BSG members gathering

Tailor for the burned

Seamstresses are the unsung heroes behind burns recovery. Occupational therapy assistant Pauline Ho is one.

FORMERLY a fashion tailor, MsPauline Ho’s (photo left) curiosity was piqued when she saw an SGH adfor seamstresses in the newspapers.That was 15 years ago, when she had contemplated quitting her job.“I didn’t see the connection between hospital treatments and clothes sewing,” said the 57-year-old.Ms Ho, now the senior of two seamstresses at the Occupational Therapy Department, learnt about pressure garments for the first time at the interview and “decided to give the job a try.”

Her sewing background was an advantage but she still spentthe first three months learning the ropes from an occupational therapist from the United Kingdom.She keeps up with sewing developments via occupational therapists sent overseas periodically for training.“The sewing is very different and creativity is necessary to think of different solutions for the patients’needs,” said Ms Ho. “The face mask is the hardest to make because we need to be very accurate when drawing and cutting holes for the eyes, nose and mouth. Once a step is wrong, we have to re-do everything.”

The job also took some getting used to. Among her initial patient encounters was a badly burnt female patient, whose screams at her garment fittings gave her the chills.“I was also afraid to see the bloody wounds initially with the scabs falling off, but I have grown used to it,” Ms Ho confessed smilingly.Hectic schedule-Ms Ho works a five-day week,stitching around 180 new pieces of pressure garments monthly. With teammate Christine, the two sew about 3,500 pieces a year.The work load increases significantly whenever there are mass accidents or terrorist attacks. Ms Ho remembers the 2002 Bali bomb blast clearly, when she rushed to sew countless pressure garments for the patients sent to the Singapore General Hospital(SGH) Burns Centre.“I did overtime every day - a lot of sewing plus alterations and newpieces for other patients,” said Ms Ho. “But it’s ok lah.”Besides sewing new garments and alterations, she manages the medical files of patients who turn up for therapy sessions, and also helps occupational therapistswith patients. With fidgety children, she’s found a biscuit will do the trick.

“Pauline sews mostof the time but she is also trained to handle patients like the elderly because they can’t stand for long. So the seamstress is also referred to as a good occupational therapy assistant,” said Ms Anna Tan, Head of Occupational Therapy and Chief of Burns and Plastic Therapy Services at SGH.Indeed, brimming with quiet pride, Ms Ho said: “I feel my job is as important as the occupational therapists’ in
helping patients recover. For this, will work
as fast as I can.”

MP calls for more skin donors to save lives

A MAN passes on his name after he dies, and a leopard, his skin, goes an old Chinese proverb. Mr Sam Tan (Tanjong Pagar GRC) suggested turning that proverb around yesterday, in a bid to get more people to come forward and donate their skin.

'Presumably the ancients liked to leave a good name or a lasting reputation behind, and perhaps leopard skins were once highly treasured,' he said in Mandarin. Today, however, donated skin could save a burn victim's life and there are just not enough of such donors here, he told the House during the debate on the budget of the Health Ministry.

'The Chinese say, you cannot take your wealth and possessions with you when you die. The same goes for your body. 'Since you cannot take it with you, why not leave behind your skin after you die? 'This would allow a sick person in need of a skin graft to have a shot at life,' said the MP.

In a separate speech in English, he said that, on average, only two to four people here pledge to donate their skin every year. In comparison, Australia had 57 donors in the first eight months of last year, while the New York metro area saw 173 skin donors in 2006. Replying, Mr Heng Chee How, the Minister of State for Health, noted that there are an average of eight deaths a year from severe burns. Most victims die from severe injuries and not because of the lack of skin grafts.

Nevertheless, Mr Heng encouraged more people to consider pledging their skin and other organs for donation. The Human Organ Transplant Act (Hota) presumes that a person aged between 21 and 60 has agreed to donate his vital organs when he dies, unless he has opted out. However, it allows for only kidney, heart, liver and cornea donations. Singaporeans can pledge to donate their skin under a separate Act, the Medical (Therapy, Education and Research) Act, said Mr Heng.

Since 1998, over 100 people here have benefited from skin grafts. Most of them had extensive burn injuries. Skin donation does not mean that a dead person will be stripped of all his skin, Mr Tan noted. Only 0.25mm to 0.4mm of skin is shaved off.
The MP said he himself had signed up for skin donation, joking that he would 'take this as a final spa treatment before embarking on the next journey'.

March 2008
By Clarissa Oon

A problem that is more than skin deep

Here is the irony: Skin is the largest organ in the human body, yet it is not covered under the 21-year-old Human Organ Transplant Act (Hota). The law, which provides for an opt-out organ donation system allowing the removal of kidneys, livers, hearts and corneas for transplantation, had gone through three major amendments. Still, skin - something doctors, especially plastic surgeons, and sympathetic MPs have been calling for, for some time - was not included on the list.

Hota was enacted in 1987 to harvest the kidneys of those who died in accidents, to be used for transplants unless the victims had earlier opted out. It underwent three major changes to extend its coverage to include livers, hearts and corneas so that more people can benefit from organ transplants. The third amendment was made this month, to allow the reimbursement of costs and expenses to living donors. The Singapore Medical Association is supportive of the call to include skin donation under Hota.

Its spokesman, Dr Tan Sze Wee, said Singapore faces a severe shortage in its skin bank and it has had to get help from countries like the United States and Australia, whose own supplies are running low. Skin donations remain rare because people do not know how useful donated skin is. It is used as a temporary dressing in cases of severe burns involving 40 per cent of the body or more, to reduce the growth of bacteria and the patient's loss of vital fluids.

It is usually discarded in three weeks. By then, new skin which had been cultivated from the patient's own cells would have grown enough to be used as a replacement. As skin is not covered by Hota, Singaporeans who want to donate their skin would need to do so under a separate Act - the Medical (Therapy, Education and Research) Act, or MTERA. Unlike Hota, MTERA is an opt-in system where people pledge their organs to be used for transplants, education or research after they die. As at the end of last year, there were a total of 46,800 MTERA pledgers.

But if there is no opt-in from the person, hospital staff will have to ask the deceased's family to consent to a donation. The problem here is that the answer from grieving loved ones is often 'no', primarily because people still mistakenly believe donating skin will disfigure the dead. This, in turn, will mean a closed coffin, and loved ones will be unable to bid a last goodbye face-to-face. The reality is that in skin donations, only the outermost layer, between 0.25mm and 0.4mm thick, is taken from flat surfaces like the thighs and back. This is thinner than a piece of tissue paper. Moreover, these areas will be concealed by clothing and will not mar the donor's appearance. One reason the Health Ministry had for not including skin in Hota was the apprehension that it could result in a high number of Singaporeans opting out.

The same inhibition had clouded cornea donations as well - the dead leaving without their eyes is anathema in Chinese culture. But its inclusion in Hota has not provoked a hue and cry. Associate Professor Colin Song, who heads the country's biggest burns unit at the Singapore General Hospital (SGH), said the shortage of skin donation here is a longstanding issue, but people shying away from the thought of donating the skin of a loved one who has died is not peculiar to Singapore. It is a problem worldwide.

Since 2006, Canada has been desperately short of skin donations that can be used to treat patients with severe burns. Skin banks in Calgary, Edmonton and Halifax are near empty. Last year, the Canadian government approved a C$35 million (S$42.9 million) funding for a national organ donation registry through the national blood donor agency. Prior to this, Canada was the only developed country without a national transplant system. Last year, The New Zealand Herald reported that American skin is being used on New Zealand burns victims because of a substantial shortage of skin donated for grafts. The shortages meant that about 10 New Zealand victims of major burns were not able to have the best treatment - human skin - for their wounds in that time. Currently, New Zealanders can indicate their wish to donate their organs on their driver's licence. The donation can proceed unless the decision is reversed or when the family does not consent.

To alleviate Shanghai's skin shortage, its Changhai Hospital developed a compound of modified cells from the cuticle and used that as a skin graft two years ago on a woman with 85 per cent burns. Singapore had only two donors to the National Skin Bank last year. One was three-month-old Ryan Wong, who died from complications following surgery for a cleft lip. The other donor is unknown. So far this year, there has been one donor - triad leader Tan Chor Jin, 41, better known as 'one-eyed dragon', who was hanged in January. He also donated his kidneys and a cornea.

Although the 60,000 sq cm of skin - or skin from 30 adult donors - in the SGH Skin Bank may be enough to meet initial needs should a mass casualty situation occur, any prolonged tragedy would have doctors scraping the bottom of the skin barrel. Perhaps when Hota comes up for review again, the scope of the Bill could be expanded to include skin. Singapore has already become a forerunner in upping the stakes of organ donation by allowing recipients to reimburse their donors - if they wish - to cover the financial losses incurred by their donors. The country could take a step further when it comes to skin donation. After all, giving is more than merely skin deep.

March 2009
By Judith Tan

About the skin bank

Background
The Singapore General Hospital's (SGH) Skin Bank/Skin Culture Laboratory was set up in 1991 to meet the skin graft needs for the treatment of patients with severe burns. It is located within the SGH Burns Centre at Blk 4 Level 3 and is run by the hospital's Department of Plastic Surgery.

Development
In 1991, the Skin Bank/Skin Culture Laboratory processed lyophilised amniotic membranes (obtained during the delivery of babies) which were used as temporary biological dressings for burn patients. But by 1997, the Skin Bank/Skin Culture moved away from the use of amniotic membranes mainly due to the potential risk of HIV transmission. Between 1991 and 2001, the Skin Bank/Skin Culture Laboratory produced cultured epithelial autograft (CEA) for burn patients but on a limited scale due to resource constraint. This technique involves growing a type of human skin cells called keratinocytes from the patient's skin biopsy in culture dishes and grafting the enlarged cultured skin sheet back on the same patient's burn site. In 1998, the Skin Bank/Skin Culture Laboratory stored its first harvested donor skin using cryopreservation (freezing down) technique. A one-year clinical study in 2000 was conducted on the use cryopreserved allograft and it was found that such grafting is a useful and effective treatment in the management of severely burned patients.

Objective of the skin bank
The main objective of the Skin Bank is to provide alternative skin coverage for massive burn patients. As donor skin was found to be an effective treatment for severely burned patients, the Skin Bank/Lab's immediate task is to build up an ample supply of donated skin.

Need for skin donation
Since 1998, the Skin Bank has had an average of 7 donors per year who consenting to donating their skin upon their death. The supply of skin harvested was not sufficient to meet the demand of massive burn cases. Therefore public education on skin donation is of utmost importance and hopefully pledges will increase once the public understands how donated skin can be used to save lives.

Chinese article on our very first meeting before the launch of BSG

This chinese article was done by a very prolific writer - Mr LTC Ang.

BSG 通讯诞生了!
欢迎所有新加坡烧伤支援小组(BSG)的成员.在您的手中是我们BSG第一期的通讯。最近,在新加坡中央医院我们聚集了烧伤生还者,是我们跨出去 的 第 一个里程碑的。我们希望借这则通讯能延伸到更多生还者,也让大家得到更多关于BSG的信息。 因此，请继续读下去。

BSG的意义
BSG是一个非利润组织. 它的宗旨是在伤痛和复原的期间,给予烧伤生还者情绪上的支援. 在新加坡中央医院烧伤部的医护人员的帮助下,创办人Ang Ming Chuang先生和Freddy Neo先生终于在2002年十月12日成立了BSG.BSG也试图提供给生还者和他们的家人更多关于烧伤的信息, 以帮助他们了解和妥善应付他们所受的伤害.它主要是努力地将生还者带出孤立隔离的生活，并帮助他们从新溶入社会。

BSG 第1次聚会！
10月12日02年，BSG在新加坡中央医院举行了她第一个的集会。 在亲切, 和善的医护人员的帮助下,我们终于能和居住在新加坡的烧伤生还者会面。
在新加坡的历史中, 这预示了一个有意义的水印. 因为这是新加坡的烧伤生还者史上第一次的聚会. 这个构想早在几年前曾经讨论过，我们了解它需要花费许多时间努力的铸造才能实现。所以功劳应归所有使这聚会成功的人们。这聚会肯定在生还者和医护人员脑海里注入一个深刻的印象。

BSG 第2次的聚会
休息了4个月后，在中央医院医务组的殷勤支持下, 年轻的BSG举办我们第二次的聚会。在2月22日03年, 中央医院物理疗练习室聚集了许多生还者和医护人员。 我们也为出席的生还者安排了一连串丰富和吸引人的活动。

首先，带动整个节目的是我们永远魅力十足的Dr Song告诉大家有关伤痕疤的管理。他解释了不同的严重程度的烧伤和因烧伤引起的併发症。伴随他的是美丽的治疗师Anna,她为Dr Song 的讲解进行同步翻译,以方便那些不太理解英语的朋友。

接下来是我们热心的BSG领导，Mr Freddy Neo 正式掀开BSG标志的啟用。BSG标志里的雄伟又年轻的凤凰象征了烧伤生还者坚韧,不屈不挠的精神。随后大家分成4个小组分享个别的经验。起初是一片异常的宁静，因为大家对自己的经历都有所保留。逐渐的，了解大家在康复的道路上都面对同样的挣扎，开始坦然的叁于讨论。什至一度大家情绪激动,还好有Dr Angeline Chan在场舒缓大家的情绪。 这次的讨论在大约4 pm结束.我很肯定生还者是带着安慰与自信回家的。

这次的聚会确实让我得到了许多宝贵的洞察力.我很庆幸自己应好朋友Xiongwei的邀请出席，尽管我不是个烧伤生还者,可能不能体会烧伤生还者经历的痛苦，但它无可置疑使我领悟到自己是多么幸运。很肯定的是这次的聚会带给我的信息是生命是如此珍贵。让我印象深刻的是生还者在他们康复道路上显示的坚韧和刚毅。

所有生还者，我向你们致敬！

November 2003

Pressure control for burns recovery

TWO sewing machines rest side-by-side, their threaded needles poised in mid-air and ready for action. A neat rack of beige lycra rolls are at one end of the room while a whiteboard scribbled with deadlines is fixed on the opposite wall. Two seamstresses take centre stage. Bent over a green workbench, they diligently cut patterns from cloth bits, snipping sounds filling the otherwise silent room.

Welcome to the sewing unit at Singapore General Hospital’s Block 1 Rehab Centre, a modest but important place where pressure garments are made. Part of the Occupational Therapy Department, it falls under the Burns and Plastic Rehabilitation specialty and primarily serves patients of the SGH Burns Centre. Pressure treatment. During burns recovery, the skin may proliferate out of control to form rigid bumps called hypertrophic scars. To limit the formation of hypertrophic scars – which can hinder mobility when they grow over body joints – garments that exert pressure are worn, said Ms Anna Tan, Head of Occupational Therapy and Chief of Burns and Plastic Therapy Services at SGH. Generally, patients wear them for at least 23 hours daily over two years. “Each pressure garment is customized to the patient’s needs and the measurements go into his or her medical files,” said Ms Tan. “This is part of the medical treatment, although not the conventional type. When the scar stops growing, they will be flatter and softer from the pressure effect.”

Making a pressure garment come in various forms such as masks, gloves, arm tubes, pants and jackets. To make a pressure garment, measurements taken by the occupational therapist are given to the seamstress who calculates the reduction in garment size necessary for the pressure effect. The design of the garment is shaped primarily based on how the patient is burnt, but other considerations are also important. For instance, “we need to know if the patient will get help from family members in wearing the garments,” said Ms Tan. Comfort for the patient is important. To avoid irritating the skin, garments are made inside out with the seams on the outside, which also allows for easy grip and wearing. Velcro zips and elastic bands are added to keep the garments secure. For the severely burnt, garment designs require creativity like using double layers for better pressure, or pockets sewn for sturdy inserts like foam and putty-like elastomer at desired spots. The material used needs to give a snug fit without restricting movement, be able to stretch four ways instead of two for conventional fabrics and ‘breathe’ for comfort.

The SGH Burns Centre is the only burns centre in Singapore and it also serves the region. As such, we need to find a fabric in a colour that suits the majority,” said Ms Tan. “Not everyone will be happy with the colour but we have to find one which won’t look like a white patch on Indians or too dark on Caucasians.”Patients return monthly to check if their garments have loosened with daily wear, or became too tight because of weight gain. Generally, a pair of garments, used alternately, lasts about three months before brand new ones are needed.

Skin donation still a tough sell

Only 2 donors last year; most mistakenly believe it means disfigurement

PEOPLE shy away from the thought of donating the skin of a loved one who has died. Consequently, there were only two donors to the National Skin Bank last year.
One was a three-month-old boy, Ryan Wong, who died from complications following surgery for a cleft lip.His parents, Mr Norman Wong, 47, and his wife Juliet, 38, donated his skin, as his other organs were too small to be viable. The identity of the other donor last year is unknown.

There is one donor so far this year: Triad leader Tan Chor Jin, 41, better known as 'One-eyed Dragon', who was hanged in January. He had asked for his skin, cornea and kidneys to be given away.

The shortage in skin donations is a long-standing issue, said Associate Professor Colin Song, director of Singapore's biggest burns unit, at the Singapore General Hospital (SGH).
A sizeable bank is needed to cope with accidents such as the one which occurred on Feb 27, when five workers suffered chemical burns from an acid spill at Chemic Industries in Tuas. Four have died.

Skin, the largest organ in the human body, is not covered under the 22-year-old Human Organ Transplant Act, so hospital staff have to ask the deceased's family to consent to a donation.
The answer is often 'no', primarily because people mistakenly believe donating a dead person's skin means disfigurement.

Prof Song, who also heads the department of plastic, reconstructive and aesthetic surgery at the hospital, said it was not the case. Only the outermost layer between 0.25mm and 0.4mm thick - thinner than a piece of facial tissue paper - is taken from flat surfaces like the thighs and back. These are concealed by clothing and will not mar the donor's appearance.
Up to 2,000 sq cm of skin - about the size of a page of this newspaper - can be harvested from those areas in an adult.
To be prepared for a crisis, such as a national fire disaster, the SGH Skin Bank needs 60,000 sq cm of skin - or skin from 30 adult donors. It has that amount now, but Prof Song said it could do with more such donations.

Singapore has had to import skin from Australia, the United States and the Netherlands, at $200 for a piece about the size of an adult's palm. In 2007, only one donation was made and, between 2004 and 2006, no more than two to four each year.
Prof Song explained that donations are rare also because people do not know how useful donated skin is. It is used as a temporary dressing in cases of severe burns of 40 per cent of the body and higher, to reduce the growth of bacteria and loss of the patient's vital fluids. It is usually discarded in three weeks. By then, new skin which has been cultivated from the patient's own cells would have grown enough to be used as a replacement.
Burn victims with less than 40 per cent burns can use their own skin for grafts, usually harvested from the thighs.

An example was Yio Chu Kang MP Seng Han Thong, who suffered about 15 per cent burns to his face, arms and chest. He had a graft using skin from his inner thighs.
To create public awareness, the SGH Burns Centre and the Burns Support Group are organising a public forum later this year to discuss skin donation.
And since 2006, the SGH Skin Bank, together with the National Organ Transplant Unit, has gone to junior colleges and polytechnics to tell students about the importance of organ and tissue donation.

The SGH Burns Centre treats about 300 burn patients a year. About 15 per cent of them have major burns, with between 30 and 40 per cent of the surface of their body burnt.

By Judith tan

Calls for skin donation to be included under HOTA

Doctors hope the Human Organ Transplant Act (HOTA) will include skin donation on its list, as Singapore faces a severe shortage in its bank. And it has had to get help from countries like the US and Australia. The call for more skin donations was emphasized at a forum on Management of Burns held at the National Library on Saturday. It was oganised by the Burns Support Group and the Singapore General Hospital (SGH) Burns Centre. Some six months ago, 3rd Sergeant Karthigayan Ramakrishnan was wheeled into SGH for burns treatment following a Taiwan fighter jet crash incident. After spending eight weeks in hospital, the 24-year-old burns survivor is now out and about. Karthigayan has gone through multiple operations and skin grafts, but he still has two more minor surgeries ahead of him. Karthigayan and other burns survivors, through their experience, are more convinced than ever of the critical need for skin donation here in Singapore. "Donor skin is very important because as soon as they cover you up (with the donated skin), it helps in the treatment and the healing process. To be very frank, I was very ignorant about it, and I never realised that it could happen to me," said Karthigayan. "We've got to create the kind of awareness; it's something that can happen to anybody... not just military men or firemen," he added.

Another recovering survivor, 26-year-old Chia Hiang Yong, was burnt after his motorbike caught fire two months ago. "The number of skin we get over the past year is amazingly little, compared with other transplants like heart transplants and all that. I think skin should also be part of the HOTA as well," said Chia.



At the forum, experts gave an update on the skin bank. "Over a 10-year period since 1998, we've had about 97 of the severe burn victims benefiting from about 320,000 square centimeters of donated skin, roughly half the size of a badminton court. 49 Singaporeans who have departed and passed on donated just over 100,000 square centimeters of skin. So we had a shortfall of about 220,000 square centimeters," said Dr Colin Song, Senior Consultant & Head of Singapore General Hospital Burns Centre. He said Singaporeans' donations to the skin bank only met a third of the burn victims' needs. Going forward, he said other countries like Australia are also running low in its skin bank, making it more crucial for Singapore to beef up its own supply.

November 2007
By May wong

This is how our BSG began

Burns unit at SGH starts support group to help patients

Singapore General Hospital has for the first time set up a support group for burns victims.The specialized burns unit at the hospital - which treats patients from all over the region - hopes the new group will speed patients' recovery.

The SQ006 crash in Taipei and the Jakarta Marriott bomb blast were both tragic events for victims who died and for those who survived but were burnt. Three years on, SAF Major Ang Ming Chuan, an SQ006 survivor, lives to tell the story of how he coped.

He and another burns patient, Freddy Neo, saw the critical need for a support group while they were in hospital, recovering together. Mr Neo said: "When we were injured we find that recovering from burns took a long time and there is no medicine that can help a burns patient except he himself that needs to go through therapy and exercises and putting on pressure garment diligently to suppress the scars."

That was what Carol Chia, who was at the Jakarta Marriott coffeehouse the day of the blast, is going through right now. She recalls the agony on the faces of her family, when they saw her in hospital. Carol said: "I have always felt that the emotional and spiritual part is 80 percent, 20 percent is a physical burn."

Such a support group recognizes that healing goes way beyond just the physical as there is the emotional trauma as well. Burns survivors in the group have been able to draw strength from those who have gone before them.

Badron Nishah Abdul Ghani, Burns survivor, said: "There are physiotherapists, psychologists, there're occupational therapists, these people are there to help you but you feel they don't understand because they haven't gone through it themselves." The support group organizes home visits, seminars and workshops to help people like Nishah, who suffered 60 percent burns from a kitchen explosion while she was in the US.