After graduation from Armed Forces Medical College on 6 December 1984 and completing a year’s mandatory internship in Military Hospital Jabalpur, I was licensed as a general practitioner. My first posting was as regimental medical officer (RMO) with 15 Dogra –an infantry unit. In this brief communication, I will be highlighting the medical aspects of my first tenure as a general practitioner which was essentially for providing primary health care to troops, their dependents, some families, emergency medical care to civilians and also periodic outpatient care to civil society for image building and altruism. My three years as RMO which spanned three countries India, Bhutan and Sri Lanka is associated with some unique experiences that I will treasure till I die. It was the era of clinical diagnosis without ECG, radiology and laboratory support in the field area. In this setting research would have been a difficult proposition unlike today’s era of tertiary care when diagnostics are indispensable even for primary healthcare.
Immediately after completing a mandatory basic military course in Lucknow, I moved to my next appointment somewhere in Northeast India. I was stationed in the Battalion Headquarters (Bn HQ) with my office in the unit medical inspection (MI) room in March 1986. Thirtytwo years back the facilities available included a mercury sphygmomanometer, oxygen cylinders, basic surgical facilities to drain an abscess or suture trivial wounds, intravenous fluids, lyophilized plasma, narcotic analgesics, mostly oral antibiotics, anti–malarial drugs including injectable formulations of quinine and chloroquine and usual medications for a remotely located MI room as the nearest hospital was eight–ten hours away by surface transport. The unit which had 13 posts was deployed over three hill ranges and a valley. Other than the MI room in Bn HQ, medical care was provided through the medical platoon, popularly also called the “Band Platoon” which comprised of infantry soldiers whose duties included dishing out labeled medicines, recording body temperature, wound dressing, communication of patient symptoms through wireless communication to me or to trained nursing assistants in MI Room. The members of Band Platoon could administer intramuscular drugs if it was an absolute necessity. My “sick report” comprised of jawans from the Bn HQ, civilians staying in vicinity, jawans coming in by military convoy from other posts which were all 4-6 hours away. As we were located in the East, daylight hours were short and movement was possible only between 0500-1500 hours Indian Standard Time. If there were two nursing assistants in Bn HQ, one was sent out with troops for patrolling, military exercises and sometimes retained for short durations at remote posts to provide confidence to the troops. All personnel were on weekly prophylaxis with Amodiaquine.
The nearest military hospital had the capacity to provide all basic specialty care including a good intensive care unit, operation theatre, internal medicine specialist, and an excellent surgeon. In those good old days, competent surgeons would take on anything from vagotomy, pyelolithotomy, cholecystectomy to internal fixation of comminuted fractures — as those days were not of tertiary health care. In addition to this, excellent air evacuation facilities were available during daylight hours if weather conditions permitted. Kudos to the higher formation for always supporting timely evacuation of patients. Of course, I had to be reasonably sure that the patient warranted air evacuation. There was a government primary health centre located on higher hill — 500 meters as the crow flies but would have taken 40 minutes of travel by a military jeep.
April 1986: I was reading in my cabin on a Sunday afternoon when suddenly there was a thunderstorm which was soon followed by lightning and gusty showers. The Adjutant, who was residing in an adjacent cabin, asked me to rush to the MI room as one jawan who was working in the communication “signal” centre had been struck twice by lightning. I immediately ran to the MI room which was at a higher level and almost 500 meters away. I found a jawan on the floor in his shared accommodation and a newly posted young Nursing Assistant trying to revive him by providing mouth-to-mouth respiration. He had also set up an intravenous (IV) lifeline with normal saline. On checking his vitals, I found that the pulse was not recordable and breathing labored. Immediately I administered two 1 ml vials of intracardiac 1:1000 Adrenaline. Cardiopulmonary resuscitation was continued and after forty minutes when his respiration became spontaneous, the medical team headed by me was very relieved. In the meanwhile, the Adjutant had managed to get the civilian doctor from primary health centre also to help out with the resuscitation. The patient’s vital parameters were restored, but he was unable to speak out and only made some unintelligent sounds. Other soldiers commended our efforts but were upset by the patient’s inability to speak. As it was already past 1600 hours, a decision was made to observe the patient in the MI room itself. On the following day he attended to all his daily chores, apparently could hear others, but still was unable to speak. Almost 36 hours later, he probably got out of the shock and started speaking, much to our relief. The only possible explanation for his sudden aphasia that I have is intense mental trauma, and not transient brain hypoxia, which however can’t be entirely ruled out.
Malaria was always a source of concern. In the ensuing eight months from May to December 1986 there were 13 patients of Plasmodium Falicprum Malaria of which one patient had bizarre manifestations. The soldier was holding on to his abdomen and was complaining of intense tummy pain followed by uttering of incoherent sounds. The second patient—a Junior Commissioned Officer placed in a remote post in the valley, had developed altered sensorium along with high fever. Both patients were confirmed to have cerebral malaria at admission in the Military Hospital. I had diagnosed them over the wireless on basis of their symptoms combined with intuition, because there was no way that I could have gone and examined them physically. Another patient who was treated in his post by IV Quinine went on to develop Blackwater Fever defined by frank persistent hematuria. Twelve patients were confirmed as Plasmodium Falicprum Malaria by smear examination in the Military Hospital where they were evacuated by air. The patient with Blackwater fever was evacuated by surface transport after 72 hours treatment in the Unit. He too was discharged with normal renal function. It had been a very rewarding experience to be able to treat/ provide timely evacuation of all soldiers.
It was December 1986 and the troops had to move to a new location. On the very last day I was given some additional responsibilities when a call came from a remote post about a soldier with no previous history of peptic ulcer disease, complaining of dyspepsia with mild abdominal pain. I asked the Band Platoon representative to administer antacids and keep me posted about his health. Sometime after sunset, I got a call which informed me, that the patient had vomited twice and the pain which had recurred was very severe. I asked the administrative authorities to arrange for his evacuation and also make arrangements for me to accompany him because I was suspecting a ruptured peptic ulcer. This was corroborated by the paramedic who said that the abdomen felt hard. I moved from Bn HQ and the patient from his post. Our routes were same after some 50 odd kilometers. After accompanying the patient for six hours we reached the Military Hospital next day at 0400hrs. The operation theatre had been activated by the surgeon who had been informed about my clinical suspicion. Immediately on arrival the patient was resuscitated and laparotomy performed. He was discharged from the hospital subsequently.
As part of goodwill to civil population the medical team had undertaken school health check for a primary school which involved medical checkup of approximately 500 children over three days. In addition to many children with severe malnutrition, skin diseases, parasitic infestations, cleft lip, I was able to identify clinically two children with Dextrocardia on the basis of location of their apex beat and heart sounds. One soldier developed excruciating left sided chest pain mimicking Myocardial Infarction. He was evacuated to the nearby Military Hospital where the electrocardiogram (ECG) was normal and a diagnosis of Myalgia Chest was made.
It was to the good luck of the Unit that we were handpicked to go to Bhutan for three months from May to July 1987. I was fortunate to have a proper built up area where I saw patients including families of soldiers from Royal Bhutan Army. I was sitting in the MI room of local unit when first few children with crepitations and fever came to me. On enquiring further history, I came to know that this was post measles and one child had succumbed to secondary pneumonia. In my tent at 9000 feet after seeing the patient in OPD (Out Patient Department), I pondered. The MI room had injectable Ampicillin and the challenge was to administer parenteral antibiotics in a peripheral set up. Some 40 kilometers away in a Border Roads MI Room a pediatrician was posted as RMO. I called him and asked if I could use parenteral Ampicillin safely in children to which he replied in the affirmative. Later in the afternoon I rushed to the MI room and asked someone to call the child’s parents along with the patient himself. This was the beginning of successful treatment of 5-6 children with parenteral Ampicillin in a dose of 25-40 mg in 3-4 divided doses and it was very satisfying to not lose even one child. Three patients including a soldier from Royal Bhutan Army with severe gastroenteritis were also managed aggressively with IV fluids and probably parenteral antibiotics.
The unit then moved to Agartala and remained there from July to December 1987. Agartala had both a Military Hospital and also a Government Hospital. After seeing my daily sick report, I loved going there to see OPD as well as ‘in patients’. I remember administering adrenaline incorrectly to an admitted patient and then praying fervently that nothing should go wrong — fortunately he survived. The same soldier who was struck by lightning in original Battalion location developed severe left sided chest pain which was refractory to IV morphine. After waiting for a couple of hours he was referred to the Military Hospital for admission with a provisional diagnosis of Myalgia Chest. The ECG was unremarkable and the soldier was discharged after three days of hospitalization.
The unit then moverd to Sri Lanka as part of Operation Pawan. (February 1988 – March 1989) I was enveloped by a feeling of utter helplessness when within a month of induction into the island, five soldiers were brought to the MI room following mine blast injury. After applying shell dressing and instituting IV fluids, two were transferred to the nearby hospital, but five died within minutes of arrival. There were two young Tamil women who were rendered first aid in MI room -one following viper bite and second for organophosphorus (OP) poisoning. The former was treated successfully, but the patient with OP poisoning could not be revived after initial recovery because the stock of Atropine was exhausted.
In this brief account I have made an endeavor to recollect and narrate some of the memories as RMO of an Infantry Battalion where my role was to provide primary health care. The interaction with Dogra troops was extremely cordial and memories are indelible. It was heartening to meet the battalion troops in my two subsequent visits. Now things have changed to some extent and point of care diagnostics by way of ECG, portable X-Ray and even defibrillators are available but reflecting about those days I think that I did my duties reasonably well.
An ex AMC immunopathologist, Col MN Mishra was RMO 15 Dogra for 3 years, worked with NHS for a year has a passion for Deceased donor transplants. He is presently working with Baptist Christian Hospital in Tezpur as Consultant Pathologist. The pics in this article are for representational purposes only.