phone conversations and emails ensued, this time also involving paediatric colleagues from KK Women's and Children's Hospital (KKH) and the National University Hospital (NUH). The previous workflow, which involved bringing children to and from these two hospitals for physical examinations, consumed a huge amount of resources. A strategy was developed that involved a team of community paediatricians assessing the children via TM consults and only bringing those who were unwell or at risk of complications during a COVID-19 infection to hospital, all in a timely manner.
Building an "army"
Planning the logistics and workflows over the following week was challenging, but even more daunting was fulfilling my promise of a volunteer workforce that as yet did not exist. How was I going to convince my fellow paediatricians in the community to "sign on" to do something never done before and with no definitive working hours yet? We could be doing TM consults during office hours or even be on a 24/7 TM call roster! However, on the very day I reached out to my colleagues scattered across Singapore, I had paediatricians steadily volunteering one by one within a matter of hours to join what was initially known as "Darryl's TM army", starting with me as the first recruit. It was built up to section strength in a day, platoon size by the weekend and we achieved company level strength with a team of 45 paediatricians by the time we held our first briefing the day before we went "live".b
We started operations on 8 October 2021 and since then, we have been reaching out to families day and night, on weekdays and weekends, within one to two days of receiving the name list. Mindful of the young age groups we were managing, we only called parents between 9 am and 10 pm, sometimes fixing later appointment times to facilitate their work-from-home schedules. In fact, we even had to reschedule appointments for some very socially-active children who were busy "Zooming" with their peers when we called! Given that they were stable and already physically "cut-off" from the outside world, my team often accommodated these little requests of many families.
One kampung of paediatricians
Looking back at our two months of operations, reaching out to all these children at home was really the culmination of "one kampung" of paediatricians from the community and public healthcare institutions (PHI) all working together to keep children safe during their HRP journey. Our fellow paediatricians in KKH and NUH were an integral part of the kampung for when we had to send children to CE for further evaluation or for admission when they were too unwell to be managed at home. This continuity of care was the result of much behind-the-scenes coordination and communication between community and PHI paediatric teams. Then there were the "neighbouring kampungs" – the operations and administrative staff from the SAF and MOH, who worked tirelessly in the background to keep all the gears and cogs turning smoothly, from the multiple conveyances to and from hospitals and community isolation facilities, to the coordination of various administrative and TM teams.
I wrote and frequently updated our standard operating procedures from day one of operations to adapt our workflows to the countless issues we faced on a daily basis. In addition, to keep the team updated on the many logistical and clinical problems encountered along the way, I collated and summarised the issues as a team debrief at the end of each day, which became known as "midnight debriefs". These started out as simple WhatsApp chats, expanded to one to two page documents and eventually evolved to Google sheets that I updated frequently, so that team members would have real-time easy access to updated workflows and solutions to frequently and not-so-frequently encountered issues. Mindful that I was the one who had brought the team together, I was also acutely aware that I had to maintain team morale and keep the team going in the right direction, as with time, fatigue was sure to set in. Thankfully, more paediatricians have joined the HRP effort and we have now expanded into several teams from that one pioneer team.
Bringing the e-book to life
Within a week of beginning operations, I realised that parents often highlighted a few similar key issues and my team members frequently had to explain or describe the same matters to parents who felt lost. Every time we ended a TM consult, we were constantly worried that these parents would not be able to reach out for help when needed. There were so many available resources already prepared in booklets and on websites, but parents were simply not digesting the information well. So, I again spent days (and nights) pondering how to communicate all the important information to parents in an easy-to-digest format. What troubled me just as much, as a paediatrician, was that many parents reported children fearing the dreaded transports to hospital by "scary-looking" ambulance crews decked out in full personal protective equipment. I thus needed a way to reassure young children (and their parents) on what happens when they had to be conveyed to CE.
Late one night, the idea to create an e-booklet specially targeted at the younger age groups was hatched. Our team could easily send the e-booklet to all parents at first contact. I immediately reached out to an old contact who wrote children's books – my children and I had enjoyed reading many of her storybooks over the years. If anyone would be able to simplify and make this topic appealing to kids and parents, it was Emily Lim-Leh! I was ecstatic when Emily replied the next day and already had an illustrator (Josef Lee) in mind. So began the formation of the e-booklet team... after settling the paediatric HRP team matters, I often spent the rest of my nights on the e-booklet, reading the many text messages Emily and Josef sent over the day, then vetting or reshaping the medical information. In essence, I supplied the e-booklet team with relevant HRP details and workflows, as well as the frequent questions the HRP team encountered, and the e-booklet team would process all that by the next evening! Within a few days, we realised that with the vast amount of information we were trying to squeeze into our little booklet, this little side project of mine had blown up into a full-fledged book! Considering that our team had never met nor worked together before, it was truly amazing that we got it ready in a record time of three weeks.
Compassion through communication
After our many encounters with families in isolation, we really empathised with many parents on the mental stresses they experienced during HRP. As paediatricians, we try our best to spend a little time to give them some reassurance even after the medical assessment has been completed. Even though we are separated by a phone screen and many kilometres apart, the human touch (albeit virtually) is still very much of value to keep spirits up for both parents and children isolated in a room at home for an extended period of time.
One advantage my team has is our multilingual capability. We could rapidly swap doctors on the spot to cater to parents in their native language. Many a time, by conversing with parents in their native language, both parties could better understand the medical or household issues, and we have averted unnecessary hospital conveyances and, more importantly, activated critical ones thanks to that. Moreover, during this stressful time, speaking to the parent (or grandparent at times) in the language they are most comfortable with gives reassurance that we fully comprehend their home situation. The other resource that has proven invaluable to parents coping with special needs children are our team members specialising in developmental issues. While it may be a little more challenging to assess these children, we do the best we can, while at the same time supporting the parent's or other caregiver's mental health.
Driven by passion
During this pandemic that has drastically affected the lives of children and their families, it is heartening to be part of this national effort – to have paediatrician volunteers from the community working hand-in-hand with our colleagues from PHI, and support from MOH and SAF. This first-of-its-kind collaborative effort is truly a work in progress, as we constantly adapt to new problems and evolve to solve them. As paediatricians, we are indeed driven to go to great lengths – keeping the paediatric HRP teams going, and spending days and nights reaching out to parents – for at the heart of all we do are the children entrusted to our care!
The free illustrated e-book was launched on 14 November 2021 and can be downloaded from author Emily Lim-Leh’s blog at https://mummumstheword.wordpress.com/, or by scanning the QR code on the right.
It has since garnered over 14,000 downloads with uncountable copies being forwarded on WhatsApp. The Chinese version was launched within two weeks and the Malay and Tamil translations will be launched soon. The e-book was specially written for children between the ages of three to eight years old, but many parents have also appreciated the easy-to-read information contained within its pages.