Tactical combat casualty care in the navy – Challenges and way ahead MV Singh, Sougat Ray, Sunil Goyal, RJ Singh, Rohit Sharma Journal of Marine Medical Society 2019 21(2):105-107

Telemedicine: A force multiplier of combat medical care in the Indian Navy Saurabh Bobdey, Shankar Narayan, M Ilankumaran, G Vishwanath, MV Singh, AK Sinha, N Anand, Kiran Maramraj Journal of Marine Medical Society 2019 21(2):108-111 The tasking of the Indian Navy has increased manifolds in the recent past due to the country's growing economic importance, increasing energy requirements, and expanding trade routes. As operational elements of the blue water Navy, Indian Naval ships and submarines are deployed far and wide for prolonged durations. Therefore, for ships and submarines to be able to operate far away from our coasts, a comprehensive afloat medical care system needs to be developed with the capability to provide need-based secondary (specialist) and tertiary (superspecialist) care to men at sea. Telemedicine is envisaged to provide the solution to medical care needs of personnel onboard ships/submarines and in remote islands/locations and support unhindered Naval operations in peace and combat scenario. Telemedicine is a genuine force multiplier; it will not only complement the present medical support and extend expertise to areas bereft of the same but will also be helpful in prolonged operations and extended deployments by providing specialist/superspecialist consultation to the men at sea. In today's world of advanced telecommunication, telemedicine is a perfect amalgamation of communication technology and medical science, which is bound to revolutionize the field of Combat Medical Care by improving both clinical outcomes and operational efficiency of the Indian Navy. The article reviews telemedicine concept, its components, utility in the provision of specialized medical care to men at sea and its limitations.

Decompression illness Ashish Tawar, P Gokulakrishnan Journal of Marine Medical Society 2019 21(2):112-115 Decompression illness (DCI) describes a syndrome complex caused by inert gas bubbles generated by an inappropriate rate of reduction in ambient environmental pressure or decompression. This “umbrella term” covers both traditional decompression sickness caused by in-situ bubble formation from dissolved inert gas and arterial gas embolism (AGE), in which alveolar gas or venous gas emboli (via shunts or by-passing pulmonary vessels) are introduced into arterial circulation. DCI occurs in divers, compressed air workers, aviators, and astronauts, but AGE could also arise from iatrogenic causes unrelated to decompression. A hundred years ago, serious manifestations and deaths were frequent in divers and caisson workers due to DCI, but they decreased greatly when decompression stops were introduced in diving practice. This review article is of interest to the doctors who face the dilemma of treating the rare syndrome of DCI that could present in the clinical spectrum ranging from itching and minor pain to severe neurological symptoms or other systemic pathology. The first aid lies in the administration of 100% oxygen, and definitive treatment is therapeutic recompression. With appropriate and adequate treatment, recovery is complete, but some severe cases may have lifelong residual deficits, even after extended and multiple recompressions.

Psychological stress in the navy and a model for early detection Puneet Khanna, Kaushik Chatterjee, Sunil Goyal, RR Pisharody, P Patra, Neha Sharma Journal of Marine Medical Society 2019 21(2):116-120 Stress is unavoidable and encountered in many shapes and sizes. Being in a state of peaceful happiness may seem like an unachievable goal. Serving in the Armed Forces brings unique challenges during peacetime, in addition to the harmful mental and physical effects of service during war. The prolonged periods of separation from family, the very threat to life and limb, the imminence of physical danger, and the likelihood of the loss of a close colleague make the Armed Forces environment, especially in combat, inherently stressful. The lethality of the modern conflicts is potentially greater, and the way that conflicts are waged is more asymmetrical when compared with the wars of an earlier era. The Navy has its own unique set of stressors. Naval operations across the entire range of conflict expose naval personnel to a multitude of stressors. These stressors can lead to varied negative mental health consequences for the service personnel as well as their families. Increased deployments entail other stressful changes in the naval units as well, such as an increased number and intensity of training exercises, planning sessions, and equipment inspections, all of which increase the workload and pace of operations. Through this article, we briefly review the literature on this subject, emphasizing on stress and its types and stressors in Armed Forces, particularly the Navy. The article also dwells on early recognition of stress and timely intervention through the Stress Continuum Model.

Critical care air transport team and patient transfer unit: A decade of experience of a zonal hospital Parli Raghavan Ravi, MC Joshi, Manish Dhawan, Sarubh Sud, MN Vijai Journal of Marine Medical Society 2019 21(2):121-129 Introduction: The critical care air transport team (CCATT) established in 2007 a vital components of medical evacuations (MEDEVAC) in north-east India. Aim of the Study: The aim of this study was to highlight the importance of obtaining epidemiological data pertaining to the patients transported by CCATT. Method: Cases were analyzed based on the following criteria: age, sex, diagnosis of patient ,spectrum of disease and trauma, ventilation modes, inotropic support, hours of illness/injury before transport, flying time, flight distance, dedicated missions, interventions done aboard the flight and outcomes in the patient within 48 hours. Results: As many as 305 patients were analysed.39.5% patients were surgical patients, 58.5% medical and 1% was pediatric. Among surgical patients 56.8% patients were of poly trauma, 22.8% had traumatic brain injury. 68.8% of the patients transported were non-battle casualties. Dedicated missions constituted 43.4%, while the longest time for CCATT to return to base was 28 hours, shortest been 4 hours.46.8% of the patients required ventilatory support.63.4% of the patients were on inotropic support. 82.6% of the patients survived first 24 hours while 72.6 % of the patient survived 48 hours. Conclusion: Understanding the epidemiology of casualties evacuated by CCATT is an imperative requirement for the developments of effective pre-deployment training to ensure optimal outcomes for critically injured.

Managing extramural neonates: Experience from a zonal hospital Vivek Bhat, Ranjeet Wishram Thergaonkar Journal of Marine Medical Society 2019 21(2):130-133 Introduction: There are many challenges in the care of extramural neonates (born outside the hospital), especially in resource-limited secondary care (zonal) hospitals of the Armed Forces. The objective of the present study was to describe the workload and complications faced in the care of extramural neonates in a zonal hospital of the Armed Forces. Subjects and Methods: The study design was descriptive. The setting was a 306-bedded zonal hospital. Records of all neonates transferred from other hospitals between January 1, 2017 and December 31, 2017 were studied. Median and interquartile range of continuous data, as well as the number and percentages of ordinal data, were calculated. Results: Seventeen neonates (10 males) were received from a median distance of 70 km. The workload comprised 539 patient-days and 12.4% of the nursery workload. The extramural neonates included 2 (11.8%) extremely low birth weight (<1000 g), 6 (35.3%) very low birth weight (1000–1499 g), and 4 (23.5%) low birth weight (1500–2499 g) babies. Thirteen (77.4%) neonates were lateral referrals from private nurseries. The complications included hypothermia in 4 (23.5%), hypoglycemia in 3 (17.6%), and sepsis in 8 (47.1%) neonates. One (5.9%) baby died after admission. Conclusions: Extramural neonates constitute approximately 12% of the nursery workload. High number of low birth weight babies, lateral referrals from other neonatal intensive care units, relatively lower but significant rates of hypothermia and hypoglycemia, high rate of sepsis and low mortality highlight the management of extramural neonates in a zonal hospital.

Evaluation of carotid plaque vulnerability using shear-wave elastography: An observational comparative study Rajeev Sivasankar, Ramandeep Singh, PI Hashim, Brijesh Kumar Soni, Rajneesh Kumar Patel, Amit Bajpai Journal of Marine Medical Society 2019 21(2):134-137 Objectives: This prospective observational, comparative study was aimed at assessing our results of shear-wave elastography (SWE) in evaluating carotid plaque vulnerability. Subjects and Methods: Sixty patients were prospectively studied over 2 years in a tertiary hospital setting and divided into two groups of 30 each. The first group consisted of patients with atherosclerotic plaques with a history of stroke, whereas the second group consisted of 30 patients with atherosclerotic plaques without stroke. Carotid plaques in both groups were studied for plaque length, morphology, and SWE measurements. All data analysis was performed using SPSS software (version 22, IBM SPSS statistics). Results: Both groups showed no statistical difference with respect to comorbidities, addictions, or anthropometry. The internal carotid artery was involved in 24 (80%) and 13 (43.33%) patients in Groups A and B, respectively. Mean length and width of the plaque were more in Group A patients than that of Group B patients on both right and left sides. Proximal stiffness (kpa) was 32.27 and 42.86; mid stiffness was 32.92 and 45.77, while distal stiffness was 26.57 and 38.15 in Groups A and B, respectively. The proximal, mid, and distal stiffness values of the plaque in Group A were less on stroke side as compared to nonstroke side with a statistically significant difference. Conclusion: SWE is a noninvasive, reproducible, and reliable imaging technique which could be used as a tool for the early detection of vulnerable carotid artery plaques.

Carotid artery plaque evaluation by shear wave elastography Faiz M H Ahmad, Subrat K Nanda Journal of Marine Medical Society 2019 21(2):138-138

Penetrating abdominal injuries due to firearms in combat zone – Single center experience AK Sharma, Vivek Agrawal, Abhijeet Lal, Abhimannyu Choudhury, Pallab Chatterjee, Manomoy VSM Ganguly Journal of Marine Medical Society 2019 21(2):139-144 Background: Abdominal trauma is a frequent indication for surgical exploration of the combat causality. Rapid transportation to trauma center, early recognition of injuries, sound surgical judgment, and timely intervention are critical for reducing mortality and morbidity. Patients and Methods: All penetrating abdominal trauma (PAT) cases admitted to a combat zone hospital from January 2014 to December 2016 were studied. Results: Forty-eight patients with PAT were evaluated and managed. Majority (66.7%) were secondary to gunshot injuries. Forty-one required operative management. Out of these, 6 (12.5%) underwent diagnostic laparoscopy and 35 (72.9%) required laparotomy. The small intestine was the most commonly injured organ which was encountered in 21 (43.7%) cases. Two (4.2%) patients succumbed to their injuries. Early resuscitation in combat zone followed by prompt evacuation to the combat hospital improved the overall outcome. Conclusion: PAT is a common cause of morbidity and mortality in combat areas. Rapid transportation, sound clinical judgment, and early surgical intervention are critical for patient survival and better outcomes.

Relationship between stigma, self-esteem, and quality of life in euthymic patients of bipolar disorder: A cross-sectional study Debajyoti Bhattacharyya, Anuj Yadav, Arun Kumar Dwivedi Journal of Marine Medical Society 2019 21(2):145-150 Background: As per the existing literature (mostly Western), bipolar affective disorder or bipolar disorder (BD) is associated with low self-esteem, high stigma, and poor quality of life (QOL). Aims: The current study aimed to assess stigma, self-esteem, and QOL and to examine their interrelationships in euthymic patients of BD in the Indian settings. Settings and Design: This hospital-based, cross-sectional study was conducted in a tertiary care hospital in Delhi over a period of 12 months. Subjects and Methods: Sixty-two adults with BD (as per the International Classification of Diseases-10 criteria) in remission were selected. Stigma, self-esteem, and QOL were assessed using the Internalized Stigma of Mental Illness (ISMI) scale, Rosenberg Self-esteem Rating Scale, and World Health Organization (WHO) QOL-BREF, respectively. Statistical Analysis Used: Data were analyzed using Student's t-test, Pearson's correlation coefficients, and multiple regression model. Results: Thirty-two percent of patients did not experience stigma (ISMI total score < 2.00). Mean total ISMI score for patients was 2.33 (mild stigma). Compared to controls, patients were found to have lower self-esteem (mean: 12.63) and lower scores on WHOQOL-BREF. Self-esteem scores were associated with all domains of WHOQOL-BREF, whereas ISMI total scores were not. Further, self-esteem was not found to be associated with stigma scores. Conclusions: Patients of BD in remission have low self-esteem, experience mild stigma, and have a low QOL. Lower self-esteem was strongly related to lower QOL, whereas stigma was not. Measures to improve self-esteem may benefit patients of BD in the long run.