Very useful method of medicare in inaccessible remote area.

1. 1

2. 2
Outlook
1) I want to share my experience of managing the patients in remote
border area of North-east, J&K and Naxals affected area of India where
forces are deployed but doctors are not available instantly in need or odd
hours, may be due to dangerous mine prone roads of ANO or cut-off road
conditions of high altitude or N-E regions in rainy season.
2) Whenever one sees a doctor, he points out complains problem-wise ie
bleeding, headache, vomiting etc. but a doctor takes these complaints
system wise because microbes attack the body system wise and also the
medicine act system wise. As for example one might be having complained
of burning near glans during micturition. For a patient this problem lies in
glans penis but for a doctor, the pathology of this burning might be located
at any point from kidney, ureter, bladder, urethra up to glans. Similarly for
bleeding per anus the pathology may originate from mouth, esophagus,
stomach, intestine, and colon rectum up to anus anywhere. Doctor tries
zeroing the pathology to reach the final diagnosis based on your complaints
& clinical parameters of your body.

3. 3
3) It takes almost 5-10 hrs to reach from boarder to BN HQ
Nalkata, Maharanichera (Tripura). There is no any hospital en
route competent enough to tackle medical emergency including
malaria. Whenever a medical emergency happens, it leaves no time /
opportunity in the hands of doctors to revert it back unless be
managed in a well-equipped hospital. State Govt hospitals falling en
route are also beyond 20 to 50 Kms from boarder. And they too use
to refer only our cases because most of them do not have specialist
facility.
4) In such scenario only thing left in our hand is do not allow such
condition which entails one for evacuation. That means the cases have
to be managed then & there only based on external manifestations
(clinical features) of the inside pathology. But we don’t have medically
skilled person there to understand these clinical features. What we
have are 10th pass constables who are trained by our set up for first
aid nursing care only that too very lightly.

4. 4
5) As we know medical science is a vast subject. Doctors
quickly screen your complaints after zeroing his knowledge
& experience towards the most probable pathology. But
sometimes patients as well as doctors might be missing in
reflecting some relevant although not problematic matters.
To minimize such mistakes in undertaking & reflecting the
complaints of a patient, role of Code/Pnemonic/Format
comes as a SOP before any planned operation comes.
6) In these areas each of our deployed companies has first
aid knowing nursing assistants only. They are locally
trained 10th passed GD constable. They are not
appropriately versed in medical matters & sometimes might
be missing in taking input by examining the case & then
reflecting his clinical status to his doctor.

5. 5
7) As we know now a days there is much hue about
telemedicine but this system starts only after a case is
reported/brought up to unit Medical officer. My
question is that who will report these cases up to unit
hospital positively without wasting mush time or it
would have been even better if we understand &
diagnose the cases in incubation period before
manifestation of external features (Signs & symptoms)
& system wise complaints.
8) For them comes the need of a common minimum
easy way format/code to ask & note the complaints of a
patient & further reflect them on set/phones to the doctor
at HQ hospital.

6. 6

7. 28
10
16
23 26
55 52 53
23 21 23 27
7
61
67
44
91
137
211
123
99
71
0 0 0 0
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN
0
50
100
150
200
250 29 BN/2010
77 BN/2009
7

8. 8

9.  NO PROBLEM
 BEING DONE REGULARLY
9

10. 10

11. PROBLEM-
MOST OF
THE
TOILET/BATHROOM
S AT BOPS DO NOT
HAVE SUPPLY-
WATER. DUE TO
LACK OF
SUFFICIENT WATER
TROOPS PREFER TO
BATH/TOILET IN
OPEN
SOLUTION-
THESE SPACES
CAN BE MADE NET-
PROOFED BY UNIT
EFFORT.
11

12.  PROBLEM :-
* LACK OF TRAINED MECHANICS
SOLUTION :-
* MORE PERSON CAN BE TRAINED WHO
CAN BE PLACED TO COYS
12

13. PROBLEM-
 OUR NURSING ASSISTANTS ARE NOT WELL VERSED IN
CLINICAL EXAMINATION AND PRESENTING THE CASES
ON RADIO-SET IN ALLOTTED TIME.
 OUR LAB-TECHNICIAN ARE NOT WELL TRAINED TO
DETECT MALARIA SLIDES.
SOLUTION-
SET-CODE SYSTEM BASED ON SIGN & SYMPTOMS MAY
BE INSTITUTED TO EXAMINE THE PATIENTS,
DETECTING COMPLICATIONS AND SUPERVISING THE
TREATMENT.
13

14. 14
MONTHS
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
BNHQ
29/101BN
NO OF SLIDE
SCREENED
1068 955 682 1086 1073 910 848 1001 1224 988 898 768
+VE CASES
DETECTED 01 02 10 06 10 23 23 21 20 08 04
MINIMIROOM
KHANTALANG
NO OF SLIDE
SCREENED
164 226 203 267 279 267 228 215
+VE CASES
DETECTED
02 08 07 14 04 02 06 12

15.  BN HQ CAMPUS IS NOT MOSQUITO-
PROOF
 TROOPS UNDER QUARANTINE
BEING SENT TO BORDER FOR
GUARD DUTY FOR 2-3 DAYS WHICH
WASHES OUT THE PURPOSE
15

16. IT HAS BEEN OBSERVED THAT RECURRENCE RATE IS HIGH IN PF
THAN PV CASES THE MATTER WHICH NEEDS TO BE BACKLOOKED
16
0
20
40
60
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
PF CASES
RELAPSE
0
5
10
15
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
PV CASES
RELAPSE

17. SHORTAGE OF BUDGET
S/NO MED NO Rs
1 RD KIT 2 200
2 Inj RT Sunate 5 750
3 Tab RT Sunate 6 110
4 Inj Ceftriaxone 5 500
5 IV Fluid 10 300
6 Others 140
Total 2000 Rs
40 Pts X 10 months = 400 Pts/Yrs
400X 2,000 = 8,00,000 Rs
Other Diseases = 2,00,000 Rs
Total = 10,00,000 Rs
17

18. 18

19. Tulpaibari is the highest
pick on SHAKHAN hills
–ridge at height of 1580
feets. This BOP can be
approached either by
western axis via Chamanu -
32 mile (101 BN area) or
eastern axis by
Kanchanpur- Khantalang
(29 BN area). Due to
ongoing fence construction
work and kachcha road it
becomes accident prone,
tiring & non pliable in
rainy season. The whole
area depends on
airdropping for ration and
all. 19

20. 20

21. NO ROUTINE SLIDE CHECK DURING CUTOFF MONTHS
TO DETECT CASES IN ADVANCE SCREENING
MINI
MIROOM
JAN FEB MAR APR MAY JUN JUL AU
G
SEP OCT NOV DEC
NO OF
SLIDE
EXAMD
164 226 203 267 279 267 228 215
NO OF
+VE
SLIDES
02 08 07 14 04 02 06 12
21

22. NEAREST HOSP
IS PHC
CHAMANU IN 101
BN AREA &
PHC WANGMOON
IN 29 BN AREA.
BOTH ARE AT A
DISTANCE OF
30-40 KMS
COVERED IN 2-3
HRS
KACHCHA ROAD
22
+
+
+

23. 23

24. Sometimes
evacuation needs
2-3 Hrs on foot
journey to reach
to vehicle point.
In such condition
patients opt for
tele monitored
supervision there
at the BOP only
24

25. IN COMING DAYS MOST OF THE BSF DEPLOYMENT WILL BE
SAME AS THAT OF NALKATA WHERE DOCTOR CAN NOT
REACHTOTHE PATIENT INTIME FORVARIOUS REASONS
1. The Roads are mined as in ANOs,N-E and J&K areas.
2. Bad cloudy weather & dense forest where helicopter can’t land sometimes.
3. In night time there is No ROP and the Roads are already mined.
4. Rainy seasons & land slide cutting/blocking the roads
5. Too much distance from unit HQ

26. Rainy seasons & land slide
cutting/blocking the roads
Bad cloudy weather & dense
forest where helicopter can’t
land sometimes
26

27. FORMATING – 1 Lecture
FORMATTING OF REGISTERS IN BN-HQ AS WELL AS IN BOP
CODING - 2 Lectures
CODING OF CLINICAL PARAMETERS, SYMPTOMS & SIGNS OF PTS
PRE-INDUCTION TRG – 5 Lectures & 2 Practical
FOR FIRST-AIDERS/N-ASSTTS- 2 EACH BOP
COMBINED BRIEFING TO ALL TROOPS – 2 Lectures
ABOUT PATHO-PHYSIOLOGY OF DISEASES & THEIR CLINICAL
EVALUATION IN PRETEXT OF COMPLICATION OF MALARIA
Leave of all N/Asstt (3 each BOP)
should be sanctioned/controlled by Unit MO

28. BOP
MI-ROOM
COY
MI-ROOM
UNIT
HOSP
COMPOSITE
HOSPITAL

29. 1. IN COMING DAYS MOST OFTHE BSF DEPLOYMENTWILL BE SAME ASTHAT
OF NALKATAWHERE DOCTOR CAN NOT REACHTOTHE PATIENT INTIME
DUETO ALREADY MINED ROADs IN ANOs ORTOO MUCH DISTANCE FROM
HQ
2. MORE NO OF PATIENT ISTO BETELEMONITORED IN LESSTIME ALLOTED
ON SET
3. VAST RANGE OF COMPLICATIONS
4. MISS-DIAGNOSIS & MISSED DIAGNOSISTHREATES
5. CHANCES OF DETECTION OF OTHER DISEASES PRODUCING SAME
SYMPTOM CODE
6. NO SLIDETEST PLASMODIUM COUNT POSSIBLE IN BORDER/COYS
7. NON AVAILABILITY OF REFERRAL HOSPITALS IN BORDER AREA
8. LENGTHY PROCESS OF AIR EVACUATION
9. CONCURRANCE OFWATER BORNE DISEASES LIKETYPHOID,DYSENTERY.
WHY CODED SYSTEM OF MONITORING

30. MORE NO OF PATIENT IS TO BE
TELEMONITORED IN LESS TIME ALLOTED
ON SET
VAST RANGE OF COMPLICATION
MISS DIAGNOSIS – MISSED
DIAGNOSIS THREATES
30

31. CHANCES OF DETECTION OF OTHER
DISEASES PRODUCING SAME SYMPTOM
CODE
NO SLIDE TEST PLASMODIUM COUNT
POSSIBLE IN BORDER
NON AVAILITY OF REFERRAL
HOSPITALS IN BORDER AREA
31

32. LENGTHY PROCESS OF AIR
EVACUATION
QUININE SULPHATE IS NOT USED
BEING LESS COMPATIBLE DUE TO
MORE SIDE EFFECTS
WATER BORN DISEASES
LIKE TYPHOID DYSENTRY
CO-EXISTING
32

33. 6 MONTH CUTOFF FROM MAY
ONWARD DUE TO HEAVY RAIN &
NON PLIABLE ROADS
FUND AVAILABLITY IS NOT SUFFICIENT TO
TREAT SO NO OF MALARIA PATIENTS WITH
FULL COURSE MAY BE INVITING FUTURE
ARTISUNATE DRUG RESISTANCE AS SHOWN BY
DATA OF RELAPSES OF TREATED PF PATIENTS
33

34. 34

35. BLOOD PRESSURE
PULSE
TEMP
35

36. R
E
S
P
I
R
A
T
I
O
N
ANAEMIA
J
A
U
N
D
I
C
E
36

37. URINE
37

38. PAIN ABD
HEADACHE
COMA
38
CONVULSION

39. • BLOOD PRESSURE
• HYPER-TENSION/HYPO-TENSION
• PULSE
• TACHY CARDIA/BRADY CARDIA
• TEMPERATURE
• HYPER THERMIA
• WITH/WITHOUT CHILL & RIGOR
39

40. • RESPIRATION
• DYSPNOEA
• WITH/WITHOUT CRAPTS
• ANAEMIA
• + ++ +++ ++++
• MILD , MOD, SEVERE, VERY SEVERE
• JAUNDICE
• + ++ +++ ++++
• MILD , MOD, SEVERE, VERY SEVERE
40

41. • STOOL
• LOOSE / HARD
•URINE - colour & input/output
•YELLOW + ++ +++ ++++
•COFEE COLOR + ++ +++ ++++
•RED + ++ +++ ++++
•NAUSEA
•VOMITING
• + ++ +++ ++++
•MILD , MOD, SEVERE, VERY SEVERE
41

42. • PAIN ABDOMEN
• + ++ +++ ++++
• MILD MOD SEVERE VERY SEVERE
• HEADACHE
• + ++ +++ ++++
• MILD MOD SEVERE VERY SEVERE
• CONVULSION , COMA , PSYCHOSIS
• + ++ +++ ++++
• MILD MOD SEVERE VERY SEVERE
42

43. BedNo
NameofPatient
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
1
CT
KeshawDas
MalariaPF+ve
130
/80
84 10
2
++ ++ - Dar
k
Red
1500/
1000
++ Cra
pts
++
NAD Pai
n
Abd
Wea
k
ness
++ - Inj
Art
esu
nate
Inj
Peri
nor
m
R/L
0-0
D5
0-0
Tab
PCM
Dig
ene
Gel
Glu
cose
Pdr
ReftoRIIMS
2
HC
RameshBhai
Tyhpoid
130
/84
86 99 ++ ++ Loo
se
moti
on
Dar
k
Red
1500/
1000
++ Cra
pts
++
NAD Pai
n
Abd
Wea
k
ness
++ - Inj
Art
esu
nate
Inj
Peri
nor
m
R/L
0-0
D5
0-0
Tab
PCM
Dig
ene
Gel
Glu
cose
Pdr
ReftoRIIMS
3
Ins
Alok
Singh
130
/80
84 10
1
++ ++ Loo
se
moti
on
Dar
k
Red
1500/
1000
++ Cra
pts
++
NAD Pai
n
Abd
Wea
k
ness
++ - Inj
Art
esu
nate
Inj
Peri
nor
m
R/L
0-0
D5
0-0
Tab
PCM
Dig
ene
Gel
Glu
cose
Pdr
ReftoRIIMS
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

44. CHART MAY BE UPDATED DAILY ON MICROSOFT
ACCESS OR HTML FORMAT.
This web page can be developed with the help of NIIT &
a team of doctors.

45. 45
CLINICAL PRESENTATIONS
• Classical in p. Vivax stages (Cold : 1/4-
1H, Hot : 2-6H, Sweating : 2-4H)
• Atypical in p. Falciparum,
Mimics -
 Common cold
 Entric fever
 Migraine
 Dysentery
 Psychiatric disorder
 Hepatitis
 Haemoglobinopathy
 Shock
 Mult- organ failure
Atypical fever
Headache
Body ache, back ache ,joint
pains
Dizziness, vertigo
Altered behavior,
Acute psychosis
Altered sensorium
Convulsions, coma
Cough, Breathlessness:
Chest pain
Acute abdomen
Vomiting and diarrhoea
Jaundice & Pallor

46. 46
Management
• Management of Uncomplicated malaria
• Management of Complications
Cerebral malaria
Generalized convulsions.
Metabolic acidosis with respiratory distress
Severe normocytic anemia.
Fluid and electrolyte disturbances.
Hypoglycaemia.
Acute renal failure.
Hyperparasitaemia.
High fever
Circulatory Abnormal bleeding
Jaundice
Haemoglobinuria
collapse, shock (“algid malaria”)
Acute pulmonary oedema and
adult respiratory distress syndrome (ARDS).

47. 47
Headache
Dizziness, vertigo
Altered behavior,
Altered sensorium
Convulsions, coma
Acute psychosis
CEREBRAL
MALARIA

48. 48
Pulmonary Oedema /
Adult Respiratory
distress syndrome
(ARDS)
 Respiratory rate
 Difficulty in breathing
 Cough
 Heart /pulse rate
 Cyanosis
 Convulsions
 Deterioration in the
level of sensorium
 Breathlessness
worsens rapidly and
the patient may die
within a few hours.
RESPIRATORY
SYSTEM

49. 49
KIDNEY
KIDNEY
FAILURE
Dark/red of
colour
Less amount
of urine

50. 50
DIGESTIVE
SYSTEM
Acute
abdomen
Vomiting
and
diarrhoea

51. 51
DIAGNOSIS
Method of
Diagnosis
Uses Comments
CLINICAL Widely
Used
Unreliable as symptoms of
Malaria are non specific.
MICROSCOPE Established Laboratory conformation
of Malaria.Technical &
Personnel requirements
not often met in facilities at
BOPs.
R D TEST
(RAPID
DIAGNOSTIC
TEST)
Recent
Innovations
PRESENTLY
USING AT BOPS

52. 52
R D TEST
(RAPID DIAGNOSTIC TEST)
 Detects Plasmodium-specific antigens in finger-
prick blood sample.
 Quick ~15mins
 Minimal training
 No reliability on power or special equipment
 Comparable to microscopy

53. 53
R D TEST
(RAPID DIAGNOSTIC TEST)
This test based on detection of P. falciparum specific
circulating proteins (antibody) in blood
Protiens (antibody) used for test are –
1) Histidine-rich Protein-II (PfHRP-ii or HRP-II)
- detects live and dead parasites
- positive up to 2-4 weeks even when parasite is dead
2) Parasite lactate dehydrogenase (pLDH)
- detects live parasite only

54. 54
COMPONENTS OF ANTIGEN
DETECTION TEST

55. 55
TEST PROCEDURE

56. 56
RESULTAS

57. 57
RESULTS cont..
One line (control)- Negative
Two lines (control and T2/P
- P. Vivex positive
Three lines (control, T2/P and
T1/Pf
- P. Falciparum/ P. Vivex positive

58. 58
Causes of Neurological Manifestations in
Malaria
Severe P. falciparum infection
High-grade fever
Antimalarial drugs - CHLOROQUINE, QUININE,
MEFLOQUINE HALOFANTRINE
Hypoglycemia
Hyponatremia
Severe anaemia and hypoxemia
Vascular disease, other Neurological infections
and diseases.

59. 59
CEREBRAL MALARIA
 Proper nursing care
 Urethral catheter, unless patient is anuric.
 Nasogastric tube to aspirate stomach contents.
 Record of fluid intake and output
 Monitor and record the level of consciousness (using
the Glasgow coma scale) Temperature, Respiratory
rate and depth, Blood pressure and Vital signs.
 Treat convulsions with diazepam, phenobarbitone or
paraldehyde
A STRICT DEFINITION OF CEREBRAL MALARIA FOR SAKE OF CLARITY- PRESENCE OF
UNAROUSABLE COMA, EXCLUSION OF OTHER ENCEPHALOPATHIES AND CONFIRMATION OF P.
FALCIPARUM INFECTION

60. 60
CEREBRAL MALARIA
PROPER NURSING CARE
MAINTAINED
NORMALTEMPERATURE
TREATMENT OF HYPOGLYCEMIA
ANTI MALARIA DRUGS- ARTISUNATE
(If Available)
EVACUATE THE PATIENT
TREATMENT

61. 61
EVACUTION TO HIGHER
CENTRES
Fever not subsides even after ---------------
Developed any complications eg
Unconsciousness/ loss of sensorium,
convulsion (cerebral malaria)
Less amount or dark/red colour of urine
(kidney failure)
Severe jaundice
Severe breathing problem/respiratory distress
(pulmonary oedema)
Abnormal bleeding
Others

62. 0
20
40
60
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
PF CASES
RELAPSE
62
0
20
40
60
80
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
PF CASES
RELAPSE

63. 0
5
10
15
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
PV CASES
RELAPSE
63
0
10
20
30
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
PV CASES
RELAPSE

64. 1 SHORT PERIOD TREATMENT BY
ACT (L/FORTE)
2 NO INTRAVENOUS TREATMENT
3 NO TREATMENT WITH QUININE
IV / ORAL
4 RESISTANCE OF INJ ARTISUNATE IN
NALKATA BORDER
64

65. 0
50
100
150
200
250
300
350
400
Since
Oct 2009
2010 2011 2012
Non Malaria Cases
Malaria Cases
Referral
65