DEATHS OF SAF SOLDIERS

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DEATHS OF SAF SOLDIERS: 9.

Ms Irene Ng Phek Hoong asked the Minister for Defence, given the recent deaths of two Singapore Armed Forces soldiers after or during jogging, whether (a) there have been cases of soldiers experiencing a sudden cardiac arrest event during training but surviving it; (b) safety measures such as defibrillators have been usefully employed for emergency care; and (c) soldiers are required to undergo cardiovascular screening to identify those at high risk of sudden cardiac death.

The Minister for Defence (Mr Teo Chee Hean): Mr Speaker, Sir, Ms Irene Ng has asked about the recent deaths of two SAF servicemen while running - one was a regular and the other was a Full-time

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National Serviceman. These have understandably given rise to some concern among Singaporeans. I would like to thank Ms Irene Ng for this opportunity to provide more information on this issue. And I take this opportunity also to extend my condolences to the families of the two servicemen, 2WO Teh Kok Lian and 3SG Ivan Ong Peng Ghee.

First, allow me to provide some details on the two cases. 2WO Teh Kok Lian, a regular serviceman aged 39, was participating in a routine run on 22nd June when he collapsed at about 8.45 am. He was given immediate medical attention and evacuated to the camp medical centre where the medical officer initiated resuscitation measures. At 9.00 am, he was transported by an ambulance to the National University Hospital. Unfortunately, 2WO Teh passed away at the National University Hospital at 9.40 am.

3SG Ivan Ong Peng Ghee, a full-time National Serviceman section instructor aged 19, collapsed at about 8.45 am after an informal, self-paced jog with several of his colleagues. He was given immediate medical attention and brought to the camp medical centre where the medical officer initiated resuscitation measures. At 9.27 am, a helicopter, which had been activated, took off from Pulau Tekong to evacuate 3SG Ong to the Singapore General Hospital. He passed away about 50 minutes after he arrived at Singapore General Hospital.

In both cases, the servicemen were given immediate medical attention on site and at the camp medical centre, and then promptly evacuated to hospital. The medical response was comprehensive and appropriate. MINDEF's safety investigations into the two incidents concluded that there were no safety breaches in both cases. MINDEF is also convening official Inquiries into the two deaths.

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Sir, the autopsy on 2WO Teh concluded that he had died from sudden cardiac arrest that resulted from an acute myocardial infarction. In layman's terms, he had suffered a heart attack. The autopsy report on 3SG Ong is not yet ready as the Health Services Authority has not completed its investigations.

Sudden cardiac death (SCD) results from sudden cardiac arrest in a person who is usually in a state of normal health. In other words, the person may not exhibit any warning symptoms or signs prior to the attack. In the SAF, over the nine-year period from 1996 to 2005, there were 19 cases of sudden cardiac deaths, ie, about 2.1 cases per year. Of these, five had collapsed during training. The others were not during training. There is no comparable data for the Singapore male population. However, a National Heart Centre study showed that there were 261 cases of sudden cardiac deaths among the Singapore male population aged 18 to 45 over a three-year period from 2001 to 2003, or an average of about 87 cases per year.

To put the issue in some perspective, allow me to share some pertinent information on the chances of surviving a sudden cardiac arrest. Dr Lim Swee Han, Senior Consultant and Head of the Singapore General Hospital Accident and Emergency Department, reported in a January 2005 paper that there was a 4.1% survival rate in 968 non-trauma cardiac arrest cases in the five-year period from 1994 to 1999. Dr Marcus Eng Ong Hock, in a cardiac arrest and resuscitation epidemiology study in 2003, reported that from a total of 548 out-of-hospital cardiac arrests in Singapore, only 2.0% survived to discharge. Even among patients who suffered cardiac arrest in tertiary hospitals, ie, while they were already in hospital, where the best care is available, the survival rate to discharge ranged from 18% to 32%, according to studies from

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various countries. Unfortunately, death as a consequence of cardiac arrest is the most common outcome even with optimal management.

Sir, let me now explain the SAF's medical screening system. Every SAF serviceman, whether a National Serviceman or regular, goes through a pre-enlistment medical examination at the SAF's Medical Classification Centre. There, he is fully assessed to determine the presence of pre-existing medical conditions. The medical assessment includes a resting electro-cardiogram (ECG), chest X-ray, blood and urine tests, and a physical examination. Individuals with a history of death in the immediate family before 40 years of age, or sudden death, are questioned more thoroughly and may be referred for specialist assessment and additional investigations.

The SAF's routine screening for heart disease in pre-enlistees is equivalent to the standards recommended by the European Society of Cardiology and International Olympic Committee, and higher than the standards in the United States recommended for competitive athletes. Our screening protocols are also similar to those used by other established armed forces. We want to be sure that our servicemen, especially the full-time National Servicemen (NSFs), are medically fit for continuous and strenuous physical training.

For regulars, the medical screening includes periodic health examinations commencing at the age of 25. All servicemen (including operationally-ready NSmen) who are 35 years of age or older, undergo medical screening for cardiac risk factors when they are required to take the Individual Physical Proficiency Test (IPPT). If the test results are abnormal, the serviceman will be referred for further specialist assessment. If the results are normal, then this medical screening is

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done once every two years until age 40, and annually thereafter. These measures exceed the Ministry of Health's clinical practice guidelines which recommend that screening begins at age 40 in the absence of any risk factors. The SAF's current medical screening regimes are comprehensive and are based on sound medical evidence of their effectiveness. They are continually reviewed to ensure that they are consistent with current medical knowledge and practice.

Sir, training in the SAF is conducted at a progressive pace. For example, during the first week of basic military training, recruits are gradually eased into the camp environment and training tempo. The recruits then go through other basic modules in physical fitness and military skills before moving on to more rigorous training. SAF commanders are always on the look-out for servicemen who may be experiencing problems during training.

Apart from progressive training, the SAF has a comprehensive safety management system that includes compulsory adequate rest before strenuous training, compulsory drinking of water before, during and after training, and pre-training screening to identify those who are not feeling well. In fact, our servicemen are regularly reminded to seek medical attention if they feel unwell. Those who seek medical attention are given full access to primary and specialist health care. Our SAF medical officers abide by the same professional ethics and standards as their civilian counterparts. They are also bound by the SAF values of professionalism, ethics and care for soldiers.

Sir, Ms Irene Ng has asked about the use of defibrillators. There are two types: semi-automated defibrillators used by medical doctors, and automated external defibrillators (AEDs) which can be

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operated by trained individuals, including our SAF medics. Defibrillators work by delivering electrical shocks to the heart, in order to convert abnormal heart rhythms back to normal rhythms. However, not all abnormal heart rhythms can be effectively treated by electric shock, and an AED would interpret the heart rhythm of a person who has gone into sudden cardio-respiratory arrest and advise the operator whether or not an electric shock is indicated. Studies indicate that if there is early defibrillation when there is a shockable rhythm, 20-50% of victims may survive.

AEDs were progressively introduced into the SAF last year to enhance medical coverage. There are currently 237 AEDs in our camps. They are operated by our medics during strenuous activities, such as the IPPT and Standard Obstacle Course test. Since its introduction, the AED has been applied once, when 2SG Ong Jia Hui was brought ashore after a diving incident last month. However, he had no shockable rhythm and the device was, therefore, not activated.

Ms Irene Ng has also asked about cases of successful resuscitation after a sudden cardiac arrest. There was a recent case, although this was not with the aid of a defibrillator. In May this year, a 27-year-old regular serviceman collapsed during an IPPT run. He had no pulse and was not breathing. He was promptly evacuated to the medical centre, where cardio-pulmonary resuscitation was begun and he was given an intravenous infusion and oxygen. The serviceman was stabilised and then evacuated to NUH. He has since returned to work.

Sir, I would like to assure Singaporeans that the safety and health of our servicemen are of the highest priority to MINDEF and the SAF. We have comprehensive and rigorous screening regimes for those coming into the SAF, including our Full-time National Service

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men. And we have appropriate safety measures and medical cover for our servicemen when they are conducting training or rigorous physical activity. Sudden cardiac death is, unfortunately, something that cannot be completely prevented, as the statistics for not just the SAF but the Singapore population at large show.

Ms Irene Ng Phek Hoong: I would like to thank the Minister for a comprehensive and re-assuring reply. But may I ask two supplementary questions?

Sir, according to medical literature, survival can be as high as 90%, if treatment is initiated within the first few minutes after a sudden cardiac arrest. Sir, I am assured that MINDEF has used defibrillators on at least one person. But can I ask the Minister why they were not used on the two recent cases of servicemen who suffered cardiac arrests?

My second question is a broader one. It relates to the whole issue of safety in training. Over the last one month, there have been about four cases of Singaporeans who have died because of their training exercises. Since a review had been completed last year, have there been full checks to make sure that they are all implemented correctly or whether there should be a further review to make sure that our soldiers' safety is paramount during training exercises?

Mr Teo Chee Hean: I am not sure where Miss Ng got her data from. The data I have is from the medical sources that I have available. If she is able to provide me with medical data that show otherwise, we will, of course, have a look at them. But from the medical data that I have and the research that has been conducted, these, unfortunately, are the statistics.

Whether or not an AED can be used in a specific case depends on the condition

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of the patient. In certain cases, the use of an AED is not appropriate and may, I suppose, cause more harm than good. In the case of the two servicemen who collapsed, in fact, they collapsed very close to the medical centre. So, they were taken to the medical centre. One collapsed only about 200 or 300 metres from the medical centre and was immediately evacuated there within minutes. The resuscitation capabilities at the medical centre are more comprehensive than those that could be provided with an AED. Unfortunately, he did not survive.

Sir, on the issues of safety in the SAF and training incidents, I would like to break these into two groups. In the case of these two runs, I would say that they are not very different in substance from what many Singaporeans, men or women, younger or a little older, would do on an average day, ie, go out for a run with a number of his colleagues. So, these two incidents, I would say, are not directly related to SAF training per se. In fact, on an average day, when a Singaporean goes out for a run, he does not usually carry an AED with him or is he particularly close to a medical centre. So, in fact, I would say that if a soldier decides to go for a run on his own or with some friends in a camp or camp facility, he probably has better medical cover than the average Singaporean has, if he decides to go out for a run with his colleagues.

The second group of incidents concerns those which involve SAF training. SAF training does have inherent risks. We want the training to be as realistic as possible but also as safe as possible. Hence, every type of training in the SAF is carefully audited. There are safety procedures and checks, and these are put into place. Unfortunately, some incidents do occur from time to time. Whenever there is an incident, we will go through a very thorough investigation

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process and inquiry process to find out what are the causes, and whether all the safety precautions were observed. If not, why? Was there anybody at fault? Was there an oversight? Or, even if all the safety precautions were observed, was there something in the system that could have been done better? And if it can be done better, then we will do so. So, I will group these into two different types of cases.

Perhaps I should also update Members of the House on the rappelling incident on 13th July 2005. First of all, I would like to convey my condolences to the family of 1SGT Shiva Mohan and the family of the foreign serviceman. MINDEF's investigation into the incident is underway, and the SAF has suspended all heli-rappelling training, pending the outcome of the investigation. Other SAF training with helicopters and the RSAF's search-and-rescue duties continue. MINDEF will conduct a rigorous and thorough investigation to examine all possible causes of this incident, eg, whether all safety processes and procedures were properly observed and what other measures might be necessary to prevent such incidents in future. All possible causes of the incident will be

considered.

The SAF mandated a two-day SAF-wide safety time-out immediately after this incident. This was conducted at the unit level by unit commanders after the commanders themselves were briefed by their service chiefs. The objective of the safety time-out was to remind and refresh commanders, trainers and instructors on the safety system to ensure that safety measures are in place and remind commanders and servicemen that safety is also an individual responsibility. The safety time-out was completed last Friday and SAF training, other than heli-rappelling which has been suspended

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pending the findings of the investigation, has resumed and so have our exercises and operations.

Dr Lily Neo: Mr Speaker, Sir, may I ask the Minister, in view of the fact that 200 people, aged 20-30, died of sudden cardiac arrest between 2001-2003, and although many of them had no symptoms and looked perfectly healthy, on autopsy, they were shown to have structural heart abnormalities and problems with heart rhythm. May I ask the Minister whether he will adopt a better screening and implement more stringent check-ups for our NSmen more regularly?

Will he ensure that the enlistment check-ups are done by doctors who have undergone training to detect early and possible heart abnormalities? Will he screen our NSmen more regularly and earlier, ie, not from the age of what he mentioned earlier, at 35 for high cholesterol, pre-diabetes and high blood pressure, as these conditions put them at risk for sudden heart attack and stroke?

Lastly, will he also offer stress ECG for our NSmen during their enlistment check-up?

Mr Teo Chee Hean: Mr Speaker, Sir, I have to be guided here by the medical professionals. As I have said just now, the SAF's routine screening for heart disease in pre-enlistees is equivalent to the standards recommended by the European Society of Cardiology and the International Olympic Committee, and higher than the standards in the United States recommended for competitive athletes. So I believe that the procedures that we have for pre-enlistees' cardiac screening are really quite up to the mark. The state of medical science is such that for this kind of screening, it is not possible to detect all conditions. Of course, at the point of autopsy, it is possible when you open up a person to detect such a condition. But as a medical

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practitioner, Dr Neo will know that there is also a risk in medical examinations, especially in invasive medical examinations, and the risk and the return must be balanced.

We do, as I have said, conduct medical screening for regular servicemen, as well as operationally-ready National Servicemen. This includes resting ECG. And if there is an indication of an abnormality, then we will do a stress test. As I mentioned just now, these measures exceed the Ministry of Health's clinical practice guidelines which recommend that screening begins at 40 in the absence of any risk factors.

Dr Michael Lim Chun Leng (Pasir Ris-Punggol): Mr Speaker, Sir, I would like to ask the Minister, in the light of scientific evidence to show that as many as half of the people who are presented with a heart attack at a hospital do not have any critical stenosis or narrowing in the heart artery, but actually only have a very minor narrowing in the heart artery, and as a result of tear at that segment, they form a clot and block the artery, resulting in a heart attack, this often occurs during exercise. Perhaps, we should consider the possibility of identifying those who go through very vigorous exercise during the NS period, ie, high-risk individuals who would be, in all likelihood, have a high risk of having a narrowing in the artery, which cannot be picked up by traditional means like treadmill testing. We know today that there are technologies available where this can be picked up non-invasively without any risk to the patient. Of course, we want to take guidelines like ESC guidelines or IOC guidelines ---

Mr Speaker: Dr Lim, what is your question, please?

Dr Michael Lim Chun Leng: My question is: in the light of things evolving, whether for specific high-risk individuals,

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we should actually look at other means of identifying them.

On the second point about AED, if we reach the A&E for a sudden cardiac death, of course, your mortality is more than 90% because it takes a long time to reach it. But if you have an AED accessible to the person within one, two or three minutes, the outcome is surely very different.

So my point is whether the Minister wants to review this need to make AED very accessible to the training areas where there are medics so that they can use it within minutes, rather than waiting to go to the medical centre which will probably take 10-20 minutes, by which time the person may be brain-dead.

Mr Teo Chee Hean: If I may just respond to the point on AEDs first. I completely agree with Dr Lim. That is why we have 237 AEDs in the SAF and we will equip it with the numbers that are necessary.

I am not a doctor but Dr Lim is an expert in this area. I am told by our doctors that not all conditions are treatable by an AED. There are such things as rhythms that are shockable and things which are not, and even if you have an AED there, it may or may not be of use to the person.

In the two cases that I mentioned, the presence or absence of an AED did not arise because the persons were very close to the medical centre and there were medical officers at the medical centres available to treat them, much better than with an AED.

On the question of whether or not such conditions can be detected, I will have to be guided by the medical professionals. I imagine that there must be panels which look at best practices in this field and when such practices advance, we will certainly advance with

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them. I am not able to engage into a detailed discussion on the merits of particular procedures or examinations which I am sure Dr Lim is much better able to do so.

Dr Ong Chit Chung (Jurong): Mr Speaker, I want to ask the Minister whether there are any comparable data of other armed forces on similar cases of heart attacks and whether there is research done by these foreign armed forces, which we can learn from.

Mr Teo Chee Hean: I do not have comparable data that Dr Ong has asked for. But I have data for the Singapore male population, aged 18-45. And National Servicemen and our operationally-ready National Servicemen are generally of that age range.

Over that period, there were 261 cases of sudden cardiac death, which is about 87 cases per year. For the SAF, there were 19 cases of sudden cardiac death from 1996-2005, which was about 2.1 cases per year. There are roughly about three cohorts' worth of males in the SAF at any one time - two cohorts of National Servicemen and another cohort comprising regulars plus operationally-ready National Servicemen who are in for their ICT. So, in round numbers, there are about three cohorts at any one time. There are about 27 cohorts of males between the ages of 18-45 in the statistics I have just cited. So there are nine times more. I think you can do the comparison, with 2.1 cases per year for the SAF and 87 cases per year for the population at large for a roughly similar age group.