CREATION OF MEDICARE WEB-PAGE

TO MONITOR INDOOR / LMC CASES ON PRAHARI-NET BASED

ON MY NALKATA MODULE OF TREATMENT

Dr CB NarayanCMO(SG), CH HZB

PREVIEWSYSTEM PREVAILING

PRHARI NET- HR MODULE- KEEP RECORD OF DIAGNOSED CASE ONLY

THE MISSING LINK (PRE-HOSPITAL MEDICARE)

(NO PRAHARI NET BETWEEN BOP - TO UNIT HOSP)

PATHO-PHYSIOLOGY OF DISEASES(IN PRETEXT TO MALARIA)

THE INDOOR / LMC CASE TREATMENT FORMAT(THE CODE- BPT AJ SUV CCA MHC)

THE MIRACLE OF ARTISUNATE(A STORY OF 29 BN)

BOPMI-ROOM

COY MI-ROOM

UNIT HOSP

COMPOSITEHOSPITAL

MISSINGLINK

THE MISSING LINK

BETWEEN BOPS & COY

NEEDS TO BE REPAIRED BY

POSITIVE MEDICARE ON

MANUAL FORMAT BASED ON

THE NALKATA MODULE

1. IN COMING DAYS MOST OF THE BSF DEPLOYMENT WILL

BE SAME AS THAT OF NALKATA WHERE DOCTOR CAN

NOT REACH TO THE PATIENT IN TIME DUE TO ALREADY

MINED ROADs IN ANOs OR TOO MUCH DISTANCE FROM

HQ

2. MORE NO OF PATIENT IS TO BE TELEMONITORED IN

LESS TIME ALLOTED ON SET

3. VAST RANGE OF COMPLICATIONS

4. MISS-DIAGNOSIS & MISSED DIAGNOSIS THREATES

5. CHANCES OF DETECTION OF OTHER DISEASES

PRODUCING SAME SYMPTOM CODE

6. NO SLIDE TEST PLASMODIUM COUNT POSSIBLE IN

BORDER/COYS

7. NON AVAILABILITY OF REFERRAL HOSPITALS IN

BORDER AREA

8. LENGTHY PROCESS OF AIR EVACUATION

9. CONCURRANCE OF WATER BORNE DISEASES LIKE

TYPHOID, DYSENTERY.

WHY CODED SYSTEM OF MONITORING

BPT AJ SUV CCA MHC

5

Bed No

Name of

Patient

Investigations/Disease

Symptoms Treatment

Diet

  

Referral /

Others  

BP

Pulse

Temp

Anemia

Jaundice

Stool

Urine

Vomiting

Chest

CVS

Abdomen

Musk/Sk

Headache

Convulsion/ Coma

Inj Inj IV fluid

Cap Tab Syp

B P T A J S U V C C A M H C 1 2 3 4 5 6

 1CT

Keshaw Das

 Mal

aria PF +ve

 130/80

 84  102

++ ++ -  Dark Red1500/1000

 ++ Crapts

++ 

NAD  Pain Abd

 Wea

kness

 ++  -  InjArtesunate

 InjPerinorm

 R/L0-0D50-0

   Tab PCM

 Digene Gel

 Glucose Pdr

  Ref to RIIMS

 

 2HC

Ramesh Bhai

 Tyhpoid

 130/84

 86 99 ++ ++ Loose motion

 Dark Red1500/1000

 ++ Crapts

++ 

NAD  Pain Abd

 Wea

kness

 ++  -  InjArtesunate

 InjPerinorm

 R/L0-0D50-0

   Tab PCM

 Digene Gel

 Glucose Pdr

  Ref to RIIMS

 

 3

InsAlokSing

h

   130/80

 84  101

++ ++ Loose motion

 Dark Red1500/1000

 ++ Crapts

++ 

NAD  Pain Abd

 Wea

kness

 ++  -  InjArtesunate

 InjPerinorm

 R/L0-0D50-0

   Tab PCM

 Digene Gel

 Glucose Pdr

  Ref to RIIMS

 

Register Format for INDOOR / LMC Cases

ALL DISEASES SHOW ABNORMALITY IN ANY OF THE NORMAL CLINICAL VALUES FOR WHICH ONE CONSULTS A DOCTOR CAN BE UPDATED TWICE DAILY IN THIS

FORMAT DURING ROUND

CHART MAY BE UPDATED DAILY ON MICROSOFT ACCESS.

This web page can be developed with the help of NIIT &

a team of doctors.

Before 2009 Nalkata used to be a synonym for toughest deployment in respect of difficult terrain & Malaria endemicity.

There was the challenge of controlling & treating almost thousands of malaria cases annually.

On my posting to that place in 2009, I ensured to reduce the malaria index drastically by applying various techniques of detection, prevention & treatment.

I developed a code of symptoms/Complication to monitor the patients sitting at far flung non accessible BOPs in pick rainy season.

The code was ‘BPT RAJ SUV PHC’. In 2010 & 2011, under my medicare, 29 BN

performed very well & completed its tenure unhurt at Nalkata.

Seeing this, TRA Ftr has approved that method for units at Nalkata with high endemicity to follow all patients based on that symptom code.

I firstly trained the troops with new ‘CODE of Symptoms/Complication’ eg . ‘BPT RAJ SUV PHC’. Formatted the registers in simple easy way & never the least I made the troops well versed in malaria through my lectures.

Due to my prompt action in prevention, detection & treatment, the patients at BOPs needing no evacuation as emergency and mostly managed then & there only within a week off duty.

MONITORING CODE WORKING WELLHere you can see that the referral % is

limited down only up to 2 – 5 % of the total PF cases at the border because this becomes sometimes necessity also to treat the cases there only at border during rainy season & odd hours.

B - BLOOD PRESSURE => HYPER-TENSION/HYPO-TENSION

P - PULSE => TACHY CARDIA/BRADY CARDIA

T - TEMPERATURE => HYPER THERMIA WITH/WITHOUT CHILL & RIGOR

A – ANAEMIA => + ++ +++ ++++J – JAUNDICE => + ++ +++ ++++

S – Stool => Loose / Hard

U – Urine => Colour & Input/Output [1500/1000 ml]

Yellow => + ++ +++ ++++ Coffee colour => + ++ +++ ++++ Red => + ++ +++ ++++V – Vomiting or Nausea => + ++ +++ ++++

C – CHEST => DYSPNOEA WITH/WITHOUT CRAPTS, RDS MILD , MOD, SEVERE, VERY SEVERE

C – CVS => HEART SOUND AUDIBLE, No Murmur A – ABDOMEN => B/Sound audible normally in all quadrants

P - Pain Abdomen => + ++ +++ ++++H – Headache => + ++ +++ ++++C – Convulsion => + ++ +++ ++++ - Coma, Psychosis

Vast Range of Complications

1. BP may fall due to fluid loss in sweating/Vomiting/respiration. As we

know there is high humidity in malaria months ie from May to Sep in border area due to heavy rain & high vegetation growth. This loss increases in case of fever, heat stroke, typhoid & dysentery.

2. We don’t have proper fluid for replacement while on duty as we use to take only plain water which causes hypo osmolarity resulting in hypotension in our body.

3. BP may increase due to stress induced high sympathetic outflow resulting from the fear of being suffering from such type of dreaded malaria that too in remote border area.

BLOOD PRESSURE

Pulse & Temperature

1. Pulse may increase as

compensatory mechanism against fluid loss & also due to fever.

2. There is increase of approx 10 beats/1degree rise of temperature. Pulse increases upto a certain limit then it started falling down till heart becomes unable to contract due to no filling induced non development of action potential.

AnaemiaMerozoits repeatedly attack RBCs

causing massive hemolysis. This results in development of anemia. Anemia leads to compromised oxygen delivery which further leads to Lactic Acidosis & RDS (Respiratory Distress Syndrome)

JaundiceIn Malaria liver is the first organ

dealing with the invasion of plasmodium. Hepatocytes get occupied & damaged in this process resulting in raised serum bilirubin level & development of jaundice. Also increased number of hemolysed blood causes increased production of bilirubin resulting in jaundice.

StoolStool may be loose due to

hyper sympathetic stage or due to ileitis/colitis following entrapment of PF Rosettes in small ileac-colic capillaries.

UrineFirstly urine becomes yellow due to

excess bilirubin secreted by the damaged hepatocytes. This may occur within 1 week of mosquito bite. Then the urine becomes coffee red color due to dissolution of starting volume of hemolysed RBC in urine. Now as further RBC hemolysis takes place urine becomes Red in color with clot at the bottom on the container. Glomerular cell don’t cope up with the increased load of hemolysed RBC resulting in increase of blood urea. Also some glomerulus gets damaged due to these increased macromolecules causing nephritis

VomitingFactors work behind excessive vomiting in PF.

Firstly due to excessive sympathetic tone of being suffering from PF, there is increased acid secretion in stomach which irritates the stomach for vomiting. Secondly PF also increases high acid output by inducing proton pump &

Lastly all control centers of brain set on high frequency signals as feedback stimulation of the Hypothalamus against PF induced hypoglycemia due to high threshold set up of higher commands in high fever CTZ gets stimulated as error resulting in increased acid release in stomach which induces vomiting.

Chesta) Here we can auscultate for Breath sound/ Crapts/Rhonchi/Wheeze/Chest-pain & Respiratory rate as well.

b) In PF malaria breath sound may be vesicular, but if pulmonary oedema develops, we may find crapts at lung base which sounds like tearing of paper in addition to dyspnea.c) In addition RDS (Respiratory Distress Syndrome) develops as a result of Metabolic (Lactic Acidosis) which is considered as the most important cause of pathophysiology of Cerebral Malaria & Anemia

CVS

Already compromised oxygen delivery system due to Aneamia & lactic acidosis induced RDS weakens the cardic output resulting in retrograde cardiac failure & pulmonary oedema. It entraps the patient in a vicious circle of

Reduced oxygen delivery > More anaerobic respiration > Reduced generation of ATP > Death of heart cells > Ultimately resulting in death of patient.

Apr 13, 2023

Ultimate

ly

resu

lting

in

death

of pa

tient.

Reduced oxygen

delivery

More anaerobic respiration

Reduced generation of ATP

Death of heart cells

Due to entrapment of PF rosettes in intestinal capillaries, a generalized ileitis like situation develops which is further added by high acid & pepsin. As rosettes may get entangled at any site there may be ischemia of pancreas, appendix, and kidney in addition to ileitis

PAIN ABD / DYSPEPSIA

HEADACHEAs the vascularity of any part of brain may be blocked due to PF rosettes that part produces ischemic pain (headache). Also all control centers of brain set on high frequency signals as feedback stimulation of the system against PF induced hypoglycemia; there is increased requirement of glucose which further induces ischemic pain.

CONVULSION/COMA/DEATH

Seizure is induced due to hypoglycemia. PF reduces blood sugar by utilizing human blood sugar. High urea/NH3 may create a situation like uremia & coma & finally death.

Metabolic acidosis (predominantly lactic acidosis)

It has been now recognized as a principal pathophysiological feature of severe manifestations of PF malaria like cerebral malaria and severe anemia. It is the single most important determinant of survival and can lead to respiratory distress syndrome. Lactic acidosis has been identified as an important cause of death in severe malaria. Lactic acidosis in severe malaria has been attributed to several causes:1. Increased production of lactic acid by parasites (through

direct stimulation by cytokines)2. Decreased clearance by the liver.3. Most importantly the combined effects of several factors

that reduce oxygen delivery to tissuesa) Marked reductions in the deformability of

uninfected RBCs  may compromise blood flow through tissues

b) Dehydration and hypovolemia can exacerbates microvascular obstruction by reducing perfusion pressure

c) Destruction of RBCs and anemia further compromises oxygen delivery.

Type of Malaria

Drug Duration Purpose

PF 1. Inj Artisunate – 00 – 00 – 0

2. Tab Lumither forte (ACT) 0-0-0-0-0-0

3 Tab Artisunate/Inj Arteether/Inj Artemether

4 Tab PQ

2 ½ days 4days 3 days  45 mg

Load reducer Main drug Tailing  2nd day & 24 hrs after tailing stat

PV Tab Larinate kit (Artisunate + SP) Tab Artisunate 200 mg Tab PQ

3 days 3 days 45 mg

Main drug Tailing 2nd day & 24 hrs after tailing x 14 days

Mix (PF+PV) 1) Inj Artisunate – 00 – 00 – 0  

2) Tab Lumither forte (ACT) 0-0-0-0-0-0 

3) Tab Artisunate/Inj Arteether/Inj Artemether 

4) Tab PQ

2 ½ days 

4days 3 days 45 mg

Load reducer Main drug Tailing 2nd day & 24 hrs after tailing x 14 days

CM Tab Lumither Forte 0-0-0-0-0-0Tab PQ 45 mg

4 daysStat

Main drug24 hrs after L/F

Note “The Nalkata Syndrome” which comprises Heatstroke, Gastroenteritis, Typhoid along with Malaria.

1. Inj ceftriaxone 3-5 days2. Inj Metron3. IV fluid along with ACT

TREATMENT

 

MIRACLE OF ARTISUNATE - “Go Blind- No Harm”A BSF Head Constable Chaman Lal of 29 BN BSF, Tripura,

hailing from Rajasthan, while on leave, falls sick with complaints of resistant headache, fever, jaundice reports to Fortis hospital Jaipur with breathing problem in semi comma stage. His CT scan brain, Malaria Ag, BMP slide ruled out malaria. As per blood investigation his liver & Kidney were found damaged 60-80 %. He was put in ICU on ventilator & was treated as a case of “Hepato-Renal Failure”. After 3 days there was no improvement & his son, an engineering student was informed about the grave prognosis.

Incidentally, I was informed being his departmental AMA. I tried to talk to his treating doctor at Fortis, Jaipur & could be able to talk to him the next day. They updated me with the investigation reports which were nothing corroborative to Malaria so he didn’t think towards PF malaria. Then I enquired what he is going to do next. His reply was wait & watch. I suggested him to go with Inj. Artisunate. But he straightway denied telling that there is no indication of Malaria so why should he go. Then I, taking every type of responsibility (including medico legal) on myself, requested him to start this Inj Artisunate. The next day that injection was given & the miracle was there. Ajust after 24 hrs that pts on ventilator & in coma for last 3-4 days became conscious & shown some movement. I further advised them to complete its full course & they followed my Nalkata regime. Subsequently reported to unit at Nalkata (Tripura) with a medical bill of Rs 80,000/=. Out of these 80,000 the cost of antimalarials were only 2000/=

Is it not a miracle, the same treatment our BSF constables practicing Since 2010 under my supervision with nil casualties?

AND THE CREDULITY OF THE JOB

“A smart and well turned out officer. Always cheerful and immaculately dressed, Officer has devised simple system for men and his staff to understand that has been very effective in controlling & diagnosing the PF and PV malaria in the AOR of the unit. As a result of his effort graph of PF & PV malaria as also other diseases has come down drastically. The number of patient required to be evacuated to BN HQ has also reduced considerably. An outstanding Medical Office.”

# Comdt, 19 Bn BSF , Nalkata

RECOMMENDATION

1

• PRE-HOSPITAL MEDICARE - No improvement in method of case take up & reflecting the same to unit hospital due to various reasons.

2• LEAVE SANCTION - & CONTROLL OF N/ASSTT BY UNIT

HOSPITAL

3• SUMO AMBULANCE - TO EVERY UNITS FOR QUICK

EVACUATION OF PATIENTS FROM BORDER

4• IS-DUTY – SEPARATE VEHICLE BE PROVIDED FOR QUICK &

SECURED MOOVE OF THE DOCTOR

5

• COMPUTER TRAINING FOR UTILISING PRAHARY-NET HR MODULES (MEDICAL) MADE MANDATORY IN DIFFERENT PHASES

Prerequisite /Recommendations for

Nalkata-module1. Leave of all N/Asstt (3 each

BOP) should be sanctioned/controlled by Unit MO

2. I ensured 3 leaves to all 55 N/Asstts under my command at Nalkata.

3. All N/Asstt be provided a refresher course for 1 month for updating their theoretical & practical knowledge which can easily be done by unit MOs.

4. Formatting the registers in simple easy way in unit hospital as well as in BOPs.

5- The data can be monitored daily through radio set or mobile phone.6- I am using the same code system to manage all types of cases at CH HZB. which resulted in smooth & secured management of patient by the nursing staff within time.7- In unit hospital & CH, it can be updated daily by N/Asstt & the condition of patients/progress can be supervised bed wise.

8- On HR-module of the prahari net we already have good medical supervision & medical analysis option but as all of us know our patients are mostly on the remote border BOPs where none except us are available in periphery of ANO & N/E units. So the need is that we should be versed in the techniques of taking clinical complaints/parameters on manual formats in register as I am doing at Nalkata since 2009 because the prahari net can not be extended up to BOP right now. The same data can be transferred by the N/staff during daily telemonitoring. The same format be maintained in unit hospital as well as in BOPs.

9- Based on that format of medicare, a starting web page can be created on prahari net to supervise all patients & LMC cases of BSF at regular interval. If clinical parameter of any case is found beyond normal limit the data may alert the doctor on that web page with certain indication eg repeated blinking or changing the color or appearance of triangle with hidden code on front page.10- The relevant data-alert can be checked & indicated measure can be undertaken within time like specific investigation, treatment or referral of that patient from anywhere in BSF set up through prahari-net.

11- Sumo Ambulance - to every units for quick evacuation of patients from border12- IS-duty – separate vehicle be provided for quick & secured move of the doctor13- Computer training be imparted to every doctors for optimum utilization of prahari-net HR-modules (medical) or its use be made mandatory in different phases.14- In ad-hock units an ambulance be authorized to move along with to provide medical cover en route.

THANKS