Defence & Security Alert August 2018 Edition by Ocean Media

150 The First and Only ISO 9001:2015 Cer tified Defence and Securit y Magazine in India

The Only Magazine Available On The Intranets Of IAF & BSF

AUGUST 2018

VOLUME 9 ISSUE 11

MILITARY MEDICINE

editor’s note

DSA IS AS MUCH YOURS,

AS IT IS OURS!

he military serves in all possible human spheres of habitation and beyond. So the military person, belonging to any remote village anywhere in the country, is liable to serve, and mostly does so to, at the opposite end of origin. So, for example, if he or she is from the deep desert of Rajasthan, they will most certainly be found on duty at high altitude posts in remote Arunachal Pradesh. This has happened in the past and is certain to happen in the future. This spectrum of deployment puts enormous stresses on the body and the military logistics. For the long time, logistics in the military was limited to analysis of equipment under use in that particular post or zone of service. For the first time, Team DSA looks at the human aspect of logistics, and in this case, the field of medical service in the military. The only time military medicine personnel come into limelight is when there is an incident that makes it a breaking news. A VIP who gets admitted to a military hospital or a soldier in an extreme scenario,

i.e., late Hanumanthappa and his rescue from an avalanche in the Siachen sector. Military medicine is a far more complex field than merely attending to news making emergencies. Every day of the year, round the clock, the medical corps personnel are taking care of combat, support services, and their families, across the country and in all circumstances. So, while some will be delivering babies of military wives, others will be on duty in a submarine on a long range patrol. And, their service people will be patrolling the high Himalayan peaks with a combat ready platoon, while some will be manning posts in the highest known battle zone, Siachen. All these duty fulfilling deployments happen without the slightest hint of publicity, or self-pity. It is simply taken as what it is, duty under oath. And, the military medical corps takes the Hippocrates oath very seriously. So seriously that they are willing to serve for it under any physical or psychological circumstances. Their primary task or mission is to save lives,

August 2018

serving in an institution that is actually authorised to take lives. It is one of the unknown truths that medical personnel have been known to save enemy lives too, for they are under oath to save lives. Which really is a remarkable commitment to duty and service. To mark the truly unique nature of their service, Team DSA produces this current issue as an ode to Army Medical Corps. Most countrymen are not aware of their nature of service, or the complexity of their deployment, and in some cases, even the extreme dangers they face. Some have made the supreme sacrifice, whilst many carry battle wounds. Another unique aspect of the AMC is that its personnel can actually change the colour of their uniform if they so choose within the three services. Given their spectrum of deployment it is only fair they get the final call on which colour they’d prefer to wear.

Manvendra Singh

DEFENCE AND SECURITY ALERT

publisher’s view

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Volume 9 | Issue 11 | August 2018 Chairman Shyam Sunder Publisher and CEO Pawan Agrawal President Urvashi J Agrawal Director Shishir Bhushan Editor-in-Chief Manvendra Singh Copy Editor Vandana Bhatia Palli Copcom & Ops OSD Navjeet Sood Graphic Designer Prem Singh Representative (J&K) Salil Sharma Correspondent (Europe) Dominika Cosic Production Dilshad and Dabeer IT Operations Amber Sharma Photographer Subhash Subscriptions Taniya Sharma Legal Advisor Deepak Gupta

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Defence and Security Alert is printed, published and owned by Pawan Agrawal and printed at Bosco Society For Printing, Don Bosco Technical Institute, Okhla Road, New Delhi-110025 and published at 4/19, Asaf Ali Road, New Delhi (India). Editor: Manvendra Singh

MILITARY MEDICINE

or any effective outcome of any activity, a good health is required. It encompasses proper diet, sleep and precautions against diseases for every human being. And when it comes to any military force, it becomes more important that the force personnel’s health is perfect in all manners. Be they at the border or at any other ground duty. Their health plays a vital role in keeping the national security upright and tight. For the military establishment in India, it is all the more important considering the various types of terrain it is required to defend. From altitudes up to 20,000 ft in the Himalayas to the jungles of northeast India and the deserts of Rajasthan where our force personnel are being posted and have to face ever newer threats internally and externally. As the climate has changed drastically in the past few decades, many new threats have arisen for the forces and health is a major concern to each individual. The forces deployed in the -40 degree and 50+ centigrade temperatures have to confront health hazards caused by extremes in climate change. Acclimatisation alone is no more the panacea for all terrains. So, special training is being imparted in which yoga plays an important part to make them fit to face such climate changes in areas of their operation. And to maintain morale at a high level, it is necessary to also ensure that separated families are comfortable and bereft of the contingencies of everyday life. It has been observed that the force personnel deployed at the high altitude and deserts face lot of deficiencies even when they are shifted to other posts. As a matter of fact, the research conducted by the military has been very supportive for the entire nation as in the discovery of the bacteria of malaria. There are many other such researches being done by military teams during the natural calamities; it’s the military medical paraphernalia which gives support to the disaster management system along with the other medical teams. In greater or lesser measure, the fact is that military medicine has played a vital role in both the combat situation as well as in support of civil authority. The research and development being done in defence laboratories has spinoffs in the civil sector. This edition was visualised by our Editor-in-Chief and designed accordingly as you will not find such articles focussed only on the issue of military medicine anywhere. I am thankful to all the contributors who have added content to this edition to make it a collector’s edition. Happy reading!

Pawan Agrawal

August 2018 DEFENCE AND SECURITY ALERT

contents

An ISO 9001:2015 Certified Magazine COMBATING HIGH ALTITUDE PULMONARY EDEMA DR BHUVNESH KUMAR AND DR RAJENDRA K GUPTA

SPINAL ARTHIRITIS â&#x20AC;&#x201C; BIOLOGIC THERAPY LT GEN VED CHATURVEDI 09 PVSM,VSM (VETERAN) EX DGMS (ARMY) & PROF RHEUMATOLOGY MEDICARE AT LOW COST AVM (DR) PANKAJ TYAGI VSM (RETD)

ECO-FRIENDLY SUBMARINES CMDE ANIL JAI SINGH (RETD)

PREVENTIVE MILITARY MEDICINE DR RAKESH KUMAR SHARMA

MILITARY MENTAL HEALTH: FIT TO FIGHT? AIR MSHL (DR) PAWAN KAPOOR AVSM,VSM AND BAR FORMER DGMS (AIR) (RETD) AND GP CAPT SUNIL AGRAWAL DMS (H) & SR ADVISOR (CM)

August 2018

MILITARY MEDICAL CHALLENGES LT GEN BHUSHAN KUMAR CHOPRA PVSM, AVSM (RETD)

KNOW YOUR AFMS: HEALERS ALL THE WAY Team DSA

THERAPEUTIC MEDICAL STRATEGY DR MANJU BALA POPLI and DR ASEEM BHATNAGAR

LIVE TO FIGHT ANOTHER DAY AIR MSHL ANIL BEHL AVSM (RETD)

HIPPOCRATIC CODE IN PRACTICE CECIL VICTOR

DEFENCE AND SECURITY ALERT

systemic BP HOSTILE WEATHER

COMBATING

HIGH ALTITUDE PULMONARY EDEMA Rapid induction to high altitude above 3,500m can increase prevalence of AMS to more than 65% within 12 hrs of arrival to high altitude, which reduces with duration of stay at HA. Patient complains of anorexia, headache, nausea, vomiting which can subside by itself or sometimes require medication. HAPE and HACE occur as severe form of AMS, which require prompt hospitalisation and treatment.

igh altitude is defined as any elevation above 8,000 ft and characterised by semi-attenuated

atmosphere, low atmospheric temperature and barometric pressure, high UV radiation and low humidity. Partial pressure of gases decreases with increase in altitude while percentage of various gases remains the same. Ascent to high altitude leads to reduction in oxygen saturation in the arterial blood due to decrease in partial pressure of oxygen in inhaled air. Apart from reduction in partial pressure of oxygen in inhaled air hypobaria, it

hypoxia of same intensity. Despite

DIPAS is actively engaged to optimise soldiersâ&#x20AC;&#x2122; performance under extreme environmental and occupational conditions applying physiological, bio-chemical, nutritional, ergonomical and

extreme environment and bad

omics approaches.

contributes to further hypoxemia by reducing vital capacity of lungs due to expansion of air below diaphragm compared to normobaric

weather conditions, deployment of troops in High Altitude (HA) terrain is an operational and strategic requirement of armed forces.

August 2018 DEFENCE AND SECURITY ALERT

Hypoxia mediated stimulation of peripheral chemoreceptors causes hyperventilation leading to alkalosis which inhibits ventilation by inhibiting central chemoreceptors initially during first or second day of induction to high altitude. Active influx of hydrogen ions into CSF as a part of acclimatisation process removes the inhibition of ventilation which, in turn, increases peripheral

chemoreceptor sensitivity to hypoxia

Hypoxia has a direct effect on

more leading to enhanced ventilation

pulmonary vasculature causing

(ventilatory acclimatization). HA

constriction and systemic

exposure produces adverse effects

vasculature to cause dilation. This

on physical and mental health of an

differential response to hypoxia is

individual. Various compensatory

due to presence of different receptors

mechanisms work together to

i.e. oxygen sensitive potassium

cope up with adverse conditions

channels at pulmonary vasculature

in normalising physiological

causing constriction of vascular

functions which together constitutes

smooth muscles and ATP sensitive

acclimatisation process. Generally,

potassium channels causing

these mechanisms start operating

relaxation of smooth muscles in

above 2,500m when partial pressure

peripheral vasculature. The rise in

of oxygen in arterial blood falls below

blood flow in peripheral circulation

60mm Hg.

causes fluid shift from intra-vascular

DIPAS is actively engaged to optimise soldiers’ performance under extreme environmental and occupational conditions

DR BHUVNESH KUMAR

to extra-vascular compartment leading to rise in hematocrit. Simultaneously, ventilation also

The writer is Scientist ‘G’ and Director, Defence Institute of Physiology & Allied Sciences (DIPAS) and has served in DRDO for over three decades, mostly in Himalayan region.

increases manifolds together with increasing oxygen levels in arterial blood. There is antagonism between the direct effect of hypoxia on resistance vessels and those mediated by chemoreceptors in both systemic and pulmonary circulation.

Defence Institute of Physiology

During first few hours of exposure

and Allied Sciences (DIPAS), DRDO

to high altitude, hypoxic ventilation

has been researching over decades

tend to override sympathetic

on high altitude physiology to

vasoconstriction in the systemic

address these issues and frame

circulation, resulting in a slight

out acclimatisation schedule

decreased systemic blood pressure.

to prevent occurrence of these

Blood pressure and systemic

conditions in troops deployed

vascular resistance then rise

at high altitude. The schedule

over at least three to four weeks

is in practice by AO 110/80 for

because of increasing sympathetic

stage acclimatisation. Three

activity and reduced tissue hypoxia

stage acclimatisation schedule

associated with acclimatisation.

is being followed at high altitude

The rise in blood pressure is not

by troops which involve a

reversed by oxygen supplementation,

progressive increase in physical

alpha or beta blockers suggesting

maladies like Acute Mountain

activity. Stage I involves six days

some different mechanism.

Sickness (AMS), High Altitude

of acclimatisation for induction

That is why rise in systemic

Pulmonary Edema (HAPE), High

to altitude from 2,600 to 3,400m

blood pressure is considered as

Altitude Cerebral Edema

followed by Stage II and III

a feature of acclimatisation at

(HACE), etc.

acclimatisation for four days each

extreme altitude. Failure of these

for 3,500 to 4,500m and more

acclimatisation mechanisms can

Generations of stay at high

than 4,500m altitude respectively.

lead to development of high altitude

altitude leads to adaptations in

August 2018

DR RAJENDRA K GUPTA The writer is Scientist ‘E’ and Medical Physiologist at Defence Institute of Physiology & Allied Sciences (DIPAS). He has been working on High altitude maladies for many years.

DEFENCE AND SECURITY ALERT

systemic BP HOSTILE WEATHER

highlander populations. These

merits at low altitude as it helps

adaptations are inherited from

HAPE Susceptibility

in ventilation perfusion matching

HAPE is a non-cardiogenic

generation to other and can

in presence of localised hypoxia

pulmonary edema characterised

differ among various highlander

like pneumonia or atelectasis.

by alveolar fluid with high

populations. Tibetans show low

However, HPV is disadvantageous

concentration of plasma proteins

pulmonary artery pressure (Ppa)

in those who are hypoxia sensitive

and RBC, which develops in

at 3,600m compared to lowlanders

where exaggerated HPV can

otherwise healthy individual after

at same altitude. Low Ppa in

precede edema formation on

24 to 72 hrs of exposure to high

Tibetans has been attributed to

rapid induction to high altitude.

altitude. Prevalence of HAPE

lesser hypoxemia due to enlarged

Pulmonary hypertension results

lungs resulting in more production

due to elevated HPV and is generally

of endothelial nitric oxide levels

resistant to oxygen supplementation

compared to lowlanders. However,

suggesting structural changes in

Ppa in Andeans living between

the vesselsâ&#x20AC;&#x201D;a feature of HAPE

3,700 and 4,500m is similar

susceptible individual. MRI

to white population after acute

studies demonstrated the HPV

exposure to similar altitude while

is inhomogeneous in normal

their haemoglobin levels are

healthy individual. However,

varies from 0.2 to 15% depending on rate of ascent and individual susceptibility to HAPE. HAPE susceptible individuals have been shown to have exaggerated pulmonary vascular response to hypoxia and exercise. Individuals, who have a previous history of HAPE are susceptible to unpredictable recurrence when exposed to high altitude again.

Screening of troops for Brain Natriuretic Peptide (BNP) at sea level may, therefore, be a useful step before their induction to high altitude elevated. Ethiopian highlanders also exhibit elevated haemoglobin like Andeans while in Tibetans haemoglobin levels were found low.

Hypoxic Pulmonary Vasoconstriction Hypoxic Pulmonary Vasoconstriction (HPV) is intrinsic

inhomogeneity increases with severity of hypoxia. The crucial role of exaggerated HPV has been demonstrated as nifedipine mediated decrease in Ppa causes reduction in incidence of HAPE from 60 -70% to 10%.

susceptible to HAPE compared to women. Other risk factors include strenuous exercise, cold weather, and recent respiratory tract infection. Cases of reentry HAPE have also been described in which high-altitude dwellers develop pulmonary edema upon returning to high altitude after a sojourn to lower elevations. In addition, HAPE susceptible individuals have shown lower lung volumes than healthy individuals to the extent that smaller lung volumes lead to

Rapid induction to high altitude

a smaller pulmonary vascular bed

above 3,500m can increase

and fewer recruitable pulmonary

prevalence of AMS to more than

vessels, this will lead to increased

65% within 12 hrs of arrival to

pulmonary vascular resistance

high altitude, which reduces with

and higher pressures when

duration of stay at HA. Patient

cardiac output rises in hypoxic

complains of anorexia, headache,

conditions. There is evidence of

nausea, vomiting which can subside

cardiopulmonary abnormalities

by itself or sometimes require

like absence of right pulmonary

medication. HAPE and HACE occur

artery, patent foramen ovale or

as severe form of AMS, which

other defects leading to pulmonary

Hypoxic Pulmonary

require prompt hospitalisation

hypertension may predispose to

Vasoconstriction (HPV) has many

and treatment.

development of HAPE.

property of vascular smooth muscle which occurs in two phases. First phase of pulmonary vessel constriction occurs with peak in few minutes while the second phase peaks at about 40 minutes. HPV is caused by increased calcium entry into smooth muscle cells of pulmonary artery via L type calcium channels.

HAPE susceptible showed that

Vigorous young men are most

August 2018 DEFENCE AND SECURITY ALERT

In early stages, individual develops

heightened hypoxic pulmonary

Currently, the available nitric

increased dyspnea on exertion

vascular response. It is likely

oxide delivery systems available

and dry cough. Dyspnea worsens

that the inhaled NO had a greater

commercially are ventilator

and become evident even at rest

vasodilating effect in the non-

based and cater for acutely ill

with increased severity of disease.

edematous regions of the lung,

moribund patients who are on

Other important features like

where it could more easily enter

mechanical ventilatory support.

tachycardia, tachypnoea, crackles

the alveoli. In contrast, no such

High-altitude pulmonary edema is

on lung examination, peripheral

redistribution of perfusion in

a life threatening disease in which

cyanosis, increased cough with

response to NO was seen in

inhaled nitric oxide is of immense

pink frothy sputum and drastic

subjects resistant to HAPE. Two

therapeutic value. Commercially

fall in peripheral oxygen saturation

sites where NO may exert its

available delivery systems are

occurs in severe cases. Prevention

beneficial effect includes: (a) the

not suitable as HAPE patients

of HAPE by drugs is only necessary

muscular pulmonary arterial

are spontaneously breathing and

when rapid ascent is unavoidable. Slow ascent 300-350 m/day above 2,000m can prevent HAPE in even susceptible. Lowering of Ppa is the primary goal of treatment which can be achieved by descent, oxygen administration or pulmonary vasodilators.

Nitric Oxide (NO) and HAPE It has been shown that fraction of exhaled nitric oxide was low in HAPE susceptible individuals compared to healthy and administration of nitric oxide evokes a decrease in pulmonary artery pressure three times larger in HAPE-S compared to control. Reduced endogenous NO synthesis in HAPE-S may contribute to

cannot be coupled with mechanical

vessels, where persons prone

ventilator. Therefore, indigenously

to HAPE may have defects in

designed and developed tailor-

NO mediated vasodilatation; (b)

made easy to operate, safe, simple,

capillary beds, where a defect in its synthesis may cause increased leaking of water, protein, and cells

compact, fixed dose nitric oxide and oxygen delivery system (Mark I & II)

Recently, DIPAS has conducted prospective studies on admitted HAPE patients at HA to evaluate the efficacy of BNP as a biomarker of HAPE susceptibility rather than from capillary rupture. Low concentration NO inhalation

would be especially helpful in the armed forces for treatment of HAPE.

when compared to the prevailing conventional and Nifedipine therapies was very effective in the treatment of HAPE. DIPAS studies have further shown that inhalation of NO and oxygen gives immense therapeutic benefit in HAPE patients. Based on these studies, DIPAS in association with R&D Engineers, Pune has designed and developed NO and oxygen delivery system (15 ppm NO + 50% oxygen) for treatment of HAPE which proved beneficial during Kargil War. Inhaled Nitric Oxide therapy has emerged as a new modality of treatment

Measuring fractional exhaled nitric oxide at HA

for a multitude of cardiorespiratory diseases.

August 2018

NO & oxygen delivery system Mark I & II

DEFENCE AND SECURITY ALERT

systemic BP HOSTILE WEATHER

Biomarker for HAPE Susceptibility HAPE is unpredictable and can have a fatal course as mortality can be as high as 50% if left untreated. Despite extensive research in the field aetiology of HAPE is unknown because previous studies on HAPE susceptibility done globally were on mountaineers and experimental protocol involve rapid ascent to HA. It is well known that physical exertion associated with rapid ascent is an independent factor for occurrence of HAPE. However, recently, DIPAS has conducted various studies on Indian army personnel who were lowlander and despite strictly following the acclimatisation schedule at high altitude, some of these personnel developed HAPE showing the characteristics of true HAPE susceptibility. Results showed existence of baseline chronic inflammation and chronic hypoxia mediated vascular remodeling in these non-mountaineers which hampers adequate compensatory increase in ventilation and perfusion at high altitude and can lead to occurrence of HAPE. DIPAS future endeavour is to customize acclimatisation schedule and formulation of strategies for rapid induction and rapid acclimatisation of troops to high altitude for intense military operations. Assessment of hemodynamic response to hypoxia is the gold standard test to predict HAPE susceptibility followed globally, however, DIPAS studies showed that baseline increase in Brain Natriuretic Peptide (BNP) levels is equally capable to predict HAPE susceptibility and because of ease of its testing can be used a potential biomarker of HAPE susceptibility. Elevated pulmonary artery pressure

Do’s and don’ts formulated by DIPAS to minimise the occurrence of high altitude maladies Do’s

Don’ts

Ascend slowly and gradually to HA.

Over confidence kills. Never be complacent.

Take proper rest for initial 3-4 days and s trictly follow the acclimatisation schedule.

Do not over exert physically.

Take plenty of fluids (water, tea, coffee, soups, etc.) at regular interval, to avoid dehydration and constipation.

Do not get unnecessarily exposed to cold and high velocity winds.

Eat well. Take regular meals even if not hungry. Have enough vegetables and fruits to avoid Avoid consuming alcohol, no smoking. constipation. Follow the SOP strictly while using ‘Bukharies’

Do not sleep with ‘Bukhari’ On.

Use sufficient cold protective multi-layer clothing.

Do not put feet directly into snow, mud and water.

Limit the period of exposure to cold, always carry extra pairs of socks, gloves, etc. on patrol duty.

Do not wear wet garments, socks, boots, gloves, etc.

Socks should be changed twice a day at least. Feet should be dry, clean and massage them from time to time.

Do not touch metallic object with bare hands and do not wash hands with kerosene or petrol.

Be active, move the limbs every now and then. Do foot parade regularly.

Do not re-warm hands and feet using direct fire. It can cause burns.

Keep your mind active. Do regular reading, solving puzzles, etc.

Avoid negative thinking about the place of posting.

Report to the MI room if you have any of the following

Avoid self-medication.

(a) Headache (b) Breathlessness (c) Chest Pain (d) Vomiting (e) Cough (f) Inability to carry out routine duties (g) Pain, tingling, burning, itching or numbness in hands and feet. Report to your senior for any abnormal behaviour you observe in your buddy.

Do not hide the facts while reporting to your seniors about any problem.

(Ppa) precedes edema formation while BNP levels correlate with mean Ppa. Retrospective studies conducted at DIPAS on old HAPE cases of Indian army personnels showed baseline elevated Ppa and BNP levels. Recently, DIPAS has conducted prospective studies on admitted HAPE patients at HA to evaluate the efficacy of BNP as a biomarker of HAPE susceptibility. Elevated BNP level has been found in

control. Therefore, it becomes clear from both these studies that subclinical pulmonary hypertension can manifest as HAPE when individual fails to acclimatise and BNP at sea level can predict HAPE susceptibility.

admitted HAPE patients compared to

to high altitude.

August 2018 DEFENCE AND SECURITY ALERT

Screening of troops for Brain Natriuretic Peptide (BNP ) at sea level may, therefore, be a useful step towards personalised risk assessment before their induction

low dose biologics PREVENTION

SPINAL ARTHIRITIS â&#x20AC;&#x201C; BIOLOGIC THERAPY

Although many diseases affect soldiers, but this disease, Ankylosing Spondylitis, has long lasting pain along with morbidity if not treated early. Since this disease is frequently neglected by young soldiers in early stages, due to which this is diagnosed late. Early disease is treatable with more success. Hence, early detection of this disease is very important even at recruitment stage by newer techniques such as blood test for HLA B27 gene detection.

obility is an important factor both in war and peace. Defence health planners are

aware of common diseases that affect the soldierâ&#x20AC;&#x2122;s quality of life and mobility. Due to rapid development of science, many diseases have been researched which can affect mobility of young soldiers. If not treated,

LT GEN VED CHATURVEDI PVSM,VSM (VETERAN) EX DGMS (ARMY) & PROF RHEUMATOLOGY Veteran officer is internationally acclaimed Rheumatologist, retired as DGMS Army. The writer also served as Hony Physician to President, Chairman Army Medical college, President of Indian Rheumatology Association & has published several papers. He is the first Rheumatologist in country to establish Ultrasound in Rheumatology and to use drugs called Biologics.

they can adversely affect military operations and also peace-time capabilities of armed forces. Also, health administrators may come out with new policies for detecting these diseases at the time of recruitment. Once upon a time, prevalence of tuberculosis was high in the society and X-ray of chest was introduced before recruitment, basically to diagnosis tuberculosis at early stage. There are many diseases which can

August 2018

cause pain in the lower back and in turn, affect the mobility of young soldiers. Most common among them is well known and called intervertibral disc prolapse. However, more dreadful and which can affect mobility of the spine on a long-term basis is a disease called Ankylosing Spondylitis. This disease is more common in individuals who carry a specific gene. This gene is called Human Leucocyte Antigen B 27 (HLA B27).

DEFENCE AND SECURITY ALERT

low dose biologics PREVENTION

Symptoms Low back pain with stiffness is the main symptom of this disease. Chest pain, neck pain and heel pain are other common symptoms. This disease can involve other organs also such as eyes, heart, lungs, brain, kidney and gut, etc. Ankylosing Spondylitis is a common disease and is more often found in men, but can also affect women and children. Without treatment, this disease progress continuously and results in fusion of spine and loss of mobility. Hence, early treatment should be done in this disease to prevent disease progression. Two decades ago, there were only few drugs for the treatment of this disease (mainly analgesics, Anti-inflammatory) which

done at the time of recruitment of young soldiers. Basic pathology of this disease is Arthritis of lower spinal joints. X-ray of pelvis joint is not very helpful for early screening of this disease. MRI pelvis is much better than X-ray for early screening of this disease. But whether MRI pelvis is cost-effective for such large screening is doubtful. Blood test for HLA B27 gene is another modality which can be used for screening for this disease. This costs less than MRI and its positivity is very much suggestive of this disease. A technique for screening of this gene is available only in big hospitals of army. Ideally, blood test for this gene can be done by an instrument called flow cytometry at the time of recruitment by storing blood and

Without treatment, this disease progress continuously and results in fusion of spine and loss of mobility decreases only pain but not prevent progression. Now a days, several drugs are there which are very effective if given during early period of the disease. Hence, diagnosis of this disease should be made as early as possible. In this disease, symptoms such as pain and stiffness are more during early morning hours especially after awakening and decrease after activity. Hence, young soldiers neglect this disease for a long period as they have fewer symptoms with activity. Therefore, disease progresses and diagnosed in later stage when major damage has already occurred. Also, drugs are less effective in later stages of this disease. Hence, all measures should be done to diagnose this disease early.

sending it to big hospitals. A policy can be made where if this gene test is positive, then that particular

Myth: HLA B 27 gene associated with Ankylosing Spondylitis is only research tool. Fact: Presently, HlA B27 gene is included in criteria for diagnosis of Ankylosing Spondylitis. Myth: Ankylosing Spondylitis is rare. Fact: Ankylosing Spondylitis is a common disease. Though exact prevalence of this disease in armed forces is not known, it is estimated that there is a high prevalence among young soldiers as this condition is more common in males. Myth: Ankylosing Spondylitis is a progressive disease that always results in a fused spine. Fact: Symptoms and severity of Ankylosing Spondylitis vary from one person to another. If treatment is initiated in early stages of disease, further progression can be prevented and avoid fusion of spine.

Writerâ&#x20AC;&#x2122;s Experience The writer has a huge experience

recruit can be re-examined in

of diagnosing and treating this

detail by a Rheumatologist. Since,

disease since 1999. While doing

biologics treatment for this disease

tenure at Army Hospital Research

is costly and that recruit would

and Referral, he realised that there

unnecessarily become a liability

is a huge workload of this disease in

to the armed forces, an early

armed forces when compared to any

detection can save many dollars

civil medical institutions. Prevalence

spend to treat this disease lifelong.

of this disease seems much higher in armed forces. This is because

Many myths surround this

of good training of primary health

disease. They are as follows:

care providers called Regimental

Myth: Earlier people used to think

Medical Officers (RMO) for picking

that it is very rare in female and

up this disease early. Since army

back pain in female is mostly

personnel have to get up early in the

during pregnancy or due to some

morning to do physical training, this

gynaecological problem.

disease can be picked easily by a

Early Screening

Fact: Fact is that significant

unit regimental officer. Symptoms of

Screening for this condition, Ankylosing Spondylitis, may be

number of females also suffers

backache are worst in early morning

from this disease.

after prolong rest. Also, there is no

August 2018 DEFENCE AND SECURITY ALERT

referral bias and most patients

work in Asian Pacific League

if not treated early. Since this

referred to Rheumatologist unlike

of Rheumatology (APLAR)

disease is frequently neglected

most civil hospitals where they

conference in Korea in 2002,

by young soldiers in early stages,

is no referral policy. Due to

Japan College of Rheumatology

due to which this is diagnosed

commercial bias, patients are not

in 2004 and many other

late. Early disease is treatable

referred to appropriate doctor i.e.

conferences at the national

with more success. Hence, early

Rheumatologist. Also, the mouth-

level. In fact, they became the

detection of this disease is very

to-mouth publicity of benefits of

leader to show the path to their

important even at recruitment

biological therapy also let to

colleagues for the treatment

stage by newer techniques such

huge referrals.

of these painful conditions.

as blood test for HLA B27 gene

They also conducted a trial of

detection so that many dollars

using low dose biologics, which

can be saved for treatment of this

resulted in huge success because

disease. Even if missed during

incidence of Tuberculosis virtually

recruitment, early detection

comes to zero in patients and cost

of this disease should be done

of treatment also comes down

on the basis of symptoms and

heavily. They can say proudly

investigations, so that treatment

that as on today, most of our

can be initiated at early stages

Indian Rheumatologists

and to prevent further progression

follow model of using low

and damage due to this disease.

The writer could attend to approximate more than 2,000 patients during his posting to Army Hospital, RR. Unfortunately, the data could not be published due to many administrative reasons. The rheumatology department of Army Hospital had dedicated equipment called flow cytometry. They could perform Blood test for HLA B27 as screening test themselves and also, could confirm the early disease due to easy availability of free MRI. In 2000, they were the FIRST in country to start effective treatment for this disease, with injectable drugs called BIOLOGICS. Cost of this biologic therapy was exorbitantly expensive but armed forces could provide these medicines for its soldiers free of cost, this resulted in huge experience of giving biologics especially in early disease. They also learn that if treated early, this disease can go in long-term remission. Even advanced disease has benefit by improvement in quality of life if treated with biologics. Since that time even national capital had one or two qualified Rheumatologists, they also got a chance to see many civil patients, who wanted their opinion. They presented their

dose biologics.

Our pioneering work of Low dose

A subset of Ankylsimg

is followed by our other colleagues

Spondylitis disease could have

world over.

Biologic therapy for this condition

very aagressive course and

What is Ankylosing Spondylitis

many young soldiers lost their hip joint. These young soldiers

(AS)?

used to be admitted for hip joint

• Inflammatory Arthritis of spinal joints and ligaments is called AS.

replacement. It was a tragic scene to announce

What age group of people are

hip joint replacement surgery for

affected?

these young lads. Physical fitness

• Disease usually starts around 19-20 yrs.

is essence of soldiery profession and these young soldiers could never reconcile about having an

Most common symptom?

artificial hip. Many young patients

• Low back pain which get worst after rest.

used to develop psychiatric problems. With Biologic therapy, they could successfully treat

What are test available to

these patients and prevent

confirm diagnosis?

hip replacement.

• X-ray or MRI of lower back. • Blood test for HLA B 27 gene.

Summary Although many diseases affect

What is current treatment?

soldiers, but this disease,

• Biologics drugs are effective.

Ankylosing Spondylitis, has long

• Anti TNF has revolutionised

lasting pain along with morbidity

August 2018

the treatment.

DEFENCE AND SECURITY ALERT

military model COST-EFFECTIVE

MEDICARE AT LOW COST

ntroduction

Medicare is an essential part of life. Protection and preservation of life, through knowledge of medicine is required from the stage of conception to pregnancy, child birth, early days, childhood, period of youth and marriage, period of early middle age, period of late middle age, period of old age, period of death (Fig. 1) and beyond. The cycle restarts with conception and continues. The need for type and quality of medical cover required, changes, as life takes its twists and turns. The cost of treatment through mother care, neonate care, paediatric care, medicine and surgery care, gynaecology care, accident and trauma care, preventive screening and early detection of disease, ophthalmic care, ENT care, endocrinology care, psychiatric care, drug abuse and addiction care, and many more niche fields, though cover all aspects of life are constantly increasing. Costly supporting specialities driven by latest technologies like pathology, histology, radiodiagnosis, nuclear medicine, genetic medicine, etc.

provide the platform to reduce errors and early diagnosis.

beyond the bonding of bearing a child in your own body. This part

Fig 1. The Health Life Cycle

Tender Love & Care (TLC) the Inherent Care System

Each part of the world has evolved medicine, as a part of its own social, cultural, ethnic and economic growth. “Cure sometimes, treat often, comfort always” by Hippocrates has been the basic drive in any form of medicare. Providing “comfort” till date falls in the domain of mothers and wives, while the father provides comfort, through a surprisingly special emotion evolved on earth, which goes

August 2018 DEFENCE AND SECURITY ALERT

of the medicare is being provided by all. It is hugely important both in good and bad times. Even when everything is fine, a life event grief is managed by this very personal resource, in the privacy of a home by those who have the fortune of having families. This reserve is used by all, especially when times are bad, when social fabric breaks down by natural or manmade events, in peace as well as in war. This asset must be formally built to make a nation strong. In recent times, its organised use

by Japanese society to resolve collective grief during a natural disaster was novel and inspiring to the world.

The Health Care System

“Treat Often” is the domain of those who are part of medical industry, in whatever the varied form it is practiced (be it through Allopathy, Ayurveda, Unani, Chinese medicine, etc.) and wherever it is provided (hospital/ home/ workplace). “Cure” is a utopian word and is very rare in the plethora of disease mankind suffers. The diseases, themselves, are also evolving and are throwing newer challenges to the tools provided by technologies of the time.

The fundamentals of the business models in the field of medicine are as poor as in any other field of business in India Military and the Nation

India, fortunately, has been a very cultured society, evolving through the surplus created beyond food and shelter by hard-working, intelligent people, who created this civilisation. In the process, it was exploited, as were other civilisations, by those who “did not have” through brute uncivilised force. The war machines were, therefore, required to keep this brute force away. It compelled the people, to keep part of their economic surplus, as a nonproductive asset, to acquire, in the beginning an Army as land force and later Navy and Air Force to protect the land mass from sea and air. These forces are active throughout the world, even now

and will remain so, in times to come. The budgets for maintaining the modern war machines thus contract and expand based on perceptions being created at economic conflict zones, resulting often in diplomatic stand-offs, which sometimes spill over to conflicts on ground.

Marketing Driven Medicine

No single system of medicine is perfect because the knowledge in this field is so limited and often, evolving. While there has been an enormous growth in predicting, diagnosing and managing diseases compared to recent past, its cost, like any recent technology is keeping it out of reach, of many populations. Perceptions are also being created in the field of medicine as is done in other fields, to hide the knowledge gaps. This is a big reason for people spending beyond their means and not for the right cause. Due to the knowledge gaps in medicine, the decision-making is being left to the patient by giving him/her various cost-driven options, outcome of many, right from the start may not be what patient is made to perceive.

The Practice of medicine in Modern India

All forms of medicines are being practised in India to varied extents. Very few of these are government or self-regulated. For several reasons, many of them directly or indirectly ride on allopathy making the original systems a hybrid system, often with no accountability. The medicare providers are the government, public sectors, private sectors and individuals. Unregulated non-allopathic practitioners, paramedic practice, family practitioners, clinics by individuals, diagnostic centres, small hospital for tertiary care,

August 2018

AVM (DR) PANKAJ TYAGI VSM (RETD)

The writer brings more than 36 years of healthcare planning and project management experience, with Indian Air Force, Indian Army, Civil Aviation and Space industry. He was in Conceptual Team for manned space programme with ISRO and is now in Airline & Airport Medical Services, Flight Safety support to DGCA & Airport Authority of India, Hospital Chain Management & Growth, Remote Medicine, Medical Tourism, Education & Hospitality. He is also Founder Director of Timespan Management Pvt Ltd (TMPL) & Triophs Medical Services Pvt Ltd (TRIOPHS).

Government Primary Health Centres, District Hospitals, Corporate Hospitals Diagnostic Centres and Clinics, AIIMS like Super Speciality Centres are all part of the Indian Medicare industry. Pharmacies and surgical, diagnostic, hospital equipment manufacturers and suppliers form the backbone of very vital ancillary medical system in India. The system has evolved over the last 100 years. There is still a huge gap between the demand and supply in all fields of medicine. When that happens, the market should be good for business of medicine, but it is not. The reasons for huge dissatisfaction at all levels, both for users and providers are many but the most important reasons, have either not been understood or have consciously

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military model COST-EFFECTIVE

been ignored by the stakeholders. The fundamentals of the business models in the field of medicine are as poor as in any other field of business in India. Trading being the main model of most of the businesses, big or small, the mainstay of making money is through margins that can be generated in the process of taking the product to consumer. The Medicare System in India is no exception and has followed the same path. Manufacturing is tough. Even if one gets into this field selling the products within India is tougher. Under these circumstances, trading is the obvious answer for business. Despite these factors, medicare is being provided by some who have

cracked the code. To understand this clearly, we need to study some of the successful models being run in the country. The answer to the genuine balanced medicare lies in secrets of running a successful enterprise despite all the chaos in the evolving sector, short of funds and resources for the moment.

Medicare Client Categories The clients seeking medical help in India generally fall in three categories: Category I are about 20 percent, who are the rich and nouveau population and looks up to corporate hospitals and clinics as their service providers. For them

August 2018 DEFENCE AND SECURITY ALERT

money is not the criteria, but they look for â&#x20AC;&#x2DC;5-star ambience facilitiesâ&#x20AC;&#x2122;. They may or may not depend on insurance as a cover for medicare needs for themselves or their families. Category II are forty percent of middle class population settled as minority in rural and majority in urban set up. This is the category which often overstretches financially to get something they cannot inherently afford but get exploited by perceptions of getting the right treatment based on cost. This category was earlier being managed by clinical practitioners, who were also the decision-makers for the families and friends living in the community with them. They

homes was removed and the patient moved into the hands of multi-speciality centres. As was bound to happen, profits took over quality of medicare. Smelling an opportunity, a few years back, the corporates moved in driven by profitmaking Diagnostic Centres. They made posh big multi-speciality hospitals that promised ‘cure’. The medicare had slowly moved from the practice of medicine to a tool-driven medicine. Enormous amounts of money and perks were offered to famous doctors with skills to move into corporate hospitals with their paramedic and technical team. The best of machines were imported and new departments got established as ‘jewel in the crowns’ of hospitals, to stay ahead of mushrooming competition.

slowly lost out to those doctors, who had individual funds as entrepreneurs and could develop Diagnostic Centres, which were run by them. These were doctors with resources, who were also knowledgeable in a special field of medicine or surgery. They had built a personal reputation, through their excellent ethical practice, keeping a good balance between commerce and medicare. This also changed, with the advent of better diagnostic tools, like histopathology machines, MRI, etc. The capital costs started rising and slowly diagnostic centres mushroomed through non-medical funding, as a part of an investment opportunity. Small time corporate

culture started taking roots in India. The medical education started getting driven by money

The existing system is now so corrupt that a complete overhaul with honest people is the only answer power rather than by competition. This period saw the decline of practice of family medicine in its pure and simple form, as people started looking for specialists at the cost of general practitioner. Slowly, the decision-maker from

August 2018

Super-speciality culture came in. With that, perceptions were created among minds by focussed advertisements to drive patients, who could afford to pay. Basically, the recovery of capital cost by investors and increasing expectations of profit margins started compromising the pioneer specialist’s way of practice, many a time unwillingly. The specialities in medicine grew to such an extent that they could not function as stand-alone specialisation, as they were dependant on costly machines, needing multiple skills to operate. Medicine, therefore, moved into board rooms and saw the best financial minds guiding profits, sometimes compromising on the care. Category III of the clients fall in poor to very poor category. These are the people who manage medical needs by home grown

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military model COST-EFFECTIVE

anecdotal medicare. They do not have any access to medicine. The governments showed their intent to bring medicare to the poor through various government funded schemes. The latest in this series is “Ayushman Bharat”, based on insurance driven medicare, with premiums for the family being paid by the government. Most of these schemes have failed and are vulnerable, as they are to be run through existing infrastructure and human resource. The real problem in managing such schemes is the inherent greed in people, to squeeze every rupee from government, without passing on anything to the poor clients. Most of those who are in charge of running the schemes are

create this new resource so vital for the country.

Successful Models in Medicare

Today is that point of time when the outside world is finding the gap in medicare and cost increasing, exponentially. Today, we need to rethink the whole model that could work for India. What India needs from medicine is reasonable primary, secondary and tertiary medicare at all stages of life. The answer to provide such medicare lies in studying and modelling based on two models: • Military Medicine Model • Successful Low-Cost Hospital (LCH) Model

Military has created for India a unique medicare system, untouched by commerce but with undiluted excellence in knowledge government employee. They have generally been made incompetent by the system and are experts in creating hinderances in commercially run enterprises. Today, no entrepreneur wants to be part of any government scheme as the ownership of such schemes will be passed on to local leaders to municipality stakeholder, etc. They hijack the well-intended schemes to project these as a big favour being done to the poor vote banks. The existing system is now so corrupt that a complete overhaul with honest people is the only answer. This is the toughest task but is the key to success of government funded schemes. Fresh young cadres need to be created. May be NCC, paramilitary forces, etc. may be the pool to

Military Model Military Medicine, worldwide and more so in India, though supported with a miniscule of resources (as compared to civil and corporate medical world) has unknowingly created an excellent infrastructure and manpower resource for the country, as it is based on non-revenue generation model of practicing medicine. Minimum resources for maximum quality of medicare is the norm. The only driving force for this cadre is camaraderie and the feeling of belonging to one group. The budgetary constraints are being managed by the best minds in the country. Military has created for India a unique medicare system, untouched by commerce but with undiluted

August 2018 DEFENCE AND SECURITY ALERT

excellence in knowledge. Each military resource was picked up through top class all India competition and then groomed to what the services needed from them. The system has worked and grown and needs to be utilised in nation-building projects.

Low Cost Hospital One Low Cost Hospital is Sushruta Hospital, being run at small town called Bengarpet nearly 50 km from Bangalore. The hospital has been named as a resource to study and replicate the model across India. It provides basic multispeciality medicare to many of Category II & III clients, without any insurance cover. The clienthospital trust has developed for the last 40 years, through the dedication and enterprise of only one MBBS qualified doctor. Other specialities have added themselves to the centre slowly. People come to the hospital for being reasonably priced. They are aware that here emergency treatment will only be given to save lives, even if you do not have any money. The cost of procedures is flexible which is decided on the spot by staff and CEO. The hospital is based on personally knowing most of the patients and their families for past 40 years.

An Integrative LCH Military Medicine Model for India The Low-Cost Hospital should be developed in harmony with the client population and will need about a decade to create the necessary trust with the community. It should be built and run by an open invite to doctors willing to invest in such a hospital. Like selection of dealers, the owner CEO is to be certified by a central agency based on his dedication,

skill and entrepreneurial drive. No further certification is required after the first time. The CEO will be fully independent to run the hospital as any entrepreneur. The only commitment by the Central Government would be to make local administration and police accountable, to provide all the help to the CEO. The local district administration is to be held responsible for providing basic amenities of water and electricity and all clearances while the local police to be held responsible for security of the hospital. An ex-servicemen doctor could be a full-time assistant to the CEO. The hospital will aim to grow to finally provide basic speciality services through MBBS family doctor, supported by local specialists in medicine, surgery, gynaecology, paediatrics and pathology. These specialists, individually, can function at multiple hospitals or on their own with suitable commercial relationship as worked out mutually by the CEO and the specialist. The infrastructure with basic amenities on rent or any other way will be handled by the CEO. The quality of medicare at minimum cost will be the mainstay and not the sophistication of the building. One such hospital would be required to cover 10 to 15 villages. The paramedics and health care workers should be encouraged

and supported by LCH as first providers of medicare. All exservicemen from the area willing to be part of this entrepreneurship should be supported by LCH. They will be the spokes for the LCH as hub.

to be directly invested by the government. They could consider directly providing some financial aid to Category III population. The rest should be left to the very capable and dignified people of this country.

Integrated Healthcare Model for India The commercial details of capital investment, operational cost and flexible payment modes are available as resource material with the author. This model is running successfully, therefore is worth replicating for category II & III clients. The government will play its role in supporting the entrepreneur. It should ensure through suitable orders in making local administration responsible and accountable, without any interference in the affairs of the LCH. This is the key for the success of providing medicare to all, across India. No money needs

Conclusion The healthcare industry in India is at crossroads. What was being touted as a panacea for all evil, has not worked too well for reasons briefly outlined above. The way forward needs to emanate from models that have worked and have been proven over time. Two such models have been explored and proposed. An integration of resources proposed is possible, proven and replicable. sThe models need to be ‘right-sized’ to ensure that the goal of pan-India medicare is achieved.

Resource References for study • Military Medicine for the 21st Century to shape the future- Colonel Michael J. Brennan, United States Army. • Multiple open resources on related topics • Armed Forces Medical Services website • Multiple personal communications with CEO Sushruta Hospital and leaders of the Industry.

August 2018

DEFENCE AND SECURITY ALERT

venomous PSYCHOLOGY

ECO-FRIENDLY SUBMARINES There is also evidence from studies conducted by various other submarine operating navies that it is not only the noxious gases and particulate matter which affects submariners but also more detailed aspects like the height of bunks, their positioning on board (if located athwartships, they are considered less conducive), cramped crew messes, the ESM and sonar consoles in the control room and constrained sanitation and exercise facilities amongst many other factors; all of these will affect stress levels on board, increase chances of illness and in the long run affect morale and retention.

August 2018 DEFENCE AND SECURITY ALERT

ubmarine – Its Composition

Submarines are unique in their design, their construction, their philosophy of operation and the kind of people who man them. They operate in an environment which is alien to mankind, both inside the submarine and outside it. Within, the submarine comprises a body of 40-60 men living and working in a sealed steel cylinder about 60 metres long, cramped and buzzing with complex machinery and electronics; for up to 45 days at a time with all the associated logistic challenges – lack of fresh water, limited quantity of fresh food for the first few days and packed food thereafter days on end,

As a mature submarine operator, the Indian Navy must, therefore, establish its own standards which can be incorporated in the submarine design confined living spaces, no privacy whatsoever, basic and inadequate sanitary facilities, diesel, grease and oil odour, a combination of contaminated gases; sleepdeprived and hot and sweaty most of the time and yet have to continue operating at sustained peak efficiency because any lapse in concentration could lead to a mistake that would send all of them to a watery grave. Hence, the challenge to a submarine is not only from the enemy but from its operating environment itself. It is, therefore, inevitable that living for years in such an

environment would have some physiological and psychological effects on those who man submarines. Various studies have been undertaken by submarine operating navies to assess these effects and introduce measures to mitigate their adverse effect. In India too, a study was undertaken by the DRDO way back in 2001 which offered a valuable insight into the challenges of the internal environment on board and suggested mitigating philosophies. Perhaps, it is time now for a contemporary review and subsequent dissemination to the submarine operating authorities, the refit organisations and the submarine design agencies to further improve the design on board towards better ergonomics, space management, machinery location, air regeneration systems, etc.

Submarines – Its Kinds

The writer is the Vice President of the Indian Maritime Foundation. He retired from the Indian Navy after 30 years as a submariner and ASW specialist and had five command tenures including four submarine commands. A postgraduate in Defence and Strategic Studies, he is keenly interested in matters of maritime.

are shallower for which smaller submarines are better suited.

Submarines are basically of two types – nuclear and conventional. While the former are driven by nuclear propulsion, the latter are driven by diesel-electric propulsion. Nuclear propelled submarines are much larger and the availability of nuclear power on board removes many of the limitations of their smaller conventional siblings. Nuclear-powered submarines are deployed for longer durations (extending up to months at a time); their crew limitations are unique to them and have more to do with endurance on board and long durations at sea. Presently, nuclear-powered submarines are operated by only six navies (USA, UK, Russia, France, China and India), so the vast majority of navies continue to operate conventional submarine which are better suited to operations in the littorals where the water

August 2018

CMDE ANIL JAI SINGH (RETD)

Affordability is the other major concern. Submarines are expensive to build, operate and maintain. However, that notwithstanding, submarines probably offer the maximum bang for the buck leading to many navies now aspiring to this capability. This article will, therefore, focus on the challenging environment on board conventional submarines

Toxic Air

Studies have shown that the close confines of a submarine where there is neither ingress of fresh air or egress of stale air for periods which could stretch from 24 hours till up to a few days can generate many pollutants and noxious gases. Perhaps, the singlemost obvious of these is the carbon dioxide exhaled

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venomous PSYCHOLOGY

by the crew which gradually increases in a dived submarine while correspondingly reducing the available oxygen. Ideally, the carbon dioxide content in the air should be about 0.03% while inside submarine, this goes up to about 1% in about half a day; further increase can be contained through various techniques which reduce the carbon dioxide to about 0.8% while maintaining oxygen between 18% and 21%. This level of carbon dioxide does not have any harmful long-term effects. The IN’s Russian origin submarines have devices called carbon dioxide burners which maintain the level at about 0.8%. However, these burners increase the heat levels in the submarine which affects the habitability on board.

fresh air to operate. This is done through the snorkel system on board; a submarine planes to periscope depth, raises its snorkel mast a couple of metres above the sea surface through which fresh air is sucked in for the diesel generators. This also provides an opportunity to recycle the air on board thus replacing the stale air with fresh air. In the older submarines of about half a century ago, the operating philosophy was different; the submarine would often surface during routine exercises in peacetime to charge batteries. This also gave the crew an opportunity to come on the bridge of the submarine for fresh air. However, that is no longer the case with modern day submarines

Presently, nuclear-powered submarines are operated by only six navies (USA, UK, Russia, France, China and India) Conventional submarines require to periodically charge their batteries. The frequency and duration is determined by the operational requirement. However, within about 72 hours or so there would be a requirement for a submarine to charge its batteries. The batteries are charged by the diesel generators which require

which remain dived for the entire duration of their sortie. In addition to the high levels of carbon dioxide, a submarine crew is also exposed to many other harmful gases and particulate matter on board. Some of the significant ones are carbon monoxide which leaks from

August 2018 DEFENCE AND SECURITY ALERT

the diesel generators, chlorine, hydrogen from the battery compartments, mercury from broken thermometers, hydrogen sulphide, aerosols of sulphuric acid from the acidic vapours that escape from the large banks of lead acid batteries that are located in the battery pits usually situated below the accommodation spaces. Additionally, the crew is also exposed to hydrazine, nitrogen oxides and particulates of both inorganic and microbial types. Each of these has harmful effects, some short-term and some with potential for long-term harm. These gaseous and particulate pollutants find their way into the respiratory tract as well as coming into contact with the human skin.

Deleterious Surrounding in Submarines

A rarely considered aspect is the living conditions on board where men are in close contact with each other in a distinctly unhygienic environment where even a bunk is shared in a ‘hot bunking’ concept followed on most submarines worldwide. This leads to infections amongst crew members from cough, sneezing, human hair, scaling of the skin (studies have indicated that an average human being sheds about 3 gm of skin a day) and other bacterial infections that spread due to human contact. There are various ways in which the pollutant levels on submarines can be reduced. Different submarine designers adopt different techniques. The most obvious way is to reduce the number of people on board. Higher levels of automation have reduced the crew size on submarines by at least 50% in the last half century or so and as technology progresses toward higher levels of automation and autonomous systems, this will further reduce. Timely replacement of old equipment, new batteries, renewal of filters, preventive

maintenance on schedule, absorption and adsorption of pollutants, etc. can further reduce the ill-effects of these pollutants. One of the reasons attributed in the open media to the explosion on board INS Sindhuratna at sea a few years ago, which led to the Chief of the Naval Staff tendering his resignation, was the presence of old batteries on board the submarine. From personal experience, this author can state how noxious the air on submarines can get with old batteries emanating foul hydrogen sulphide vapours.

Competent Officers

There is no doubt that the environment on board a submarine is not conducive to good health and as submariners spend more time at sea, the adoption of mitigation technologies will become increasingly important. However, in addition to the physiological aspects, there are also the psychological aspects of 40-60 people living on board in the closed confines of a dived submarine for up to 45 days at a stretch. Imagine the effects of stress in a high pressure combat scenario with inadequate sleep and shared sleeping spaces and still having to maintain a high degree of alertness, both mental and physical, and the effect this can have on crew fatigue and reducing efficiency. To ensure that the submarine continues to operate like a well-oiled fighting machine requires skilful leadership. That is why Submarine Commanding Officers are chosen carefully after a stringent qualification process which not only tests the professional competence but also the leadership skills of the individuals. The Indian Navy has been operating conventional submarines for over 50 years and there are no studies available to evaluate the long-term effects of exposure to a submarine environment. Empirical evidence to

evaluate this need to be collected and assessed for different periods and the actual time spent on board submarines, both at sea and in harbour. For example, Indian submariners, since the mid-1980s, have spent far more time dived than their predecessors and perhaps present day submariners too. It is interesting that submariners of the Royal Australian Navy who served on the Oberon class submarines have raised compensation claims for the ill-effects they have suffered due to the environment on board and quoted many of the pollutants discussed earlier in this article as the reason. Their claim has been admitted and is being examined.

Improved Environment Now that the Indian Navy has begun to operate nuclear

to the ambient atmospheric and water temperatures, the relative humidity, the water salinity levels, the atmospheric conditions, the hydrographic profile, the manning philosophy, ergonomics on board, all of which have a direct effect on crew fatigue, etc. There is also evidence from studies conducted by various other submarine operating navies that it is not only the noxious gases and particulate matter which affects submariners but also more detailed aspects like the height of bunks, their positioning on board (if located athwartships, they are considered less conducive), cramped crew messes, the ESM and sonar consoles in the control room and constrained sanitation and exercise facilities amongst

Ideally, the carbon dioxide content in the air should be about 0.03%. In a submarine, this goes up to about 1% in about half a day submarines also, this study could be included for these as well. With the experience gained over the last 50 years as well as the advances in technology, constant efforts are being made to improve habitability on board. The availability of Reverse Osmosis plants on board has ensured a much healthier supply of fresh water to the crew which in itself greatly enhances the habitability, hygiene and sanitation on board. However, a lot more needs to be done. The Indian Navy has been operating submarines of Russian, German and now most recently, French origin. The next submarine building programme (Project 75-I) will also be based on a foreign design. The operating environment in European waters is very different from that prevailing in the Indian Navyâ&#x20AC;&#x2122;s area of operations particularly with regard

August 2018

many other factors; all of these will affect stress levels on board, increase chances of illness and in the long run affect morale and retention.

Systematic Modifications

As a mature submarine operator, the Indian Navy must, therefore, establish its own standards which can be incorporated in the submarine design, whether indigenous or imported because the operating environment, the demographic of the crew, the ambient conditions on board, the quality of the leadership, the motivation and morale are all typical to it. This would require extensive study and the findings may require a re-think on many aspects of submarining, some of which may need systemic changes which the IN should be agile and willing to adopt.

DEFENCE AND SECURITY ALERT

jungle warfare

WARRIOR CARE

PREVENTIVE

MILITARY MEDICINE Combatant can survive in the jungle by studying its characteristics, dense vegetation with limited visibility, heavy cross compartmentalisation, streams and rivers, heat and humidity, few roads, numerous tracks and limited communication, by undergoing strenuous drills that make them conversant with guerrilla warfare and low-intensity conflicts. The troops are trained in worse conditions they have to eat and sleep like animals.

ndia has faced Naxalite– Maoist insurgents for a long time. Besides this, the low intensity Guerrilla Conflicts and Special Military Operations like swift and clinical Surgical Strikes, demand that the combatants are fully trained and equipped for deployment at any locations, even in inclement weathers and remorseless terrains including jungles. Jungles can occur virtually on all landmasses and may incorporate numerous vegetation and land types in different climatic zones. Jungle warfare is a term used to cover the special techniques needed for military units to survive and fight in jungle terrain. Battlefield elements such as hothumid regions and challenging environments and terrains with stresses like lashing winds and torrential rains, etc. present environmental health threats, can prove lethal and adversely affect the performance of our soldiers.

Challenges Faced in Jungle Warfare

Dense vegetation hinders movement of soldiers making infiltration slow

and arduous. Warriors face other challenges like the excessive loss of body fluids due to perspiration, the increased concentration of the blood plasma and urine, the elevation of body temperature due to physical exertion at high external temperatures, the effects of the sun, and the cooling of the body surfaces by the relatively cool winds at night. All these tend to lower the overall immunity of the body. Further, jungle conditions impose logistic difficulties and limitations on igniting fire. Jungle environments can also be inherently unhealthy, with various tropical diseases that have to be prevented or treated. In Jungle warfare, soldiers encounter not only with enemies but also more formidable adversary in the form of climate and nature. Typically, jungles are overgrown dense thicket tangled vegetation at ground level and covered with or dominated by trees. Insect vectors, land leeches, microbes, fungus and poisonous snakes are other

August 2018 DEFENCE AND SECURITY ALERT

nuisance in jungles. Combatants must have basic knowledge of the fundamentals of personal hygiene and self-protection against poisonous plants, noxious insects, and venomous reptiles, for maintaining their health in the

Troops engaged in jungle warfare should exercise every precautionary and preventive measure in order to avoid injury and infection following insect bite/sting and vector-borne diseases adverse climate. Basic knowledge of preventive medicine can help protection against jungle diseases.

Insect Bite/Sting and Vector-Borne Diseases

Arthropods dominate the presentday land fauna especially in hot and

humid climate including marshy land. The insects like beetles, fire ants, bees, wasps, hornets and flies (sand fly, black fly, etc.) are menace and real nuisance in a jungle. They bite and sting to protect their hives or nests or when disturbed. Insects may bite by puncturing the skin with their mouthparts. Bites or stings from these species may usually cause only mild irritation, redness and swelling. Biting insects inject various substances such as anticoagulants (to prevent blood clotting) and vasodilators (to open blood vessels) in their saliva during feeding to ensure a flow of blood. The presence of these substances in the saliva can lead to local skin reactions, and rarely, systemic reactions (symptoms felt throughout the body) including triggering of anaphylaxis (serious allergic reaction) in the victim. Scratching of the inflamed irritation from the insect bite leads to inoculation of

the infectious organism into the host through resultant wounds. Therefore, bites/stings can result in local skin trauma, allergic reactions (ranging from small local reactions to life-threatening systemic reactions), secondary skin infections or transmission of infectious disease (vector-borne diseases). Death from bee stings is 3 to 4 times more common than death from snake bites. Protection from insect and tick bites is essential to help prevent vector-borne diseases. Bloodsucking insect or animal can be vector to a host of deadly diseases such as malaria, dengue, chikungunya, yellow fever and Zika, etc. (Table on the next page). There are many species of mosquitoes, some which bite during daylight (e.g.Â AedesÂ spp), others are more active from dusk to dawn (e.g. Anopheles spp). During the process of biting the causative organism may

August 2018

DR RAKESH KUMAR SHARMA The writer is Director, Defence Food Research Laboratory, Mysore, is a post graduate in Pharmacy from Panjab University, Chandigarh. He is Ph. D. from University of Delhi and elected fellow of five Professional/ Academic Bodies. Dr. Sharma has 20 patents and over 330 publications to his credit besides contributing 53 chapters in books and editing 14 books/monographs.

DEFENCE AND SECURITY ALERT

jungle warfare

WARRIOR CARE

Land Leeches

be deposited on the skin or into the bloodstream.

Protective Gears

Troops engaged in jungle warfare should exercise every precautionary Disease

Pathogen

Vector

Transmission

Malaria

Plasmodium falciparum, vivax, ovale, malariae

Anopheles spp. Mosquitoes

Anthroponotic

Leishmaniasis

Leishmania spp.

Lutzomyia & Phlebotomus spp.

Zoonotic

Trypanosomiasis

Trypanosoma brucei gambiense, rhodesiense

Glossina spp. (tsetse fly)

Zoonotic

Chagas disease

Trypanosoma cruzi

Triatomine spp.

Zoonotic

Dengue

DEN-1,2,3,4 flaviviruses

Aedes aegypti mosquito

Anthroponotic

Yellow fever

Yellow fever flavivirus

Aedes aegypti mosquito

Anthroponotic

Encephalitis (West Nile, Lyme, etc.)

Flavi-,alpha- and bunyaviruses

Mosquitoes and ticks

Zoonotic

Lymphatic filariasis

Brugia malayi, timori, W.bancrofti

Anopheles, Culex, Aedes mosquitoes

Anthroponotic

Onchocerciasis

Onchocerca volvulus

Simulium spp. blackflies

Anthroponotic

and preventive measure in order to avoid injury and infection following insect bite/sting and vectorborne diseases. Insecticides and insect repellents have been used for the control of these vectors as avoiding bites is the only means of prevention. Protection from insect and tick bites is best achieved by personal protective measures such as wearing protective clothing, using insect repellent and sleeping under impregnated bed nets. DRDO has developed Long Lasting Insecticidal Nets (LLIN) available under the name ‘Defender Net LLIN’ and are washproof till 20 times. These are impregnated with deltametrin - a synthetic Pyrethroid insecticide. Even customised head masks and gloves/socks can be made with this. Pyrethroid are used in very small quantities enough only for vector species and very safe for human beings. Vaccines or malaria prophylactic course should be taken wherever recommended before the crucial and long missions.

Leeches are extremely irritating and disgusting blood suckers in humid rainforest areas. While most leeches live in fresh or salt water, a small fraction of the blood-sucking

cigarette, salt, soap, or vinegar to the leech. Salt works for both avoiding and for removing leeches. Leeches found in tropical climates were found to drop off from the bite site if some salts are sprinkled

parasites are terrestrial that are one of the most annoying in damp marshy jungles where they can fall on you as you walk under them or brush past them or you can get them on you while you wade though streams or nallahs. Leech bites are generally alarming rather than dangerous, though a small percentage of people have severe allergic or anaphylactic reactions and require urgent medical care. Symptoms of these reactions include red blotches or an itchy rash over the body, swelling around the lips or eyes, a feeling of faintness or dizziness, and difficulty in breathing. Covering legs, arms and other patches of exposed skin stop these intruders from reaching your body. If you do find a leech attached to you, don’t pull it off, as the mouth parts can remain under your skin and leave a slowly healing granuloma, or lump. Common removal techniques are to apply a lit

August 2018 DEFENCE AND SECURITY ALERT

over it. Best method to apply is to take a good amount of salt onto your palm, add a few drops of water to just make it a bit of a paste, and then, marinate the sides of your shoes and the top portion with this paste. Anti-Leech Sock, Tobacco Sock and Lady’s Stockings are the other effective ways of preventing leech bite. During World War II, Japanese army used Dettol application on their hands, necks and legs to prevent leech bites. Herbal mosquito and leech repellent spray and Leech Repellent Cream, developed by DRDO repel the mosquito and land leech. The spray or impregnation can be applied on the socks or cloth material to deter the leeches. Spraying DEPA multi-insect repellents on to ordinary hiking socks is also useful.

Poisonous Reptile Menace

DRDO has developed herb/spices oleoresin based snake repellents in

the form of aerosol/powders effective against deadly poisonous snake including Spectacled cobra (Naja naja), Banded krait (Bungarus fasciatus), Monoocled cobra (Naja kaouthia), Saw-scaled viper (Echis carinatus) and Russell’s viper (Daboiarusselii).

Survival Issues in Jungle Warfare

The Wildwood Survival website contains information on wilderness survival skills from the viewpoint of the ancient philosophy of living in harmony with the Earth, which is what might be called “wilderness mind”. Food which is not in sealed, airtight containers, are subject to the rapid deteriorating effects of damp heat. Mess personnel must be especially watchful that food is not allowed to spoil and those storage areas are dry and airy. Rationing food and supplies is a must. DRDO has developed a number of light-weight ready-to-eat/ drink packaged precooked foods for jungle warfare including survival rations. Combatant can be trained on use of edible plants, fish, worms, frogs and even snakes and scorpions. The edible plants rich in phytochemicals and B vitamins, vitamin C, terpenes, flavonoids and other antioxidants which make them more useful in combat operations. Functional food to combat jungle warfare is another grey area being researched. DRDO has developed Asparagus racemosus based lehya, viz. Amruth raksha sanjeevini and Asparagus based ready-to-reconstitute powder as Anti-fatigue food with cardio-protective, anti-stress, antioxidant, performance booster, immune modulator, anti-hypertensive properties and helpful to increase performance enhancement and also proved to have relief in stress conditions to ensure the health and combat effectiveness. DRDO has developed a dark chocolate formulation, called choco whiz which contains ingredients that promote

wakefulness and sustained attention for longer duration. The chocolate provides complex carbohydrates and proteins as energy source, thus ensuring slow release of glucose into blood. This not only prevents sugar crash but also ensures sustained attention for longer time. The components of the chocolate increase the synthesis and release of dopamine in the brain and increase the levels of norepinephrine. Chocolate being a rich source of dietary tyrosine, leads to the increase in brain dopamine levels and therefore, promotes alertness. This chocolate also contains vitamins and antioxidants that combat oxidative damage to brain caused by prolonged periods of wakefulness. The composition of chocolate ensures that there is sufficient supply of macro and micronutrients to the system to maintain energy balance. It supplies body with nutrients that promote alertness and sustain it without boosting insulin. The phytochemcials present in blue berry, avocado, green tea, leafy green vegetables, omega-3 fatty acid rich fish, water, chocolates, flax seeds and nuts are reported to improve our concentration.

the extreme limits of soldiers. Troops are trained to feed on venomous vipers, dogs and monkeys as part of military exercises to sharpen their skills in jungle survival and combat.

Training for Jungle Warfare

Successful jungle combating emphasises effective small unit tactics and leadership. Prime duty of the Military Commander is to ensure that health and combat effectiveness of their troops is not compromised under such circumstances anytime so that the assigned mission under jungle conditions is effectively accomplished. Preventive or Preventative Military Medicine that focusses on the healthcare and aims at protecting, promoting, and maintaining wellbeing of soldiers, is very helpful for assuring health and well-being. In the context of jungle warfare, it means proactive approaches of medical practices and care of the warrior that are designed to avert and avoid undesirable harm. Military medical personnel should always be ready to serve their combat brethren by taking measures to prevent disease, disability, and death.

Combatant can survive in the jungle by studying its characteristics, dense vegetation with limited visibility, heavy cross compartmentalisation, streams and rivers, heat and humidity, few roads, numerous tracks and limited communication, by undergoing strenuous drills that make them conversant with guerrilla warfare and low-intensity conflicts. The troops are trained in worse conditions and have to eat and sleep like animals. They have to face difficult situations and hostile environment like war and are trained to enhance their skills like guerrillas. They are primarily trained in counterambush skills. The soldiers are trained to hide themselves in the forest which helps them to hide in the jungle warfare during war from the enemies. The jungle craft also tests

August 2018

Following units are specialised in jungle warfare in India: • COBRA (acronym for Commando Battalion for Resolute Action) is a specialised unit of the Central Reserve Police Force created to counter the Naxalite problem in India. • The Indian Army maintains an elite Counter Insurgency and Jungle Warfare School which is used to train domestic and foreign units in methods for countering irregular warfare. 21st Battalion of Parachute Regiment (India) was originally trained for use in jungle warfare. • The MARCOS is the special operations unit of Indian Navy and is well trained in jungle warfare

Logistics for Jungle Combating

DEFENCE AND SECURITY ALERT

armed forces

SOCIAL TOXINS

MILITARY I

ntroduction

MENTAL HEALTH: FIT TO FIGHT?

The armed force of any country is raised with primary goal of guarding the nation against external threats and maintains the territorial integrity on land, in air and at sea (1). The military man is considered physically fit and mentally robust due to tough selection, strenuous training and strict rules which transform him into battle-worthy and disciplined soldier. During service, the armed forces personnel are exposed to severe stress and strain due to inhospitable weather conditions, isolated posts, extreme high altitude or desert, combat environment and disturbed family life. Mental health issues become not only a matter of high significance but extreme priority for Commanders towards healthy work force. The time-tested combat training, unit ethos, camaraderie and mental health programme is keeping the morale high for Indian Armed Forces.

Present Scenario

Global - About 1.1 billion people worldwide are suffering from poor mental health and disability (2). The prevalence has alarmingly increased by 18% in the last decade as per latest estimates of WHO. The suffering is equally distributed in both high and low income group countries. If we look into statistics, mental health conditions like depression is only second to CAD as per WHO report 2016. Even in high income countries, nearly 50% of people do not get adequate treatment and across the globe the countries are only spending 1-5% of government health budget in mental health. India - A study by the GOI shows that one out of every sixth Indian needs mental health help. In India, 50% of corporate is under chronic stress with 30% having problems such as addiction and marital discord and 20% suffering from depression. The media referred the

August 2018 DEFENCE AND SECURITY ALERT

322 million

AIR MSHL (DR) PAWAN KAPOOR AVSM,VSM AND BAR FORMER DGMS (AIR) (RETD) findings of ‘National Mental Health Survey of India 2015-16’ as follows: ‘India needs to talk about mental illness’ (3). The lifetime prevalence of mental morbidity varies from 8.1% to 19.9% in different states of country. The age group between 40-49 years was predominantly affected by psychiatric disorders (4). Increase in invisible mental problems such as suicidal attempts, aggression and violence, widespread use of substances, increasing marital discord and divorce rates emphasise on the need to prioritise and make a paradigm shift in the strategies to promote and provide mental health services in India (5). Armed Forces - Armed Forces personnel are part of same social milieu and cut across many societies and community at large. They are not immune to mental disorders and bound to have stress, anxiety and other psychiatric disorders as seen in civilians. However, sound mental health programme and inbuilt ethos and discipline of armed forces keep them going. The military leadership and age old ethos is a big strength with comprehensive, continuous and sustained efforts at all levels. Notwithstanding this, the armed forces personnel do face stressors that are widely different from their civilian counterparts. These include prolonged separation from families, deployment in inhospitable terrains,

consistent vigilance of sensitive locations, low intensive conflicts and terrorist activities, etc. The training of armed forces personnel to a large extent makes sincere efforts to mitigate the unwanted effects of such stressors. It is, therefore, essential to first address the myths and facts associated with military mental health.

Myths and Facts about Military Mental Health

• M yth: There is a high prevalence of mental disorder, especially PTSD in armed forces. • Fact - Mental disorder affects about 1.1 billion population worldwide and the same is increasing alarmingly every year. However, in armed forces the prevalence is estimated to be 200-250 per lakh population which is far less than global and national estimates. Civilian PTSD (non-combat PTSD) is a reality in outside world. The stress and emotional outburst after sexual violence, threatened death, domestic abuse, rape and sexual assault is increasing every day. One out of every nine women develops PTSD in civil which are about twice the average of men. The PTSD is now more common in civil than the combat forces (6).

August 2018

The writer is an alumnus of AFMC (Pune), did MHA from AIIMS, DNB in Health and Hospital Administration, MMS, M Phil and MBA. He served in various professional and administrative appointments in the Army and superannuated from IAF as Director General of Medical Services and has more than 40 publications to his credit. He has been the architect of Cadre restructuring and Manpower augmentation in AFMS and has spearheaded the Mission Zindagi programme of IAF for augmenting the mental health of air warriors. He is the only AFMS officer to be awarded the COAS Interservice Integration Trophy in LDMC and Col Pyarelal Gold Medal in NDC.

GP CAPT SUNIL AGRAWAL DMS (H) & SR ADVISOR (CM) The writer is an alumnus of AFMC and presently posted as DMS (H) and Senior Advisor (CM) in IAF. He has been on deputation to Govt of Botswana and Assoc Prof in AFMC. He has many publications including chapters in the WHO text book of “Preventive Medicine & Public Health” and “Text book of Community medicine’’ for MBBS students.

DEFENCE AND SECURITY ALERT

armed forces

SOCIAL TOXINS

• M yth: There is a high rate of suicides amongst soldiers. Fact - There are more than 8,00,000 suicides per year worldwide out of which more than 1,00,000 are from India only. Globally, one person commits suicide every 40 seconds. Suicide is the second leading cause of death in 15-29 year age group. As per WHO data of 2015, the National average of suicides is 15.7 per lakh population whereas the suicide rate of armed forces is minimal and ranges between 6-9 per lakh population. The suicide in Armed Forces is not only a loss of trained manpower

depressed; it is a health problem resulting from changes in brain structure or function due to environmental and biological factors. The suppression of expression leads to depression.

Mental Health Programmes

Even though the incidence and prevalence of depression in the armed forces as well as suicides is much lower than the civilian counterparts and amongst the other armed forces personnel of more developed Nation States, every trained man / woman in the armed forces is important both for the country as well as for the forces.

The military leadership and age old ethos is a big strength with comprehensive, continuous and sustained efforts at all levels but has ripple effects on the morale of troops. Thus, each and every suicide is investigated, pondered and analysed for system modification. • Myth: The Mental Health Programme is not a priority in armed forces. Fact - The most effective and coordinated programme implemented at various levels of armed forces is mental health/ suicide prevention programme. The mental health is given top priority and is an important KRA of service Chiefs. • Myth: Depression is something that strong people can just ‘snap out’ by thinking positively. • Fact - No one chooses to be depressed, just like no one chooses to have any other health problem. People with depression cannot just ‘snap out’ their depression as someone with diabetes can’t just snap out diabetes. It is not a sign of weakness or laziness to be

The armed forces, have therefore, taken active steps that are dynamic in nature to ensure that not a single trained staff becomes victim of any mental health disorder that is preventable. The mental health/ suicide prevention programme is a top driven vertical programme where its implementation is planned and monitored by service heads. Various high-ranking committees (e.g. PERAC i.e. Psychological Evaluation and Remedial Action Committee in the Air Force) are formed in triservices which meet twice a year to discuss critical issues and crosscutting measures. The brief details of various activities conducted in armed forces are: • Employment of civilian psychological counselors in station for routine and high risk counselling. • Extensive Health Education Campaigns with sharing experiences, lectures,

August 2018 DEFENCE AND SECURITY ALERT

motivational talks. • I n house awareness movies depicting specific issues of armed forces. • Training of service personnel in counselling, identification of red flag signs and referral to psychiatric care hospital. • Welfare measures for families and dependents through wives welfare organisations. • Toll free 24x7 helplines for round the clock counselling and discussion. • Analysis and in-depth investigation of all suicides and attempted suicide cases. • Practice of alternate system of healing like Yoga, Art of living, heartfulness, etc.

Way Forward

The Indian Armed Forces is one of the most physically fit, highly disciplined, professionally competent and mentally robust military of present times. In spite of prolonged terrorism, extreme weather conditions, hostile environment, family separation and poor infrastructures, they are able to deliver highest security and peace with full zeal and fervor. The future of Indian combat will be scifi, cyber and mental warfare which will require some changes in overall leadership and man management. Some suggested changes are: 1. Dynamic and New Organisational Leadership: There is nothing wrong with current leadership. The acts of valour like high risk missions, surgical strikes, extreme risk natural calamity rescue missions and long-term terrorisms are examples of mentally and psychologically fit armed forces. The new age organisational systems are tending towards a state where the self-overtake the larger good, people become means to an end and ambition replaces prudence. It enforces a disintegration of your intellect, physical and spiritual being, emotions and so also of

the people you lead. A dynamic new age organisational leadership perfused with professionalism is the requirement of hour (7). 2. Digital and Social Media Impact: Relentless inputs through social media chase you without being mindful of your location, time of the day, engagement status, mental well-being and perception. The modern day reality is that we have more virtual friends then real ones and mostly fragmented inside. We forward likes and smileys but desist talking and caring. One feels being pulled in many directions. In this digital age, our communication, decisions and resulting actions have to be well-prepared, well-thought and coordinated. The armed forces function with age old ethos, camaraderie and regimentation without feeling the possibility of repercussions in an environment of â&#x20AC;&#x2DC;Virtual Socialismâ&#x20AC;&#x2122;. 3. Communication: Involvement and engagement with the troops is the primary requirement. Creating and fostering a culture where people do not fear to communicate their innermost feelings is essential to get honest inputs and feedback. The challenge for the leader is to set all round right balance in all vertical and horizontal communication. 4. Talking Treatment: Simply talking and sharing your feelings can be helpful. Sometimes, it is hard to express your real feelings even to close friends. Talking things through with a trained counsellor

or a therapist can be easier. It is always a relief to get things off your mind, which will help you to be clear in your life and about other people. There may be a counsellor at your unit or your doctor can refer you to a local counselling service. 5. Dignity and Self-worth: Recognition, appreciation, respect and humanity should be allowed to grow for creativity, personal growth and self-expression. Being strict and firm need not be complimentary with being rude and angry. Dignity and self-worth can do wonders to the summative confidence levels of organisation and must never be compromised. 6. Social Inclusion: Team sports and collective training can reform group support and coping skills of failure and inadequacies. These activities help us bond, share, fraternize and express ourselves contributing overall to the organisational well-being. 7. Preparing for Future: Modern warfare not only requires obedient and disciplined soldiers but people who are thinkers, contributors, empowered and not afraid to take decisions. Access to information, analysis, implementation and modification is practically available to all. We have to undertake paradigm shift of teaching our troops responsible use of social media, information, knowledge and skill to ensure constructive engagement.

8. Psychological First Aid (PFA): Psychological First Aid is a training programme that teaches members of the public how to help a person with mental health problem (including substance abuse). Like traditional first aid, Psychological First Aid does not teach people to treat or diagnose mental health or substance abuse. Instead, the training teaches people how to offer initial support until professional help is received or until the crisis resolves. Mental health problems are common in the community, so members of the public are likely to have first contact with people affected. It teaches how to recognise psychological problems, how to provide support and what are the best treatments and services available. The reduction of stigma and discrimination against mental health problems are collateral benefits of training of common people in PFA.

Conclusion

The Indian Armed Forces have always remained physically fit and mentally robust in the extremes of climate, inhospitable terrain, low conflict sustained warfare and social isolation. Over the years, the military ethos, disciplined training and timetested drills have not diluted and are still well engraved in their regimental culture uncontaminated with social toxins and media infection. In spite of unlimited fake news, myths and aspersions created on Indian Soldiers, the article brings out ground facts of one of the best forces in the world.

References: (1) Prabhu HRA. Military Psychiatry in India. India Journal of Psychiatry 2010 Jan; 52 (suppl 1) : S314-316 (2) Max Roser, Kennah Ritchie. Mental Health. Cited on internet at https://ourworldindata.org/mental-health. April 18 (3) Afshan, Y. India needs to talk about mental illness, The Hindu, 23 October 2016. (4) R Srinivasa Murthy. National Mental Health Survey of India 2015-16. Indian Journal of Psychiatry. Vol 59; Issue 1; page 21-26, 2017. (5) Suresh Bada Math, Ravindra Srinivasaraju. Indian Psychiatric epidemiological studies: learning from the past. Indian Journal of Psychiatry, 2010; Jan 52 (suppl 1) : S95-S103. (6) Non Combat PTSD.www.facesofptsd.com (7) Rajeev Hora. Human Centred Leadership : Thoughts on Suicide Prevention. Apr 2018.

August 2018

DEFENCE AND SECURITY ALERT

high altitude MORTALITY

MILITARY MEDICAL CHALLENGES Key to healthy and prolonged staying at these areas is to not only follow the guidelines strictly but also have good understanding of the problems by all concerned. The trust that soldiers have in medical backup and cooperation that exists between care takers, care providers and higher authorities have resulted in having very low incidences of residual morbidity and negligible mortality related to these conditions.

August 2018 DEFENCE AND SECURITY ALERT

ost-independence,

high at all times. Well, it is not

India has

easy for even the most trained

encountered three

and absolutely fit armed forces

conventional wars

personnel to guard the country

way back in 1962,

under such adversaries and it is

1965 and 1971,

equally difficult for the medical

involving not so friendly country

professionals also who need to be

China on northeast and definitely

always on their toes to fight the

hostile and enemy country,

battle against high altitude related

Pakistan in western and northern

diseases. Like it is important for

borders. Due to its geography, the

any soldier to be absolutely fit

major part of Indian borders in

mentally and physically before

northern India and northeast area

being posted to HAA, similarly it

are in high altitude. When we say

is equally important for medical

high altitude, it conventionally

teams as well to be fully fit and to

denotes 9000â&#x20AC;&#x2122; above sea level and

be well-trained professionally.

LT GEN BHUSHAN KUMAR CHOPRA PVSM, AVSM (RETD) The writer had an eventful tenure spanning almost 40 years in Armed Forces Medical Services. He acquired specialisation in Surgery and Orthopedics and was appointed as Commandant of Artificial Limb Centre, Pune, Army Base Hospital, Delhi and AMC Centre Camp; College, Lucknow. He has vast experience of military medicine in high altitude and low intensity conflicts trauma care. He was also instrumental in organising International Congress of Military Medicine held in New Delhi, Nov 2017.

naturally to guard the borders and country, large numbers of

I had three tenures, all in Ladakh

Indian Armed Forces troops have

region from my younger days

to stay in high altitude area (HAA)

when I was in medical and

all through the year braving the

infantry battalion in Leh and

High altitude illness is a collective term for a cluster of acute clinical syndromes that are a direct consequence of rapid ascent to high altitude

Kargil, respectively and then during thick of militancy in valley during Kargil War and finally, as Brigadier medical, responsible for deployment of medical resources at corps level in HAA and advisor to corps commander on all health issues of troops in HAA. It provided me great opportunity to understand and analyse the magnitude of problems our men faced while being posted at HAA

unfavourable weather and low

and also to find ways and means

atmospheric oxygen state. High

to minimise the health hazards

altitude may be of wet nature as

of HAA to the extent possible.

seen in northeast and is relatively

And, I must put it on record that

less difficult to manage or dry

commanders at all levels are

type like that is prevalent in

always concerned about the health

Ladakh and glaciers and this type

of their deployed troops and they

of HAA poses great challenge for

are always willing to help and go

medical fraternity to adopt and

all out in saving every life by all

practice preventive measures

means. To that extent, DRDO is

against high altitude related

also committed for the same cause

diseases and take effective and

in no less manner.

timely action to manage them to avoid morbidity and mortality and to keep up the morale of troops

Without going too much into technical aspects, I would be

August 2018

discussing the high altitude medicine as to be understood by a common man and appreciated by all concerned whether medical or administrative authorities so that best can be delivered to our spirited fighting troops and the soldier till the last post should feel confident and comfortable that there is a strong administrative and medical back up to take care of him in case of any high altitude related catastrophe and he will be promptly evacuated and taken to the appropriate medical set up for best possible care so that he also does not end up with any residual disability. There is time tested medical set up in place which is doing great yeomen service in most professional manner and is always being appreciated and applauded by all stakeholders from the highest placed commanders, armed forces medical authorities to civilian administrators as well.

DEFENCE AND SECURITY ALERT

high altitude MORTALITY

Basic Facts

of brain and lungs. But if proper

• High Altitude (9000’ – 12000’)

acclimatisation schedule is

• Very High Altitude

followed than even extreme high

problems and come out winner.

altitude can also be adapted

Common High Altitude Problems

without supplement oxygen.

Lot of work on high altitude

This process of physiological

medicine is done all over the

Barometric pressure falls

adjustment of adaptation of

world and if we talk about our

with increasing altitude in a

subsequent internal responses

continent, India and China,

proportional manner. Therefore,

to combat low oxygen

both have made great advances

though the O2 percentage (21%)

available at different levels

in understanding the issues

remains constant but due to

of high altitude without any

related to altitude problems and

rarified air the partial pressure

routinely use of oxygen from

found the best ways to fight

of oxygen decreases resulting in

external source and carrying

for the benefit of our soldiers.

primary insult of high altitude

on with routine activities

Establishment of High Altitude

i.e. hypoxia. At about 19000’, the

for any duration is called

Medical Research Centre (HAMRC)

barometric pressure is one half

acclimatisation. These integrated

at Leh in 1990 by DRDO in

that of sea level so ultimately

responses improve oxygen

consultation with office of Director

the oxygen available to alveolar

delivery to the cells through

General Armed Forces Medical

spaces in lungs and subsequently

adjustments in the respiratory,

Services (DGAFMS), physiologists

to heart, vessels and all organs of

cardiovascular and hematologic

and medical specialists have

body reduces considerably.

systems and argument the cellular

contributed tremendously in

oxygen uptake and utilisation

identifying number of high altitude

mechanisms. I shall not further

diseases and evidence based

Rapid ascent from planes to high

deliberates on complexity of

recommendations which have been

altitude viz., greater than 9000’

mechanisms related to medical

adopted to prevent, overcome and

can cause number of disturbances

physiology but rather concentrate

treat all problems related to the

ranging from mild sickness to

on common understanding and

area. Syndromes of high altitude

life threatening hypoxic edema

how best to fight out high altitude

are attributable to hypobaric

(12000’ – 18000’) • Extreme Altitude (above 18000’)

Acclimatisation

hypoxia. High altitude illness is a collective term for a cluster of acute clinical syndromes that are a direct consequence of rapid ascent to high altitude. The acute syndromes affecting brain are Acute Mountain Sickness (AMS) and High Altitude Cerebral Edema (HACE). Those affecting lungs are High Altitude Pulmonary Edema (HAPE) common illnesses are well illustrated in the table on the next page. These definitions on the diagnosis of altitude illness were adopted at the 1991 International Hypoxia Symposium held at Lake Louise in Alberta, Canada.

Lake Louise Consensus on the Definition of Altitude Illness

August 2018 DEFENCE AND SECURITY ALERT

The Lake Louise Consensus on the Definition of Altitude Illness In the setting of a recent gain in altitude, the presence of headache and at least one of the following symptoms:

AMS

Gastrointestinal (anorexia, nausea or vomiting) Fatigue or weakness Dizziness or lightheadedness Difficulty sleeping

Hurdles In spite of adequate knowledge and required medical infrastructure, there are still some hurdles which at times are detrimental to the health of troops at HA. Though, there is strict practice of inducting only otherwise fit personnel after thorough check up at planes and subsequently at various staging camps, there may be missed precondition which may predispose to such illness e.g., mild hypertension, early interstitial lung disease, diabetes and old coronary artery disease, etc. These personnel if inducted are at higher risk of developing HAPE and all these co–morbidies will be unmasked and then all these personnel will have to be evacuated to planes.

Can be considered “end stage” or severe AMS. In the setting of a recent gain in altitude, either:

HACE

The presence of a change in mental status and/or ataxia in a person with AMS Or, the presence of both mental status changes and ataxia in a person without AMS

In the setting of a recent gain in altitude, the presence of the following: Symptoms: at least two of: Dyspnea at rest Cough Weakness or decreased exercise performance

HAPE

Chest tightness or congestion Signs: at least two of: Crackles or wheezing in at least one lung field Central cyanosis Tachypnea Tachycardia

I have intentionally brought out these well-researched and documented criteria so that for understanding of even common person, attention should be paid to any individual suffering from any of the above symptoms and he should be immediately evacuated to medical set up for further evaluation and treatment. Occurring of high altitude illness has nothing to do with the fitness level of the individuals and it cannot be predicted in spite of all precautions and following strict acclimatisation process that who will suffer and who will not. Though most common serious high altitude

more susceptible to HAPE either due to some unknown mechanism or not adhering to acclimatisation schedule strictly and taking reinduction lightly presumably due to their earlier experience of not suffering any illness.

illness is High Altitude Pulmonary Edema (HAPE) which commonly occurs within the first 2 to 4 days of ascent to HA, most generally on second night but most dangerous illness is High Altitude Cerebral Edema (HACE) and is most common cause of death related to high altitude illness. It is a medical emergency and should be treated aggressively by descent of up to at least 2000’ in addition to giving oxygen. Other medicines and supportive treatment to be given as per advice of attending physician in hospital. At this juncture, it is also emphasised that re-inductees especially after leave and temporary duties are

August 2018

Second hurdle is to procure necessary equipments and ensuring that maintenance of these equipments is being carried out routinely and timely which is not always easy. Not only this, many a times operational requirements force the troops to move from HA to extreme altitude without being fully prepared for the same and the adversary of weather and other natural calamities at their areas like avalanches or landslides further impede early evacuation to the hospitals. Many areas on borders are inaccessible by any means during winters for months together and it is impossible to evacuate a patient even by helicopter or stretcher bearers. It

DEFENCE AND SECURITY ALERT

high altitude MORTALITY

is very demoralising for anyone not to be able to reach at medical facility due to adversary of nature. Availability of oxygen cylinders and HAPE bags in functional state at all times and at all posts is at times difficult to achieve. These are highlighted just to reiterate that all concerned should be alert and aware of these facts so that as far as possible preventive actions are taken without any shortcuts and no compromise is made on availability of required equipments.

Guru Mantra to Stay Healthy at HAA Though it is well known that no one is immune to get HA diseases, it does not mean that proper medical inspection is not done

history of AMS or HAPE. This is also recommended for people who visit for short durations for 2-5 days as tourists or otherwise. But it should be given with caution in patients with allergies to sulfa drugs as this drug also contains sulfur. In spite of all these, if one gets HA illness prompt and fast evacuation to high altitude hospital or straight away to well-equipped hospital in planes for definite thereuptic treatment should be done. At high altitude, there is a saying that ‘don’t be GAMA in land of LAMAs’. Being knowledgeable and aware about HAA and its consequences helps a person to be less susceptible to ill effects of HA. If one has to stay at HAA then staying healthy and happy is the mantra for enjoying life at high altitude.

Many a times operational requirements force the troops to move from HA to extreme altitude without being fully prepared for the same prior to induction and it should be ensured that only otherwise fit personnel are inducted at HAA. Secondly, ascent should be slow and gradual and laid down acclimatisation schedule is followed strictly. Proper sleep, adequate water intake, regular structured exercise, indulging in sports and other recreational activities and remaining in positive frame of mind are the keys for healthy and happy stay at HAA. A word about Diamox. This is a well proven drug of choice for prophylaxis against AMS. Indications for taking this drug on medical advice also include rapid ascent (in a day or less) to altitude greater than 1000’ and a past

Scope for More Though there is enough expertise and understanding of diagnosing and treating HA illnesses, we still need to focus on how best we can further reduce the incidences of these illnesses by adopting certain measures and innovations. Few such issues are discussed in following paragraphs: Creation of infrastructures with state-of-art medical facilities: There is requirement of creating advanced medical care centres at more forward locations so that effective measures can be taken in preventing and managing the problems before they can be evacuated to low altitude areas. Recreational facilities: At Leh,

August 2018 DEFENCE AND SECURITY ALERT

there are probably adequate sports and recreational facilities in form of lawn tennis, badminton, indoor gymnasium and golf course for officers and their families but there is definite requirement of creating these facilities for other personnel as well not only at Leh but at various other forward posts also. This will help in keeping troops more fit physically and less prone to the illnesses. Role of DRDO: DRDO can play significant role in combating HA problem by having their study and research teams at all important medical echelons so that their research can recommend drugs or compounds which need to be taken for prophylaxis or for cure purposes. At present, the teams of DRDO is researching more towards green revolution which is also a great positive step as this is likely to augment environmental oxygen concentrations thereby preventing many HA illnesses and problems.

Role of local high landers civilians: Local high landers are much less prone to HA effects due to their genetic and environmental adaptation and this human resource should be trained and employed locally in all medical setups to support and help the medical personnel in management of HA diseases. These civilian personnel can also be used on regular basis for casualty evacuation purposes.

Chronic Hypoxia: Generally, there is no mention or research on chronic ill effects of stay at high altitude areas on low landers who generally spend 2-3 years at a time at high altitude with some breaks in between during leaves etc. Loss of hair, forgetfulness,

drop in performances after coming back to planes and affections of certain dental and skin diseases, etc. has not been scientifically studied and not much is available in any Indian or western medical literature as to what extent chronic hypoxic condition make personnel susceptible to above problems. It is suggested that some interest to be shown in this aspect also and long term studies need to be done to establish or rule out effects of chronic hypoxia on low landers. But one fear or myth needs to be dismissed that there is no cause of worry on account of impotence and staying at HA does not in any way makes a person impotent.

Clothing, nutrition and sanitation: There are well established norms for clothing and nutrition and these form important part in preventing the high altitude illness along with maintaining good personnel hygiene by having regular bath and practice of washing hands. Similarly, sanitation issues also must not be neglected because all these small efforts help in overall reducing the incidences of such problems.

Futuristic Trends: There is lot of scope for refinement and improvements from their present status in many areas. There is need for speedy casualty evacuation from even difficult posts during winters and creating helipads at as forward as possible to ensure that no soldier suffer because of not being evacuated in time to the medical aid post. All over world, efforts are on to develop effective and light weight HAPE bags and clothings and DRDO is playing a key role in this area. There is requirement of having portable oxygen cylinders at all post and

at all times and establishment of oxygen generating plants as close to deployed troops as possible so that refilling of cylinders is done when needed. Medical authorities should organise more conferences in which expert should deliberate and educate all young doctors and paramedical staffs about complexities of high altitude diseases. An approach towards rapid acclimatisation is also an effort in this direction and early results are very encouraging and it is hoped that if this could be following for complete high altitude sector without any detrimental effects on soldiers’ health, it will go a long way in minimising high

trust that soldiers have in medical backup and cooperation that exists between care takers, care providers and higher authorities have resulted in having very low incidences of residual morbidity and negligible mortality related to these conditions. Acclimatisation and close observation of re-inductees is one important aspect in this regard. It should be ensured that suitable infrastructure is provided to the troops and all equipments related to high altitude medicines are of best quality with provision for round the year maintenance. In any battle against enemy ultimately I feel three things that matter. Firstly,

And keeping a soldier physically fit and mentally tough at high altitude areas at all times is probably the most daunting task faced by medical fraternity altitude illnesses and will be boon for operational requirements as well.

Conclusion There is no doubt that combination of adversaries of whether with hypoxic environment of high altitude poses great challenge for armed forces personnel and medical authorities alike in preventing menaces of HA related illnesses and also treating and managing the problems expediously to minimise morbidity and mortality related to these. Medical authorities and commanders at all levels are well aware of this and they leave no stone unturned to see that no life is lost because of weather or high altitude related issues. Key to healthy and prolonged staying at these areas is to not only follow the guidelines strictly but also have good understanding of the problems by all concerned. The

August 2018

the soldier should be physically fit and mentally tough. Secondly, his personal weapon must fire when needed and thirdly, if causalities happen they must be evacuated speedily without causing any further damage to the body at the right medical establishment. And keeping a soldier physically fit and mentally tough at high altitude areas at all times is probably the most daunting task faced by medical fraternity. A very high level of mental motivation, commitment and dedication is needed by all. I conclude by paying respect to both soldiers and doctors by quoting: “They both stood there day in, day out….. One stood between enemy and the nation… The other stood between death and life….. Soldier they called one, Doctor they called the other”

DEFENCE AND SECURITY ALERT

medical care PARAMEDICS

KNOW YOUR AFMS: HEALERS ALL THE WAY Team

AFMS has a glorious history of serving the Indian Armed Forces in war and peace as well as in missions abroad. The Army Medical Corps is known for its dedication, commitment and professionalism. The corps has been in the forefront in rendering yeoman service to the citizen during disasters and natural calamities as also extending medical care through “Operation Sadbhavana” in the remote areas of Jammu and Kashmir.

n April 3, 2018, the Army Medical Corps (AMC), which has also been extending service to civilians during disasters and natural calamities, celebrated its 252nd anniversary. The corps has come a long way from its modest beginning as the Bengal Medical Service on January 1, 1764, to become a comprehensive medical service in the country providing health services to the servicemen, veterans and their dependents. Armed Forces Medical Services (AFMS) is an inter-services organisation headed by the Director General Armed Forces Medical Services (DGAFMS) who functions directly under the Ministry of Defence. It is responsible for providing health care services to armed forces personnel, their families and other beneficiaries as mandated. The present shape and structure of the AFMS was given by the Armed Forces Medical Services and Research Integration committee chaired by Dr. B. C. Roy in 1948. Based on the recommendations of this committee, the Government of India integrated the Medical Services of the Army, Navy, and Air Force and created the appointment of DGAFMS on August 18, 1948 in the rank of Lt Gen and equivalent. The Director

General, Armed Forces Medical Services is the Medical Adviser to the Ministry of Defence and is also the Chairman of the Medical Services Advisory Committee (MSAC). Also, the DGFAMS is the cadre controlling authority for the AFMS.

History

Very little is known of the medical organisations that existed in the Indian armies in ancient times. However, Kautilya’s Asthashastra shows that during battles, physicians with surgical instruments (Sastra), medicines and drugs in their hands besides women with prepared food and beverages stood behind the fighting men.

The Army Medical Corps was formed as a wartime necessity for attracting suitably qualified men for service in a rapidly expanding army The Army Medical Corps came into existence as a homogeneous corps of officers and men on the pattern of the Royal Army Medical Corps on April 3, 1943, by the amalgamation of the Indian Medical Services, the Indian Medical Department and the

August 2018 DEFENCE AND SECURITY ALERT

Indian Hospital and Nursing Corps. The Corps was formed as a wartime necessity for attracting suitably qualified men for service in a rapidly expanding army.

Indian Medical Service

The history of the Indian Medical Service (IMS) dates back to 1612 when, on the formation of the East India Company, the Company appointed John Woodall as their first Surgeon General. The company expanded activities in various parts of the country which necessitated the formation and maintenance of regular bodies of troops in India. As a consequence, they commenced employing military surgeons from 1745 onwards. It was not until 1764 that these surgeons were made into regular establishment of the company’s armies. Thus, the Bengal Medical Service was formed in 1764, the Madras Medical Service in 1767 and the Bombay Medical Service in 1779, for the three Presidency Armies of Bengal, Madras and Bombay. The three medical services were combined into the Indian Medical Services (IMS) in April, 1886, under a Surgeon General to the Government of India. The medical services into a separate Medical Corps exclusively for the Defence Services was first conceived in 1939 with the outbreak of World

War II and with the formation of Indian Army Medical Corps on April 3, 1943, the extinction of the IMS as such were merely a matter of time. On August 14, 1947, the service was finally wound up and AMS was rechristened as Army Medical Corps. The then President of India, Dr S Radhakrishnan, had presented the Presidential colours to AMC on its raising day on April 3, 1966. AFMS has a glorious history of serving the Indian Armed Forces in war and peace as well as in missions abroad. The Army Medical Corps is known for its dedication, commitment and professionalism. The corps has been in the forefront in rendering yeoman service to the citizen during disasters and natural calamities as also extending medical care through “Operation Sadbhavana” in the remote areas of Jammu and Kashmir.

Maj Laishram Jyotin Singh was awarded Ashok Chakra, highest peace time gallantry award on January 26, 2011. He was born in 1972 in Manipur, India. He was commissioned in the Army Medical Corps in 2003, and he was posted with the Indian Embassy in Kabul in 2010. Just 13 days after his posting, a suicide bomber attacked the guarded residential compound where he was staying. Maj Singh confronted the terrorist unarmed and forced him to detonate his vest, which resulted in his death.

Conclusion

The medical components of the three wings of the armed forces have their Medical Directorates headed by the Director General Medical Services (DGMS) in the rank of Lt Gen (and equivalent). The DGsMS function under their

Combat Operations and Decorations

The Indian Army Medical Corps has seen combat and active operations in all operations and wars the Indian Army was involved, as part of combat formations or as hospitals apart from providing lifesaving services in tertiary/referral hospitals around the country. Capt. John Alexander Sinton of the Indian Medical Service was awarded the Victoria Cross during World War I in Orah Ruins, Mesopotamia while serving with a Dogra battalion (presently a mechanised infantry battalion). 80 Parachute Field Ambulance was the first medical unit to be raised for airborne operations and to provide medical cover to 50 Indian Parachute Brigade in 1941. Also, of interest would be that the first Indian paratrooper was a medical officer, Lt (later Col) AG Rangaraj, of 153 Indian Parachute Battalion in 1941. He later commanded 60 Indian Parachute Field Ambulance in Korea and was awarded the Mahavir Chakra, the second highest gallantry award.

respective Service Chief in matters of day-to-day administration, operational commitments and logistics and are responsible for the day-to-day administration and proper functioning of the Service under them. Any matter with inter services bearing is referred to the DGAFMS. With the strength of about 7,000 doctors, 700 dental doctors and 4,000 members from military nursing service, the organisations are providing comprehensive medical care both in peace and field and ensures that peculiar ailments and problems related to military services are managed in professional manner. For this, the team has infrastructure of almost 300 hospitals in both peace locations and field area and is adequately supported by one lakh of paramedical staff especially trained for routine and military medicine. AFMS gives due importance to the military medicine and its endeavour is to train every health care provider to understand and manage the peculiar issues related to military medicine. Due importance and priority is given to research projects related to military medicine. Regular training and practice drills are undertaken in understanding and combating Chemical, Biological, Radiological, Nuclear (CBRN) warfare related medical problems and managing disasters. AFMS is an active member of International Committee of Military Medicine (ICMM) and doctors and men are being regularly sent to other countries to get trained in military medicine. It was a unique and great honour for AFMS to have hosted the 42nd World Congress of the International Committee of Military Medicine from November 19-24, 2017, at Vigyan Bhawan, New Delhi. There are bound to be new challenges and greater expectations but AFMS is committed to this tough journey in most patient and professional manner.

August 2018

DEFENCE AND SECURITY ALERT

jungle warfare WONDER DRUGS

THERAPEUTIC MEDICAL STRATEGY Jungle terrain, often without good roads, is most of times inaccessible to vehicles. This makes transport of injured difficult, which in turn places a responsibility of on-the-spot combat casualty treatment. The medical person has to treat casualties while under fire, and face the urgency of getting the wounded to higher-level of care area with minimum morbidity and mortality. In situation of Jungle warfare, understanding the principles of how soldiers are to be treated at the point of injury is very important.

ungle warfare is

Jungle terrain, often without good

has been to make an all out effort to

defined as the military

roads, is most of times inaccessible

solve the medical and health related

activities and tactics

to vehicles. This makes transport

problems of troops.

involved in fighting in

of injured difficult, which in turn

jungle terrain. The war

places a responsibility of on-the-

The main battlefield emergencies

here is fought under

spot combat casualty treatment.

to be taken care are (1) Bleeding,

extraordinary circumstances and

The medical person has to treat

(2) Sepsis, (3) Shock/Hypovolemia

the troops posted here are primarily

casualties while under fire, and face

and (4) Pain. Therapeutic Medical

trained in counter-ambush skills.

the urgency of getting the wounded

Strategy in Jungle Warfare is to stop

The soldiers are trained to hide

to higher-level of care area with

the bleeding, avoid sepsis, maintain

themselves in the forests during

minimum morbidity and mortality.

blood volume and alleviate the pain.

attack from the enemies. The jungle

In situation of Jungle warfare,

warfare tests the extreme limits of

understanding the principles of how

INMAS has developed a number

soldiers. They have to face difficult

soldiers are to be treated at the point

of life saving solutions in terms

situations, eat and sleep in worse

of injury is very important. Better

of research drugs & devices,

conditions and hostile environment

pre-hospital care reduces morbidity

augmented by reverse-engineered

like war.

and mortality.

products for the combat casualties

Most of the times there is just one

Institute of Nuclear Medicine and

Wound Instant Sealants,

Medical Personnel and medical

Allied Sciences (INMAS) is the only

Battlefield Antiseptics, Battle

bag to take care in case of combat

medical lab of DRDO. It has been

Field Intravenous Fluids, Battle

casualty. Numerous challenges are

entrusted with R&D in number of

Field Instant Pain Killers, and

faced by medical personnel providing

areas of concern to Defence Sector.

Special Dress Material would be

care under battlefield conditions.

This includes Drug Development

discussed. These are innovations/

Much is to be done in a short

in non-commercial niche areas like

import substitutes made using

amount of time for the wounded.

Combat Casualty Care. The goal

indigenous material and technology

during jungle warfare. Bleeding

August 2018 DEFENCE AND SECURITY ALERT

and have been made cost-effective.

1. Bleeding Wound Instant Sealants: Chitosan Products

Lyophilized Chitosan wound covers are suitable for sealing superficial wounds and burns. They are also used as a topping on deep wounds

Statistics show that 90% of

packed with absorbent materials.

casualties in a battle field that die,

Bleeding time gets reduced by almost

do so before they get medical care

50%. Wound cover application

and 94% of these die because of

gives clean bloodless wound that is

hemorrhage. The first two steps

psychologically beneficial.

in combat casualty care are to

DR MANJU BALA POPLI

determine if the patient is breathing

Chitosan Gel is suitable for sealing

and then stop the bleeding.

wounds by twin action: haemostasis,

Chitosan is a natural biodegradable

by chemical action, and by filling

polymer with wide applications in

action. It can be used for wounds

pharmacology sector. Few of the

on the limbs, and also cavities such

chitosan products for therapeutic

as abdomen and thorax. The gel

use in case of jungle warfare

is poured out into the wound and

are Chitosan Wound Dressings;

held with physical pressure for few

Lyophilized Chitosan Wound Cover,

minutes till the bleeding stops. It is

Chitosan Gel and Chitosan Dry

topped by chitosan wound cover. If

Gel Injector for Cavities. Chitosan

the wound is deep, then fillers like

forms a film over the wound and

silk / cellulose granules may be used

this coupled with platelet and RBC

after chitosan gel. Chitosan gel is

aggregation stops the bleeding. Its

safe for facial wounds and those on

antibacterial and wound healing

mucus membranes.

The writer has in her credit 28 years of academic and clinical experience. She has been a part of various health projects undertaken by national as well as international organisations. She has been awarded 8 times at national and international forums. Presently, she is a joint director in Department of Radiological Imaging, Institute of Nuclear Medicine & Allied Sciences (INMAS).

property are of added benefit. Chitosan Dry Gel Injector for Cavities Chitosan Wound Dressings are made

is chitosan powder packed in an

by embedding medical gauze into

injector device with membranous

chitosan gel. They are used for small

diaphragm. The Impinger is pushed

cuts/ lacerations.

down after putting the syringe deep

DR ASEEM BHATNAGAR

inside the bleeding wound. The pressure on syringe bursts open the diaphragm releasing the powder. The external pressure is applied to stop the bleeding. It is topped by chitosan wound cover.

2. Battlefield Antiseptics: HOCl (Hypochlorous Acid) The Wonder Drug HOCL, a natural endogenous constituent in human and animals, is an important part of Fig 1. Chitosan Wound Dressing, Lyophilized Chitosan wound cover, Chitosan Gel and Chitosan Dry Gel Injector

the immune system. It is produced by neutrophils. On invasion of the cell by a bacteria/ foreign substance, there is initiation of

August 2018

The writer is currently working as Radiation Safety Officer in DRDO. His areas of specialisation include Nuclear Medicine, Thyroidology, Drug & Biomedical Development. He has over 150 peer reviewed papers and has filed for 30 patents.

phagocytosis. Large quantity of superoxide is produced which is broken down and converted to HOCl. The HOCl molecule penetrates the bacterial cell wall and destroys bacteria engulfed by the neutrophil. Despite the substantial activity of HOCl against microorganisms, it is not

DEFENCE AND SECURITY ALERT

jungle warfare WONDER DRUGS

cytotoxic to human cells because of its endogenous presence. Jungle warfare wounds have significant infection risk. The standard approach is to treat with antibiotics. However, overuse and misuse of antibiotics is breeding resistant strains of superbugs. A safe and effective alternative method for managing infected wounds is by using a more nontraditional cleansing agent. While the use of HOCl does not obviate the need for antibiotics, it augments treatment and speed of wound healing. Undesirable side effects and antibiotic resistance gets reduced.

bacterial toxins or to mitigate the prolonged and potentially destructive immune system response to bacteria and their toxins. Pure 0.01% HOCl is well tolerated by human tissues and has both broad-spectrum antimicrobial activity and can rapidly neutralise bacterial toxins. Some wounds do not undergo an orderly set of stages of healing and become chronic. Chronic wounds, and infections associated with them, are responsible for a considerable escalation in morbidity and the cost of health care. Diabetes, venous stasis, peripheral vascular diseases and pressure ulcerations can result in chronic wounds. An open wound is a favourable niche for bacterial colonisation and infection. There is formation of Biofilm, a complex structure of microorganisms generating a protective shell, allowing bacteria to collect, proliferate and adhere to the wound. Biofilm is an impediment for healing of wounds. It forms a physical barrier to bacteria from an external environment,

Fig 2 . HOCL A rapidly progressing bacterial infection of soft tissues affecting war injures is necrotizing fasciitis. Bacterial toxins cause local tissue damage and necrosis, as well as blunt immune system responses. A self-propagating cycle of bacterial invasion, toxin release and tissue destruction can continue until substantial amounts of tissue become necrotic. Neutralization of bacterial toxins improves the results. While existing treatment places substantial emphasis on rapid eradication of the bacterial infection that has initiated the necrotizing fasciitis, there are few attempts to either neutralize

leading to an increase in virulence and antibiotic resistance. In one of the clinical trials in USA in 2015, use of the hypochlorous solution as part of a wound care regimen, promoted wound healing and decreased the use of antibiotics in 41% of patients. Wound Clinics and Vascular Laboratories, USA, published a research article (Journal of the American College of Clinical Wound Specialists 2016) -Effects of Hypochlorous Acid solutions on Venous Leg Ulcers. The researchers concluded that the care protocols which clean, debride, pack and dress with hypochlorous acid

August 2018 DEFENCE AND SECURITY ALERT

solution reduce the effects of some comorbidities and accelerate healing. HOCL solution is a generic antiseptic marketed in India at 100 ppm. At more than 300 ppm, it is potent and destroys most microorganisms, thus qualifying as a battlefield antiseptic. It is more efficacious, safe and cheaper than povidon iodine. It contains OCl, liberates nascent oxygen and chlorine in contrast to other antiseptics which generally liberate only one species. The triple oxidizing attack on bacteria and immediate action makes is more effective. Data suggests that it is safe on human conjunctiva, skin and raw tissue. INMAS has produced safety and efficacy data that was instrumental in getting marketing approval at a concentration which makes it particularly useful in extensive, dirty and chronic infected wounds.

3. Battle Field Intravenous Fluid: Glycerated Saline It may not be safe or feasible to give blood / plasma / colloidal fluids in pre-hospital sites in case of trauma with extensive blood loss. Efficacy of Normal Saline is limited. Glycerated saline is a marketed product traditionally used for managing brain edema. INMAS has researched over the fluid and found that; (a) it enhanced blood pressure twice the level achieved by normal saline in hypovolemic models, and (b) enhances survivability to more than twice the level as achieved by normal saline in lethal blood loss animal models. Marketing approval was given for its expanded use based on INMAS data. Due to hygroscopic behaviour and micelle formation, Glycerin provides oncotic

pressure in addition to osmotic pressure. This causes transfer of fluid from edematous compartment to the vascular compartment. This reduces inflammation in the traumatic injuries and transfers the ‘waste’ fluid from edema to vascular compartment. This can be lifesaving, particularly if the traumatic edema is in the brain or lungs, and in hypovolemia.

4. Battle Field Instant Pain Killers: Nalbuphine A strong pain killer is required to alleviate the pain of brutal and mutilating war injuries. Severe mutilating trauma calls for efficient management of pain. Morphine is the most potent and effective strong painkiller. Its greatest disadvantage is its addictiveness. Patients receiving morphine, even in healthy prescribed doses, can become physically dependent on the drug. It causes fatigue, inattentiveness and mood swings. Morphine also decreases a person’s ability to perceive and respond. It is also a

Fig 3. Glycerated Saline Glycerated saline can be given in (1) Traumatic injuries, with massive blood loss, along with saline as a pre-hospital treatment and (2) Extensive edematous injuries. Glycerated saline does not freeze till -180C. Therefore, it is useful at high altitude. Normal saline freezes around -80C. In-vitro and In-vivo studies have shown that though glycerine is biocompatible and is a regular excipient of injectables and infusion products, contact with red blood cells in high concentration may cause hemolysis. A single dose of 100ml should be given as a slow infusion. A combination of glycerated saline with Mannitol is preferred. There is no claim to replace blood / plasma which are the preferred IV fluids. The only claim is that it is

respiratory depressant. Nalbuphine is a potent semiopioid analgesic. It is as potent as morphine without its associated side effects. 10mg injection

Fig 4.Nalbuphine injection, Nasal Drops and Nasal Spray

Nalbuphine hydrochloride (intramuscular / intra-venous) is a marketed formulation given

drugs fast to the CNS. Therapeutic

for moderate-to-severe pain

dose is known to build up in the

control. INMAS has developed

CNS within 5-7 minutes using this

and characterised a new route

route, which is even faster than

(submental/sublingual) that

the IV route. However, the route

appears feasible for field use by non-medical personnel. Submucosal space offers great advantage compared to intramuscular route for injecting emergency drugs: (a) fast absorption due to more vascularity, (b) painless route, and (c) safety in terms of infection.

should be used only occasionally for emergency as continuous use may predispose to infection. We have tested nalbuphine’s feasibility as a drug for this route and found it eminently suitable. The main medical advantage is on-spot fast treatment by non-medical

better than normal saline alone, in

INMAS has also developed

the battle field. Glycerated saline has

Nalbuphine Nasal Drops and

life-saving capacity in short term, to

Nalbuphine Nasal Spray in

have time in hand for the Medical

accordance with its industrial

personnel till the patient reaches a

partners. Olfactory nerve canal is

higher care facility.

a well-known route for delivering

August 2018

untrained personnel.

5. Special Dressing Material: Absorptive / Medicated Dressing material for bleeding wounds

DEFENCE AND SECURITY ALERT

jungle warfare WONDER DRUGS

Normal cotton dressing used for bleeding wounds has suboptimal absorptive capacity and is soiled after some time. Replacing cotton with a higher absorptive material is desirable in cases of excessive bleeding. Sanitary napkins and diaper industry uses absorptive substances that can absorb significant amount of fluid and allow only one way movement of the fluid. Absorptive, Cellulose fibrebased wound dressings have been made with similar principal and are more effective in stopping the bleeding and keeping the wound clean. Additionally, antiseptics/ antibiotics /curcumin can be impregnated in the dressing which acts as a slow drug release system. In heavily bleeding deep wounds, putting a dressing over the wounds can actually enhance the bleeding by â&#x20AC;&#x2DC;sucking outâ&#x20AC;&#x2122; the blood. Conventionally, simple gauze pieces are packed inside the bleeding cavity and dressed by a pressure bandage.

An indigenous medical kit being explained to the then Defence Minister of India

More safe and effective is to put in a long stuffed absorptive strip

rather than individual gauze pieces.

are presented above, indigenously

It has 4-5 times higher capacity to

developed at INMAS, an effective

absorb blood. Packing also creates

and efficient wound care strategy

physical pressure to stop bleeding.

can be formed.

On removal, there is no possibility of dressing material being left in the

Conclusion

wound/cavity by mistake.

The products developed by INMAS for Jungle Warfare /Combat

Fig 5. Absorptive/ Medicated Dressing material for bleeding wounds

Wound healing is a complex

Casualty Care are now at the stage

process and is a topic of ongoing

of implementation. Animal and

research worldwide. In an effort to

preliminary human data has been

address this, the European Wound

created and documented. These

Management Association set up a

products are innovations/import

Patient Outcome Group to produce

substitutes made using indigenous

recommendations on clinical data

material and technology. They are

and collection on wound care which

also cost-effective. CAPF / Ministry

was published in Journal of Wound

of Home Affairs have recommended

Care in 2010. Armed with the

their induction into the paramilitary

knowledge on different interactive

forces while efforts are on with

dressing materials two of which

Services for induction.

August 2018 DEFENCE AND SECURITY ALERT

evacuation INTENSIVE CARE

LIVE TO FIGHT ANOTHER DAY Flight surgeons of the IAF receive good training as well as live experience to execute the evacuation effective and safe for the patient. Aircraft have finally reached the capability of the true flying Intensive Care Unit, and plans are afoot to even have a capsule “roll on – roll off” Operation theatre to do definitive life-saving surgery while in flight. Airbus Industrie and Lockheed have already made such concept Operation theatres and they are being evaluated.

AIR MSHL ANIL BEHL AVSM (RETD) The writer is an alumnus of Armed Forces Medical College, Pune. He specialises in the field of General and Plastic Surgery and has served Indian Air force for 39 yrs. As head of medical services of IAF, he has been awarded Ati Vishisht Seva Medal in 2010 for his meritorious services. He was also appointed Honorary Surgeon to President of India in 2013. Currently, he is Director, Plastic & Reconstructive Surgery, Fortis Memorial Research Institute, Gurgaon.

ar is serious

off the battlefield was under his

future operations of the army,

business,

own power, or with the aid of a

and in some states were costly,

people do

comrade. Even the ancient Greeks

due to war pensions or payments

get hurt.

and Romans, who had military

required, which often were not

Every

surgeons and occasionally field

paid to the relatives of those killed

soldier

hospitals attached to their forces,

in combat. Further, evacuation of

going into war knows that and has

failed to provide any viable means

the wounded required that other

some trepidation (Well, maybe not

of evacuation.

combatants be removed from the

the Gurkha as immortalised by our

fight to provide their transport, or

foremost soldier Sam Bahadur).

Historically, the advent of the

tied up transport needed for other

If he can be assured of a resilient

first truly organised military

military functions. To an extent,

and effective medical help, then

medical systems which included

the ability to move patients

the trepidation eases.

evacuation capabilities was found

from the battlefield developed

in the army of the Byzantine

much more slowly than did other

Empire. Scribones, stationed

medical capabilities in the

a hundred meters behind the

18th century armies.

Defunct Evacuation Techniques In the wars fought during earlier

action, served as corpsmen

times, there was no organised

with the mission of rescuing the

The Early Days

system for evacuating wounded

wounded during battles. They

Napoleon’s surgeon-in-chief,

from battlefields. During these

were paid for each casualty

Dominique Larrey, recognised this

wars, the slightly wounded

they rescued. “Natural triage”

and organised the first structured

used to get enslaved, and the

decided which casualties would

casualty evacuation. He

seriously wounded were killed

receive care and which would

introduced dedicated horse-

or left to die on the field. The

not. Wounded soldiers who did

drawn carriages that entered the

only way a casualty could get

live were simply a hindrance to

battlefields to retrieve and care for

August 2018

DEFENCE AND SECURITY ALERT

evacuation INTENSIVE CARE

ships and aircraft, each and

christened “Flying Ambulances”

every modality of transport has

Military medical leaders then

which as originally designed was a

been used for the carriage of

worked on the growing realisation

light wagon used to take surgeons

casualty. Increasingly, aircraft

that the goal of military medicine

forward to the casualties, rather

are being used for patient

should not be merely to provide

than the reverse. However, in

transportation. The main

austere medical care but rather

his later years, Larrey developed

advantage of air evacuation is the

these “ambulances volantes” into

speed. Rotary wing aircraft have

patient-carrying vehicles, which

helped overcome the barriers

actually had provisions for en

of terrain. The main disadvantage

route care, and thus, engendered

is of resource availability, the

the beginning of true patient

availability of the aircraft, the

evacuation systems. World War

weather conditions, risks in the

II saw the first widespread use

theatres of war, and the space and

of motorised field ambulances to

weight hauling limitations. Fitness

transport casualties, helicopters

for air evacuation has to take into

were introduced during the Korean

consideration the effect of the

War and perfected during the

hypobaric environment on the

to provide the highest-quality

Vietnam War. This had resulted

medical care possible in an

in dramatic decrease in the time

austere environment. This ushered

taken for wounded soldiers to

in MEDEVAC—the difference

receive treatment, a fact often

hinging on the medical care

credited with the improved

provided en route. This requires

casualty survival rates. As a

synchronisation between skilled

result, of those evacuated who

persons tending to the casualty

lived to reach a medical facility,

and the infrastructure available

about 98% survived, hospital stays

to him, be it the standardised,

were reduced, and the overall risk of dying in combat if wounded was reduced to less than 1/2 of the

physiologic processes, especially since they are compromised in an

risk during WWII.

injured/sick patient

We must appreciate that wounded

Like everything else, air

soldiers must still be transported, usually by manual or litter carriers, to a vehicle or helicopter waiting a safe distance from the conflict. Carrying an 80 kg soldier with another 20 kg of critical gear over rough terrain remains an exhausting task with few

evacuation too had its share of detractors. When it was proposed during WW I, the response of the War Department was “the hazard of being severely wounded was sufficient without the additional hazard of transportation by airplane.” We have progressed

technological advances.

from the days when the casualty

Air Evacuation

the cockpit and evacuated. It was

From human back-pack, stretcher with bearers, mule saddles, animal drawn carts, motorised land transport, boats,

MEDEVAC vs CASEVAC

the wounded soldiers. These were

was strapped to the wing next to only the force of circumstances combined with improving aviation technology that the opposition of the conservatives could be overridden.

August 2018 DEFENCE AND SECURITY ALERT

dedicated vehicle or the life-saving equipment on board adequate to tackle exigencies en route. In easier terms, CASEVAC is using the next conveniently available opportunity to shift the patient with stabilisation being done only at the definitive centre, MEDEVAC, on the other hand, is by a dedicated mobile vehicle (terrestrial, water or airborne) and skilled personnel who are able to stabilise the patient while still in transit so that he has the best chance of full survival. The key principle is that MEDEVAC itself is a medical “intervention” or procedure subject to physician judgment. When and where a patient is evacuated, and

by what means, should always be

This determines the priority

was indigenously up scaled from

determined by a physician, either

of evacuation

a mere Patient Transport Unit

directly or through delegation

(PTU) into a Critical Care Air

by protocols and standing

Modern Intensive Care

operating procedures. Geneva

We are now truly able to say

Multiple such teams have now

Convention also differentiates

“Patients are not cargo; patients

been trained, equipped and

between Medevac and Casevac.

are not passengers; patients are

have been optimised during IAF

The convention mandates that

patients.” Modern armed forces,

exercises. Almost each type of

MEDEVAC aircraft and ground

including India, have moved on

transport aircraft has been fully

transport be unarmed and well-

to MEDEVAC with skilled teams

deployed to carry a full load of

marked. Firing on “clearly marked

and infrastructure. Each armed

casualties and the CCAT team

and identified” MEDEVAC vehicles

forces person carries a first aid

has been on board to provide

would be considered a war crime

kit including dressings to stop

effective treatment in fli fght

under Article II of the Geneva

bleeding, a pain killer and an

stabilisation. Flight surgeons of

Convention.

antibiotic etc. plus the training

the IAF receive good training as

in first aid. A few selected ones

well as live experience to execute

amongst them are then designated

the evacuation effective and safe

Once the casualties are identified,

as Battle Field Nursing Assistant

for the patient. Aircraft have

the resources are matched to the

(BFNA) and provided additional

finally reached the capability of

need. Commonly the resources

training as well as medical

the true flying Intensive Care

are overwhelmed, this is when

equipment.

Unit, and plans are afoot to even

The Evacuation Process

the armed forces apply Triage

Transport Team (CCATT).

have a capsule “roll on – roll off”

(literal meaning = to sort). Triage identifies the most severely injured patients with the greatest chance of surviving. Weightage is given to both the severity of the injury as well as the chances of survival. This means there may be a patient with a very severe injury (e.g. a head injury with exposed brain matter) where the chance of survival is lower compared to the others, he gets a lower priority. The prioritisation score is applied as a colour coded disc and affixed to the patient for ease of identification in the chaotic state. Red is commonly used to identify patients who must be transported immediately. Yellow is typically used to identify patients who are urgent, but could be

The IAF too has adapted to

Operation theatre to do definitive

transported in a second group.

these requirements. The first the

life-saving surgery while in flight.

Green tags indicate non-life-

portable intensive care unit

Airbus Industrie and Lockheed

threatening injuries, and black or

called LSTAT (Life Support for

have already made such concept

grey tags identify patients who

Trauma and Transport) unit was

Operation theatres and they

are found to be deceased.

imported over a decade ago. It

are being evaluated.

August 2018

DEFENCE AND SECURITY ALERT

evacuation INTENSIVE CARE

Aero-Medical Considerations Air Evacuation causing changes in

on breathing and blood 2.

Inaccurate delivery of tidal

circulation.

volume in mechanically

Swelling of limbs beneath

ventilated patients.

pressure with increasing altitude

a fitting plaster cast which

10. Miscellaneous Problems.

affects several physiological

can result in pinching off

11. Exhaustion of oxygen

processes, as well as the

the blood vessels/ nerves.

functioning of life support and

supply. 12. Disposal of patient body

Expansion of air

monitoring equipment. The low

filled cuffs and body

atmospheric pressure can lead

cavities due to reduced

to expansion of trapped gases in

environmental pressure.

In the past, the hazards of air

Nausea, vomiting because

evacuation precluded several

effects. With the availability

of motion sickness and/or

medical conditions. The trained

of skilled attendants, special

abdominal distention.

and expert flight surgeons’

Difficulty in manual

groups have been able to tackle

care we have, the air evacuation

measurement of pulse

almost all of them so that almost

has become safe for almost any

and blood pressure due to

every patient can be offered the

noise/vibration.

advantages of speedy evacuation

Inaccurate reading of

and the best chance for survival.

automatic non-invasive

Special measures include:

blood pressure.

•

the body with serious deleterious

preparations and anticipatory

fluids and excreta.

Patient Litters in a C-17 Globemaster type of casualty. In the IAF, the flight surgeons and their teams

like the CCATT are trained in air evacuation. 7.

a chest tube to neutralise

Special attention is paid to

interference between

the pressures across a

anticipate and pre-empt

avionics and monitors.

Pneumothorax.

situations like: 1.

Introducing and maintaining

Electromagnetic

Hypoxia and its effects

Difficulty in hearing audio alarms.

August 2018 DEFENCE AND SECURITY ALERT

•

Careful positioning of patient to avoid rise in intra cranial

•

pressure (ICP).

fighting troops, who perceive that

viable. It became evident that

Maintaining central venous

they will be cared for, and makes

the evacuation of patients would

pressure in cases of acute

everything worth creating all

become the norm, not only for

blood loss with haematocrit.

the resources.

their sake, but also to de-clutter

Having pressure bags handy to •

•

the operations areas. Thus, the

speed up rate of flow.

Flying into an active landing

concept of putting large medical

Patients with cardiac rhythm

zone to pick up wounded is a

establishments on the ground

problems are kept connected

dangerous job. Data from the

in the forward area is rapidly

to automatic defibrillators.

Army Aeromedical Evacuation

losing favour, in light of improved

Congestive heart failure with

in Vietnam, “... slightly more

evacuation systems. For rapid air

acute pulmonary edema

a third of the aviators became

evacuation, it is obvious

patients are placed on

casualties in their work, and the

that air supremacy will need to

ventilatory support.

crew chiefs and medical corpsmen

be maintained.

Spinal injuries as well as all fractures are immobilised. A note of caution: Pneumatic splints also change pressures during flight, hence they should be avoided. Even blood

The ability to move patients from the battlefield developed much more slowly than did other medical capabilities in the 18th century armies

pressure cuffs are affected. •

•

Patient is monitored regularly

who accompanied them suffered

and oxygen saturation is

similarly. The danger of their

maintained > 90% ( by

work was further borne out by the

supplemental oxygen if

high rate of air ambulance loss to

need be).

hostile fire: 3.3 times that of all

Chemical injections are

other forms of helicopter missions

given to patients with acute

in the Vietnam War.”

From the olden days when a liability to today when military leaders realise the value of casualty evacuation as a force multiplier in war reminds me of the quote by Gen George S Patton,

psychosis for the duration of the flight.

casualties were considered to be

“Patriotism is not dying for your

CONCLUSION

country, patriotism is making the

Present evacuation trends

other B****** die for his country.”

Close liaison between the aircrew

indicate that both air and ground

and the medical team cannot be

ambulances will serve in the

over emphasised – what Cabin

battle areas of the future, but

altitude to be maintained keeping

the increased depth, width and

both the medical as well as the

complexity of the operational areas

operational factors in mind,

indicates a recurring need for both

Diversion to another airfield if so

lateral and rearward movement.

Crystal Gazing The next paradigm could be to establish Formula 1 race type of “Medical Pitstops” with multiple teams working simultaneously to complete the task at hand and

obligated, etc. Operation Desert Storm was the

if possible, even turn around

International data indicates that

first to demonstrate that the

the skilled soldier to complete

Casualty survival rates can reach

concept of having large medical

the fight. Would it be possible to

90% if MEDEVAC were called and

facilities forward which could

reduce turnaround time to hours

pick up the casualty within 1.5

provide definitive surgery on all

rather than in weeks or months?

hours from incident. This has a

patients and hold them until

I, for one, am looking forward to

huge morale boosting effect on the

they were “stable” was no longer

seeing that.

August 2018

DEFENCE AND SECURITY ALERT

lethal diseases ARMED FORCES

HIPPOCRATIC CODE IN PRACTICE I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug. — World Medical Association version called the Declaration of Geneva. 48

August 2018 DEFENCE AND SECURITY ALERT

he requirement of

danger. Aviation, too, has its own

medical evacuation

specialisation in medicine.

quickly acquired a

different dimension

The central theme of military

because battle

medicine is to conserve manpower

casualties and

and such has been the effect of

the consequences of a rapid

measures adopted by military

deployment of unacclimatised

establishments (especially in the

personnel into high-altitude

perfervid European context) over

terrain had to be dealt with on

the millenium that it came about

priority. All along from the plains

that more soldiers died from

area of Jammu in the south to

diseases rather than

the mountains of Leh and Ladakh

gunshot wounds.

in the north, the Indian Armed

Forces had to switch quickly to

The focus of attention remains

what is known in military

the speed with which a casualty

parlance as airborne casualty

is removed from the conflict zone

evacuation (Casevac).

to the nearest field hospital in

what is known as the “medical

The Indian Armed Forces had to innovate, and fast. They pressed mules into service to carry the seriously injured down from the mountains

CECIL VICTOR The writer has covered all the wars with Pakistan as War Correspondent and reported from the conflict zones in Vietnam, Laos and Cambodia in South East Asia as well as from Afghanistan. He is the author of “India: The Security Dilemma”.

evacuation” or “medevac” stage. From horse-drawn carriages to motorised ambulances and the

they were in his private clinic.

induction of women nurses into

A formal structure coincided

battlefield hospitals adorned

with the creation of the East

with the red cross (Florence

India Company in 1612 and

Nightingale) –the enemy cannot

the establishment of presidency

target these hospitals under the

armies in Bengal where the Bengal

Geneva Conventions and would

Medical Service was created in

be liable to face a war crime

1764 followed by the Madras

trial if he did – has helped deal

Medical Service in 1767 and the

with battlefield trauma even as

Bombay Medical Service in 1779.

Military medicine is multi-

the lethality and accuracy of

The Indian Medical Service was

dimensional; ranging from

weapons in the order of battle have

formed in 1886 and treatment

treatment of gunshot and shell

improved exponentially.

and management of casualties

effect in the forward edge of

was organised in graded fashion

battle area during wartime to

Susruta’s Legacy

the creation of prosthetics for

While wound care and

co-terminus with the deployment

the amputees and victims of

management is as old as warfare

of the regiments. By 1916

conflicts. Given the diverse nature

itself, the history of military

garrison hospitals appeared on

of the Indian terrain, it has been

medicine in India coalesced under

the scene and the Indian Army

necessary to create methodologies

the British Raj. We have had

Medical Corps (later the AMC) was

for ensuring that the man who is

Susruta conducting operations

created with the amalgamation

to fight in such conditions is aware

and treating arrow, knife and

of all its constituents in April

of and capable of controlling the

spear wounds behind battle

1943 with headquarters in Pune,

effects of such ailments as high-

lines in very ancient times. The

Maharashtra. Two years after

altitude sickness and survival in

instruments that he developed

the attainment of Independence

turbulent sea surface and sub-sea

for the treatment of wounds were

from Britain, the entire military

disasters that are an ever-present

as useful in the battlefield as

medical system was reorganised

August 2018

on priority and largely functioned

DEFENCE AND SECURITY ALERT

lethal diseases ARMED FORCES

under the Director-General Armed

that come pouring in from the

It was only after Pakistani troops

Forces Medical Services which

battlefield. This process is known

disguised as tribals invaded the

handled in a holistic manner the

as “triage” or making sense of

kingdom of Jammu and Kashmir

entire wellness requirements of the

chaos by selection. More and

in 1948 that the urgency for the

Army, Navy and Air Force – one of

more, managing battlefield trauma

induction of qualified doctors

the few inter-Services institutions

is the first aid kit that includes

to deal with military casualties

to have an embedded philosophy

coagulents that ensure that

and peacetime hazards was

of “joint operations”.

wounds are sanitized even before

felt. The Armed Forces Medical

a doctor becomes available to

College was established. The

First Responders

make an assessment and begin the

Maharaja’s accession to India and

Pre-Independence, the basic

process of evacuation.

the deployment of Indian troops

requirement of removal of wounded

into Srinagar even as Pakistani

personnel from the battlefront for

While the Indian Army has fought

troops were knocking at its gates

treatment in field hospitals away

in every war that the British were

brought to the fore the need for

from the din of battle was assigned

involved in Africa, Middle East and

medical facilities to deal with both

to the Indian Hospital Corps and

Europe, the medical paraphernalia

battlefield casualties as well as the

the Indian Bearer Corps.

was totally a British infrastructure

hazards of nature and terrain.

and Indians were assigned menial

Central to the process of “medical

hospital jobs and as stretcher-

The J&K Deployment

evacuation” is the handling or

bearers during World Wars I

The requirement of medical

prioritisation of the casualties

and II.

evacuation quickly acquired a different dimension because battle

Military medicine would not be complete without mention of the work done on prosthetics to enable wounded soldiers to return to active life

casualties and the consequences of a rapid deployment of unacclimatised personnel into high-altitude terrain had to be dealt with on priority. All along from the plains area of Jammu in the south to the mountains of Leh and Ladakh in the north, the Indian Armed Forces had to switch quickly to what is known in military parlance as airborne casualty evacuation (Casevac). While in the foothills of the Himalayas, it was possible to manage casualty evacuation in the traditional manner; it was in the higher mountainous reaches that the Indian Armed Forces had to innovate, and fast. They pressed mules into service to carry the seriously injured down from the mountains to points where they could be either airlifted to base hospitals further inland or be treated in make shift hospitals

August 2018 DEFENCE AND SECURITY ALERT

with better facilities than were

of 2017 is not the India of 1962”.

raise a new Mountain Strike Corps

available on the forward edge of

Undoubtedly so, but there is still a

with permanent jurisdiction in

battle area.

lot to be done to ensure easy and

Arunachal Pradesh. This ensures

comfortable means of providing

that any attempts at misadventure

After the Ceasefire in 1948, India

Indian troops posted on the

can be dealt with speedily (as was

began to reorganise its military

undefined Line of Actual Control

Dhoklam intrusion) unlike what

medicine infrastructure in Jammu

with China better medical facilities.

happened in Chumar and Depsang

and Kashmir. More and more

when it took more than a week

helicopters and aircraft began to

In the immediate aftermath of the

for Indian troops to show up and

be used in tandem fashion using

Chinese invasion in 1962, India

confront the Chinese intruders.

the incoming flights to carry much

experienced a jolt brought about

needed food and military supplies

by the fast induction of troops

The lesson in this is that fit and

and the outgoing flights took away

into high altitude positions. This

healthy troops need to show boots

led to an accumulation of fluids

on the ground 24/7 to be able to

in the lungs — a condition known

stymie Chinese expansionism in

as pulmonary edema. It took the

the Himalayas.

Indian military establishment

some time to create a curriculum

Military medicine would not be

of induction that ensured that

complete without mention of the

the personnel climb higher after

work done on prosthetics to enable

the casualties to base hospitals in Punjab and Delhi. This process was largely confined to Jammu and Kashmir and much of the rest of the border with China from Ladakh in the west to Arunachal Pradesh in the east was neglected in the hope that the

Fit and healthy troops need to show boots on the ground 24/7 to be able to stymie Chinese expansionism in the Himalayas

mighty Himalayas would continue to stand as sentinals against any invading force and the Chinese, quite definitely, were not going to attack. We were, therefore, totally disillusioned when the Chinese attacked in strength in both the east and the west in 1962. That was a psychological trauma that has stayed with the nation ever since.

Post-Chinese Invasion This forced another round of infrastructure development which continues to this day. The slow pace is dictated by the fact that the projects for road development in the Himalayas have been extremely tardy and several sectors are totally dependent on airborne sustenance. The Dhoklam standoff on the China-Bhutan border elicited the stentorian claim that “the India

being acclimatised and have

wounded soldiers to return to

become used to the rarefied

active life. DSA, some months ago,

nature of the atmosphere in

highlighted the mindset of Maj Gen

the high mountains. This factor

(Retd) Ian Cordoza who chopped

has tended to constrain Indian

off his own wounded leg with a

military deployment at short

khukri and showed amazing grit to

notice in the mountains and the

return to command his battalion

tendency of both Pakistan and

on an artificial leg. Then, there is

China to periodically stoke tension

the case of Lt Gen Vijay Oberoi

along both the Line of Actual

who lost a leg in Jammu and

Control with China and the Line

Kashmir when he was just a young

of Control with Pakistan. There

Captain in the army and went on

is need to ensure presence of

to become the Vice-Chief of Army

well-acclimatised troops at “rest

Staff at a time when the army was

stations” (as different from “peace

suffering a shortage of officers.

stations” in the plains) so that

They owe their sense of confidence

there is room for quick shift of

to the prosthetics designed miles

troops from one sector to another.

away from the battlefield. These

celebrated cases underscore how

Largely to deal with the problem of

important it is to conserve the

acclimatisation, India has had to

fighting man.

August 2018

DEFENCE AND SECURITY ALERT

July 2018

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