1. CREATION OF MEDICAREWEB-PAGE
TO MONITOR INDOOR / LMC CASES ON
PRAHARI-NET BASED ON MY
NALKATA MODULE OFTREATMENT
Dr CB Narayan
CMO(SG), CH HZB

2. SYSTEM 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)

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

4. 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

5. 5

6. 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

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

8.  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.

9.  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.

10. 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.

11. MONITORING CODEWORKINGWELL
Here 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.

12. B - BLOOD PRESSURE => HYPER-TENSION/HYPO-TENSION
P - PULSE =>TACHY CARDIA/BRADY CARDIA
T -TEMPERATURE => HYPERTHERMIAWITH/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 => DYSPNOEAWITH/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

13. 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.

14. 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.

15. Anaemia
Merozoits 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)

16. Jaundice
In 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.

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

18. Urine
Firstly 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

19. Vomiting
Factors 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.

20. Chest
a) 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

21. 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.

22. 7-Jun-14
More
anaerobic
respiration
Reduced generation
of ATP

23. 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

24. HEADACHE
As 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.

25. 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.

26. 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 tissues
a) 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.

27. 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 0-0-0-0-0-0
Tab PQ 45 mg
4 days
Stat
Main drug
24 hrs after L/F
Note “The Nalkata Syndrome” which comprises Heatstroke,
Gastroenteritis, Typhoid along with Malaria.
1. Inj ceftriaxone 3-5 days
2. Inj Metron
3. IV fluid along with ACT

28. -
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?

29. “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

30. 1
No improvement in method of case take
up & reflecting the same to unit hospital due to various reasons.
2
3
4
5
• COMPUTERTRAINING FOR UTILISING PRAHARY-NET HR MODULES
(MEDICAL) MADE MANDATORY IN DIFFERENT PHASES

31. Prerequisite /Recommendations for
Nalkata-module
1. 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.

32. 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.

33. 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.

34. 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.

35. 11- Sumo Ambulance - to every units for
quick evacuation of patients from border
12- IS-duty – separate vehicle be provided
for quick & secured move of the doctor
13- 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.