好文齊分享 - CPR/AED FAQ
呢篇係一短救護同業寫的解說
就住社會同網絡上常見的疑問去解答
如果有其他問題想問可以留言
我下星期考完試寫一篇詳細的FAQ 🙂
#全民急救
#任何人
**更新** << 直線抽擊大眾對 “CPR” 和 “AED 使用” 的誤解 >>
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近日 “任何仁” 於香港的急救界引起了很大爭論,相信看倌不感陌生。看著留言,發現大眾仍對 CPR (心肺復甦法)和 AED (自動體外去顫器)的使用有很大誤解。我現借此日誌作闢謠,希望各位能把內容分享開去!
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開始前,大家要先明白以下概念:
當人的心臟停頓和呼吸停止,他經已是臨床死亡(Clinically Dead)。CPR 的心外壓和人工呼吸只是勉強的維持這 “ 死者” 身體的氧份供應,為他爭取時間接受進階治療。根據統計,每延誤 CPR 1 分鐘,能重啟心臟的機會便下降 10-12%...
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以上所說解釋了院前心臟停頓(Pre-Hospital Cardiac Arrest)的低生存率,這些患者打從一開始已經死了。也許是電影劇和電影的過份渲染,讓大眾誤以為接受 CPR 的患者仍生存,“震一震” 或 “咳一咳” 便會甦醒過來。
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如何能殺死一個已經死掉的人?沒可能!
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假設進行 CPR 的施救者未能正確進行 CPR,只要並非刻意便沒有刑事 (Criminal)責任。疏忽(Negligence)是民事訴訟的範圍,控告的一方至少要證明以下兩個情況:
i) 施救者的錯誤行為(Wrong Act)造成控方所述的損傷或惡果;
ii) 施救者的錯誤行為違反一般大眾對他的常理期望。
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現實沒有 “Walking Dead”,死掉的人無法被再次殺掉。進行 CPR 的施救者又如何 “錯誤地運用 CPR” 去傷害死者?況且患者於 CPR 前已經心臟停頓,心臟停頓無法由錯誤的 CPR 引起。根據美國心臟協會和多個國際組織,CPR 和 AED 是沒有接受訓練的市民也該進行的急救程序 ,進行 CPR 和使用 AED 的施救者當然沒有違反大眾的合理期望。如上述兩點也無法確立,又如何有法律責任?
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世事如棋局局新...假設施行 CPR 的 "任何人" 真的被追討民事索償而且成案,這類案件一定需要專家證人。但,誰是專家?
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於 1992 年,包含美國心臟協會(AHA)在內的多個國際頂尖機構成立了 ILCOR(International Liason Committee On Resuscitation),讓全球專家一起制定復甦和搶救指引。很多醫科書內的治療,甚至是現時香港醫院跟隨的搶救指引,也是 ILCOR 產物。
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ILCOR 建議 Layperson(外行人,也是我們說的 “任何人”)也應該對懷疑心臟停頓(Suspected Cardiac Arrest)的患者進行 CPR。
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根據 ILCOR,“任何人”的定義為:
i) 沒有接受任何急救訓練的人(Untrained);
ii) 只接受過心外壓(Hands only CPR)訓練的人非醫護人員;
iii) 接受過心肺復甦訓練(包括人工呼吸)訓練的非醫護人員。
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我真的想不到任何比 ILCOR 更有份量的專家。如果全球最指標性的專家們也未能安撫懼怕被起訴的不安,那便別去協助他人了。話說回來,活於一個所有人也不願協助他人的社會,其實也是危險便是了。其實地球真的很危險,移居火星是唯一出路!
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另外,我又發現部份急救証書持有人竟然是推廣全民 CPR 的阻力。論點普遍如下:
i) 如果任何人也能使用 AED 和進行心外壓,為何要有急救課程和証書?
ii) 如牽涉急救相關的訴訟,持有急救証書較有保障。
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針對首論點...也許某些人花了太多精神時間去完成急救課程,把急救神化。我以相同的句語結構說:
如果任何人也能使用手機 / 相機和拍照,為何要有攝影課程和証書?
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答案顯然易見!上文經已說過 CPR 和 AED 無需專業訓練,但有相關經驗和知識卻能把效果發揮更好。如果有日我於街上心臟停頓,我希望有不懂急救的旁人立刻替我進行 CPR,也不願呆10分鐘才接受專業的救護員為我進行 CPR!這 CPR誤會使我的生存機會降低至接近 0%...
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第二個論點,我的答案會讓部份人失望。持有急救証書不代表任何保障!我沒聽說過香港或澳洲有急救相關的現實案例,只能用曲線例子比喻:
會計師從事核數工作,但一次疏忽卻讓客人損失大量金錢,客人以民事訴訟追討賠償...大家覺得這會計師曾就讀的大學會給予任何幫助嗎?
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解決了最大的責任問題,我轉為解釋臨床考慮。很多曾接受過 CPR 訓練的人質疑 “任何人” 會錯誤進行心外壓,結果得不償失!雖然質疑的人普遍只是以幻想情況作論證,但我卻要以理論和實例回覆!
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首先要說的便是 CPR 可能引起的副作用:「CPR 會引起肋骨折?」
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相信有不少看倌也聽說過...除了一般 KOL 解說的:
i) 心臟停頓下,肋骨折已不重要;
ii) 心外壓引起的肋骨節,不會有「插穿內臟」的情況,
我還想說個人經歷...
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現實進行心外壓時總會感到 “o卡 o卡聲”,但並不一定因為骨折。當我仍於醫院心臟加護科(CCU - Coronary Care Unit)工作時,看過很多的肋骨 X 光片,發現其實 CPR 引起肋骨折的個案約只有 1/3。胸骨(Sternum)和肋骨(Rib)之間由軟骨(Cartilage)連接,這些軟骨能隨著年紀發生鈣化(Calcification)。心外壓移動著這些鈣化的接口軟骨,引起不順暢的 “o卡 o卡聲”。但話說回來,肋骨折是 CPR 意料之內的潛在副作用,又怎能被說是醫療疏忽?
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看過以上的所有內容,大概也能猜到以下:
心外壓按壓位置不準確不是 “問題”!
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錯誤的位置會降低心外壓的功效,也增加造成骨折的機會。但如果患者已無心跳,患者已經沒有惡化更差的可能。 Any CPR is better than no CPR!這也是為何美國心臟協會提倡任何人也能進行 CPR 和使用 AED,也是為何外國會於電話中教授救助人替患者進行 CPR 的依據。
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於澳洲維多利亞,救護控制室會為致電救護車的市民提供急救指引。如報案人的形容疑似心臟停頓個案,職員會於電話中指示求助人立刻施行 CPR。作為澳洲救護員的我過往處理過多個仍有心跳但卻被進行 CPR 的病人。
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最常見的便是因為濫酒 / 藥而引致人事不醒,其次便是不同原因的昏厥情況。這堆患者大部份又會因心外壓帶來的痛楚而作出反應,施救者亦很快會停止進行心外壓。人體不是紙紮的,骨骼可抵禦一定的外力。綜合我從事院前救護和醫院急症室的經驗,大部份接受過 CPR 的非心臟停頓患者也不會因而受傷或出現心律不整。
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如這些患者並非因內科問題而人事不醒,普遍也能於 6 - 8 小時的觀察後出院。當然我也遇過因心外壓而肋骨折的長者,但這些骨折只需保守治療(無需手術,讓骨折自然癒合),讓他們人事不醒的內科情況才是留院的原因。
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因為重要所以要說三次:
這些個案中,沒有一位施救者被傷者以訴訟追討賠償!
這些個案中,沒有一位施救者被傷者以訴訟追討賠償!
這些個案中,沒有一位施救者被傷者以訴訟追討賠償!
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話說回來,專業的醫護人員也會偶爾於仍有心跳的患者進行心外壓(如:全面哽塞的昏迷患者、心跳過慢的兒科病人...)。我不是在建議大家於仍有反應的患者身上進行心外壓,只想強調現實不如幻想。
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回到理論層面,ILCOR 建議 “任何人” 為懷疑心臟停頓的患者進行心外壓。這些患者同時有兩個徵狀:
i) 突然人事不醒(Suddenly unconscious/unresponsive);
ii) 不正常呼吸、沒有呼吸(Abnormal/Agonal Breathing, Apneic)。
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可以留意 ILCOR 的指引已沒有要求“任何人”檢查患者脈搏,這也是為何部份最新的急救課程已不再救授學員檢查患者脈搏才進行 CPR。其實當患者深層昏迷和沒有呼吸,那僅餘的心跳也不會維持多久。此外,研究也發現很多人(包括醫護人員)會因懷疑患者仍有心跳而延誤 CPR,所以美國心臟協會已於多年前指出一般急救無需檢查脈搏才施行 CPR。始終心臟每停頓 1 分鐘,生存機會便減少 10-12%。時間,便是一切!
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當 ILCOR 也建議急救過程無需先檢查脈搏才進行 CPR,換句話說,向有心跳但沒完全反應的患者進行 CPR 便不是疏忽了!
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對於 CPR 的解說暫告一段落,我想談談 AED 的使用。也許香港的急救機構為 AED 設計了專門的課程和證書,又或是電視電影中把心臟電擊神化了... AED 於市民眼中猶如 Rocket Science,否則康文處也不會有多部 AED 作裝飾用途。
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AED 本為沒有急救知識的市民而設,有語音功能去指示每一步驟。如果使用者有弱聽,它也有閃燈、國片和文字指示如何使用。某些 AED 更會教導施救者進行 CPR,指示心外壓的速率等等。現實使用上比iPad 或 iPhone 更容易,所以煩請別跟我說使用 AED 前要有證書等的說話。
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那麼,該何時使用 AED?簡單說,如患者需要 CPR 便應接駁 AED!
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AED 的電腦會分析患者心律(心臟的電流狀況),如有需要便建議電擊。電擊原理如電腦的 “Restart 鍵”,把心臟雜亂的電流停下來,希望心臟能自動重啟。使用 PC 的看倌一定會有以下經驗, Restart 後也未必一定能進入 Windows,可能依然發生同樣錯誤...AED 也可能這樣,需要多次電擊才能救活病人,或是最後無功而回...
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聽過很多人也擔心 AED 會錯誤電擊有心跳的患者。首先這是 AED 電腦的決定,不會是人為錯誤。使用者只要確認患者沒有呼吸和反應才接駁 AED,便沒有甚麼責任問題。話說回來,這跟 施行 CPR 的要求沒有分別。其實,AED 會進行電擊的心律只有 VF(Ventricular Fibrillation)和 VT (Ventricular Tachycardia)兩種。前者指心臟處於震顫狀態而沒有輸出,患者一定昏迷不醒。後者有點複雜,但患者昏迷便暗示心臟輸出已無法讓腦部和身體運作,進行電擊也是合理。當然,如患者清醒便別啟用 AED了。
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以上略談了大眾對 CPR 和 AED 使用的常見的誤解,希望能為部份市民釋疑。如有其他問題,歡迎留言發問交流。
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其實及早 CPR + AED 使用能大幅增加心臟停頓患者的生存率。以下為澳洲維多利亞救護服務(Ambulance Victoria)的 2014 - 2015的數據:
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由一般途人替患者進行 CPR 和首次 AED電擊,患者的生存率分別高達 69%(Survival to Hospital)和 49%(Survival to Hospital Discharge)。
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但如果等救護車到場才由救護員進行 CPR 和首次 AED 電擊,患者生存率分別只有 48%(Survival to Hospital) 和 26%(Survival to Hospital Discharge)。
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我一雙手能救活的患者有限,但於大家的協助下便有機會救活無限的患者。Saving lives is a team effort,別讓無知抹殺患者的生存機會!
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其實,文科生習醫的奇幻旅程也寫了一篇很好的 CPR 文章:
https://www.facebook.com/artstudentinmedicine/posts/337309393715130
#全民AED #全民CPR #任何仁 #SavingLivesIsATeamEffort #PAD
*Hoke RS, Heinroth K, Trappe HJ, Werdan K. Is external defibrillation an electric threat for bystanders? Resuscitation. 2009 Apr;80(4):395-401. Epub 2009 Feb 10. Review. PMID: 19211180.
同時也有10000部Youtube影片,追蹤數超過2,910的網紅コバにゃんチャンネル,也在其Youtube影片中提到,...
coronary care unit 在 Lee Hsien Loong Facebook 的精選貼文
By now, you have probably heard about my father’s red box. Minister Heng Swee Keat posted about it last week. The red box was a fixture of my father’s work routine. It is now on display at the National Museum of Singapore in his memorial exhibition.
Some of my father’s other personal items are there too. His barrister’s wig (of horsehair) from when he was admitted to the Bar. And a Rolex Oyster Perpetual watch given to him by the Singapore Union of Postal and Telecommunications Workers after he represented them in the famous postmen’s strike in 1952.
I enjoyed my visit to the exhibition a few days ago. Was happy to hear that many of you went yesterday. The exhibition will be on until 26 April. – LHL
MR LEE'S RED BOX
Mr Lee Kuan Yew had a red box. When I worked as Mr Lee’s Principal Private Secretary, or PPS, a good part of my daily life revolved around the red box. Before Mr Lee came in to work each day, the locked red box would arrive first, at about 9 am.
As far as the various officers who have worked with Mr Lee can remember, he had it for many, many years. It is a large, boxy briefcase, about fourteen centimetres wide. Red boxes came from the British government, whose Ministers used them for transporting documents between government offices. Our early Ministers had red boxes, but Mr Lee is the only one I know who used his consistently through the years. When I started working for Mr Lee in 1997, it was the first time I saw a red box in use. It is called the red box but is more a deep wine colour, like the seats in the chamber in Parliament House.
This red box held what Mr Lee was working on at any one time. Through the years, it held his papers, speech drafts, letters, readings, and a whole range of questions, reflections, and observations. For example, in the years that Mr Lee was working on his memoirs, the red box carried the multiple early drafts back and forth between his home and the office, scribbled over with his and Mrs Lee’s notes.
For a long time, other regular items in Mr Lee’s red box were the cassette tapes that held his dictated instructions and thoughts for later transcription. Some years back, he changed to using a digital recorder.
The red box carried a wide range of items. It could be communications with foreign leaders, observations about the financial crisis, instructions for the Istana grounds staff, or even questions about some trees he had seen on the expressway. Mr Lee was well-known for keeping extremely alert to everything he saw and heard around him – when he noticed something wrong, like an ailing raintree, a note in the red box would follow.
We could never anticipate what Mr Lee would raise – it could be anything that was happening in Singapore or the world. But we could be sure of this: it would always be about how events could affect Singapore and Singaporeans, and how we had to stay a step ahead. Inside the red box was always something about how we could create a better life for all.
We would get to work right away. Mr Lee’s secretaries would transcribe his dictated notes, while I followed up on instructions that required coordination across multiple government agencies. Our aim was to do as much as we could by the time Mr Lee came into the office later.
While we did this, Mr Lee would be working from home. For example, during the time that I worked with him (1997-2000), the Asian Financial Crisis ravaged many economies in our region and unleashed political changes. It was a tense period as no one could tell how events would unfold. Often, I would get a call from him to check certain facts or arrange meetings with financial experts.
In the years that I worked for him, Mr Lee’s daily breakfast was a bowl of dou hua (soft bean curd), with no syrup. It was picked up and brought home in a tiffin carrier every morning, from a food centre near Mr Lee’s home. He washed it down with room-temperature water. Mr Lee did not take coffee or tea at breakfast.
When Mr Lee came into the office, the work that had come earlier in the red box would be ready for his review, and he would have a further set of instructions for our action.
From that point on, the work day would run its normal course. Mr Lee read the documents and papers, cleared his emails, and received official calls by visitors. I was privileged to sit in for every meeting he conducted. He would later ask me what I thought of the meetings – it made me very attentive to every word that was said, and I learnt much from Mr Lee.
Evening was Mr Lee’s exercise time. Mr Lee has described his extensive and disciplined exercise regime elsewhere. It included the treadmill, rowing, swimming and walking – with his ears peeled to the evening news or his Mandarin practice tapes. He would sometimes take phone calls while exercising.
He was in his 70s then. In more recent years, being less stable on his feet, Mr Lee had a simpler exercise regime. But he continued to exercise. Since retiring from the Minister Mentor position in 2011, Mr Lee was more relaxed during his exercises. Instead of listening intently to the news or taking phone calls, he shared his personal stories and joked with his staff.
While Mr Lee exercised, those of us in the office would use that time to focus once again on the red box, to get ready all the day’s work for Mr Lee to take home with him in the evening. Based on the day’s events and instructions, I tried to get ready the materials that Mr Lee might need. It sometimes took longer than I expected, and occasionally, I had to ask the security officer to come back for the red box later.
While Mrs Lee was still alive, she used to drop by the Istana at the end of the day, in order to catch a few minutes together with Mr Lee, just to sit and look at the Istana trees that they both loved. They chatted about what many other old couples would talk about. They discussed what they should have for dinner, or how their grandchildren were doing.
Then back home went Mr Lee, Mrs Lee and the red box. After dinner, Mr and Mrs Lee liked to take a long stroll. In his days as Prime Minister, while Mrs Lee strolled, Mr Lee liked to ride a bicycle. It was, in the words of those who saw it, “one of those old man bicycles”. None of us who have worked at the Istana can remember him ever changing his bicycle. He did not use it in his later years, as he became frail, but I believe the “old man bicycle” is still around somewhere.
After his dinner and evening stroll, Mr Lee would get back to his work. That was when he opened the red box and worked his way through what we had put into it in the office.
Mr Lee’s study is converted out of his son’s old bedroom. His work table is a simple, old wooden table with a piece of clear glass placed over it. Slipped under the glass are family memorabilia, including a picture of our current PM from his National Service days. When Mrs Lee was around, she stayed up reading while Mr Lee worked. They liked to put on classical music while they stayed up.
In his days as PM, Mr Lee’s average bedtime was three-thirty in the morning. As Senior Minister and Minister Mentor, he went to sleep after two in the morning. If he had to travel for an official visit the next day, he might go to bed at one or two in the morning.
Deep into the night, while the rest of Singapore slept, it was common for Mr Lee to be in full work mode.
Before he went to bed, Mr Lee would put everything he had completed back in the red box, with clear pointers on what he wished for us to do in the office. The last thing he did each day was to place the red box outside his study room. The next morning, the duty security team picked up the red box, brought it to us waiting in the office, and a new day would begin.
Let me share two other stories involving the red box.
In 1996, Mr Lee underwent balloon angioplasty to insert a stent. It was his second heart operation in two months, after an earlier operation to widen a coronary artery did not work. After the operation, he was put in the Intensive Care Unit for observation. When he regained consciousness and could sit up in bed, he asked for his security team. The security officer hurried into the room to find out what was needed. Mr Lee asked, “Can you pass me the red box?”
Even at that point, Mr Lee’s first thought was to continue working. The security officer rushed the red box in, and Mr Lee asked to be left to his work. The nurses told the security team that other patients of his age, in Mr Lee’s condition, would just rest. Mr Lee was 72 at the time.
In 2010, Mr Lee was hospitalised again, this time for a chest infection. While he was in the hospital, Mrs Lee passed away. Mr Lee has spoken about his grief at Mrs Lee’s passing. As soon as he could, he left the hospital to attend the wake at Sri Temasek.
At the end of the night, he was under doctor’s orders to return to the hospital. But he asked his security team if they could take him to the Singapore River instead. It was late in the night, and Mr Lee was in mourning. His security team hastened to give a bereaved husband a quiet moment to himself.
As Mr Lee walked slowly along the bank of the Singapore River, the way he and Mrs Lee sometimes did when she was still alive, he paused. He beckoned a security officer over. Then he pointed out some trash floating on the river, and asked, “Can you take a photo of that? I’ll tell my PPS what to do about it tomorrow.” Photo taken, he returned to the hospital.
I was no longer Mr Lee’s PPS at the time. I had moved on to the Monetary Authority of Singapore, to continue with the work to strengthen our financial regulatory system that Mr Lee had started in the late 1990s. But I can guess that Mr Lee probably had some feedback on keeping the Singapore River clean. I can also guess that the picture and the instructions were ferried in Mr Lee’s red box the next morning to the office. Even as Mr Lee lay in the hospital. Even as Mrs Lee lay in state.
The security officers with Mr Lee were deeply touched. When I heard about these moments, I was also moved.
I have taken some time to describe Mr Lee’s red box. The reason is that, for me, it symbolises Mr Lee’s unwavering dedication to Singapore so well. The diverse contents it held tell us much about the breadth of Mr Lee’s concerns – from the very big to the very small; the daily routine of the red box tells us how Mr Lee’s life revolved around making Singapore better, in ways big and small.
By the time I served Mr Lee, he was the Senior Minister. Yet he continued to devote all his time to thinking about the future of Singapore. I could only imagine what he was like as Prime Minister. In policy and strategy terms, he was always driving himself, me, and all our colleagues to think about what each trend and development meant for Singapore, and how we should respond to it in order to secure Singapore’s wellbeing and success.
As his PPS, I saw the punishing pace of work that Mr Lee set himself. I had a boss whose every thought and every action was for Singapore.
But it takes private moments like these to bring home just how entirely Mr Lee devoted his life to Singapore.
In fact, I think the best description comes from the security officer who was with Mr Lee both of those times. He was on Mr Lee’s team for almost 30 years. He said of Mr Lee: “Mr Lee is always country, country, country. And country.”
This year, Singapore turns 50. Mr Lee would have turned 92 this September. Mr Lee entered the hospital on 5 February 2015. He continued to use his red box every day until 4 February 2015.
(Photo: MCI)
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