Beyond NJ 9842

by Nitin A Gokhale

  Since the Nursing Astt at Bila saddle had been evacuated, and the fact that the battle was to be focused in this area, I was moved up to this location. It was a chilling one Km walk to this post with shells flying all around. The men at Bila saddle (both of 8 JAK LI and 3/4 GR) were overjoyed to see me. I actually realized that the mere presence of an RMO in the battlefield contributes significantly to boosting morale, thus helping the war effort. A new RAP was dug. It was essentially a large bunker in the snow covered by a CGI sheet. Unlike Bila base, I did not have the luxury of a fibre glass hut with a bukhari inside to serve as the RAP. Intense shelling and the fact that Ojha had been evacuated a day earlier, ensured that everybody operated only from the bunkers. There was no scope of cooking, and all were to survive on biscuits, chocolates or Chikki till the battle was over. It is at these heights that you realize the importance of cooked food. The men as such did not like biscuits and chocolates. In any case where was the time to eat?

  The night of 23 September saw a fierce attempt by the Pakistanis to capture our post. Sheer guts, raw courage and determination ensured that the enemy was beaten back. The toll on both sides was heavy. I received innumerable casualties from Ashok and U Cut. All had serious gunshot wounds. The main problem remained maintaining an IV lifeline. While we physically thawed the IV fluids by putting them in warm water, but the moment we started a lifeline the IV line would freeze. Finally, assisted by some men of 3/4 GR we used burning stoves under the IV lines to keep them going. Warmth to these men was provided by extra sleeping bags and pain killers were administered copiously. There was no other option, but to tie a tight shell dressing as a tourniquet to control bleeding in a large number of cases. Additional casualties were treated in another bunker. We had by now become experts in timing our movement while going from one bunker to another, as taught to me by the JCOs. The moment a shell landed or burst we would come out and sprint to the next bunker, thus taking advantage of the time between two bursts. Thereafter, the snow scooter did shuttle service between my RAP and the helipad to take these brave injured soldiers to the ADS once the choppers arrived at first light.

  Though we beat back the enemy on that night, but it had taken its toll on us. The loss of friends, dehydration (as it was difficult to thaw ice for water since the entire area was coloured black due to the soot of the enemy shells) and non availability of cooked food did bother us. We were also running short of manpower to fight out the attack that was slated for the night of 24th. Reinforcements were picked up by chopper from the inducting troops of 3/4 GR from Camp I and Camp II which were at significantly lower heights, and dropped on the battlefield. It is a tribute to the acclimatization schedule developed by the Indian Armed Forces Medical Services, that once the acclimatization schedule was followed, we had negligible cases of HAPO. However, this was battle and it did not give any time for acclimatization. Since these men picked up by the choppers, were not acclimatized, almost all of them were complaining of a splitting headache and some were vomiting. They were exhibiting signs of Acute Mountain Sickness. Two developed HAPO. However, seeing the current situation, I could only afford to evacuate the HAPO cases. The rest had to fight regardless of their current medical condition due to the call of duty. I gave them a pep talk, a tablet of an analgesic and a tablet of Lasix, in an attempt to ward off HAPO. This was all that was available in my drug list to take care of AMS and hopefully prevent HAPO at that time.

  Another case demonstrating the spirit of camaraderie, brotherhood, determination and selflessness by the infantry soldier merits narration. At around 1700 hrs on the 24th, a group of nine soldiers of 8 JAK LI trooped into my RAP to have a chat with them. They had come from Ashok and U Cut and were to go back for the night defence again. Each of these brave men had not eaten for 48 hours and were feeling numb in their feet (wet socks and the inability to remove shoes due to battle conditions) due to severe frostbite. They were fully aware that if they survived the battle, they would be losing a substantial part of their toes to frostbite. They asked me if I thought that they were medically fit for war. I did not have the heart to lie to them, and told them that they are fit cases for casualty evacuation, but then who will fight the war? The senior among them pointing to a young 20 year old boy among themselves said “We have not come to be evacuated. The post has to be defended as it is the question of IZZAT of the Paltan. But Sir, this boy is the nephew of Nb/Sub Lekhraj who died yesterday. Their family cannot afford to lose another boy in this battle. He is the only male member left in their joint family. Please evacuate him only”. The boy was evacuated by me as a case of severe frostbite. Out of the balance eight brave hearts, four lost their lives on that fateful night defending Ashok and the rest sustained significant injuries. Till date I feel humbled by the selflessness exhibited by these men. It also brought out the role played by the RMO in not only treating casualties, but also building morale and thus contributing to victory in battle. For this the men must have complete faith in the RMO and the latter should be honest with them.

  A stroke of luck occurred on the 24th evening. By accident, we latched on to the enemy radio frequency and thus were capable of monitoring their move and taking appropriate action. This greatly helped our artillery battery commander who could bring down focused fire on the enemy based on their location. At around 4 am on 25 September an officer casualty of 3/4 GR who was brought to me and told me that the enemy had reached the top, and the Gorkhas were doing hand to hand fighting with their “khukries”. In a tactical masterpiece, the Air Defence Artillery gun located at Bila base was tasked to fire in a ground role by engaging the top of the ridge where the enemy was advancing. It was the first time in the history of air defence that this gun was used in a ground role. This, and the bravado of the Gorkhas broke the back of the enemy. Daylight forced them to call off the battle. The Indian Army had successfully defended Saltoro ridge in the battle codenamed OP VAJRASHAKTI. On Republic Day 1989, I was awarded the Yuddh seva medal, the first AMC officer to be awarded this honour. My nursing assistant Ram Sewak Ojha deservedly got the Sena medal (Gallantry) for his act of valour.

  This battle demonstrated the closeness with which the Armed Forces Medical Services integrate with the fighting arms in war. We live with them, rejoice in their moment of glory, and grieve with them as a part of them, besides providing medical care to them. It brings out that an AMC officer is a Soldier doctor, and not the other way around, in the true spirit of the Corps motto viz “Sarve Santu Niramaya”.

  The medical support of the glacier is provided right up to the FDL with the medical officer being deployed at each company (Coy) location (as against the traditional deployment of a medical officer only up to Battalion HQ level). The MOs and nursing assistants totally integrate themselves with the infantry subunits they are with, and this keeps up the morale of the soldiers, thus minimising psychological problems and enhancing operational efficiency in such harsh conditions. Operations in the glaciated environment of Siachen have opened a new chapter in the history of modern warfare. Never before has man battled with nature and fought in such extreme conditions. Siachen has turned a new leaf in medical tactical doctrine. Conventional thinking and textbook philosophy do not apply in this unusual environment. Innovations and improvisations entailing a high degree of mental mobility are a must for the successful conduct of operations in such an environment. The Indian Armed Forces Medical Services have done a tremendous job in providing health care and succour to our soldiers on the glacier. The medical chain has always functioned as a well oiled machine, thus not only saving a large number of brave lives, but earning the appreciation of Commanders at all levels. Siachen has indeed brought out the best in our men, clearly proving the immortal words, “When the going gets tough, the tough get going”.

  In the summer crevasses open up in large numbers

  The glacier in all its majesty

  XI

  Medicine Men: Siachen Saviours

  ‘Nothing that is learnt in Medical School applies here’


  The Siachen glacier presents an unique set of environmental challenges for the human body. These include low oxygen, partial pressure due to reduced barometric pressure at high altitudes (HA), extreme cold, high levels of ultraviolet radiation and low levels of humidity. Survival on the glacier involves battling not just these gruelling environmental conditions, but also combating long periods of isolation, making do with tinned and preserved foods, battling to obtain clean drinking water, living in cramped inhospitable temporary shelters without electricity, and the absence of a host of things considered essential and taken for granted by civilised society. Add to this the constant threat of enemy action, which requires man and machine to be fighting fit and alert 24 × 7.

  Siachen therefore becomes the toughest call of duty for Indian soldiers. As an Army doctor says: “The human body makes adjustments in its functioning to enable individuals to live and work at these extreme altitudes. These adjustments constitute the phenomenon of altitude acclimatisation. Acclimatisation, which largely involves increase in the rate and depth of breathing, and increase in haemoglobin levels in the blood, however, does not allow the human body to function on Siachen as it does at sea level. At an altitude of 5,000m for example, the levels of oxygen in the blood of a healthy soldier would be similar to that of a patient with a severe lung disorder at sea level. While such patients are admitted to ICUs, confined to beds and treated with continuous oxygen therapy, and soldiers at 5,000 m with similar levels of oxygen in their blood perform intense physical activity and fight the enemy!”

  ECG being recorded on study subjects at the Base Camp

  Studies have shown that medical problems can occur within a few days of reaching high altitudes, or at times even after months of stay on Siachen. Acute Mountain Sickness is one of the commonest acute high altitude illnesses encountered by almost 20 to 30 per cent soldiers on arrival at high altitudes. Tough doctors say this condition is largely benign and self-limiting if recognised and treated in time, but it is extremely distressing and often demoralising for soldiers. This is quite understandable since a healthy, physically fit soldier suddenly finds himself experiencing headache, nausea and loss of appetite for no apparent reason which spooks him, often causing him to wonder what other terrible things lie ahead.

  Prolonged stay at these high altitudes presents a completely different set of medical challenges. The human body is not designed to reside and function at such altitudes, and successful altitude acclimatisation does not occur at such heights. With added effects like impaired absorption of food from the intestine, dulling of taste sensation and severe loss of appetite, combined with low oxygen levels, impaired nutrition, raised haemoglobin levels, lack of mobility and dehydration makes the soldier susceptible to a host medical ailments. These could range from raised blood pressure, increased susceptibility to infections and weight loss, to life threatening events like blood clots in the lungs, brain, intestines, spleen and heart. Many soldiers also report sleep disturbances, impaired memory and loss of libido. Whether these conditions are reversible on returning to sea level and what, if any, are the long term consequences of having served at such extreme altitudes, still remains to be scientifically studied.

  This is where medicine men step in.

  Over the years, the Army Medical Corps (AMC) has instituted an excellent system whereby health lectures begin at the sea level, and continue through every transit camp on the way up to high altitude posts. The soldier is made aware of the likely response of his body to the peculiar set of challenges that high altitudes throws at the human body. This knowledge empowers him to recognise features of high altitude illness right at the beginning, and seek medical attention promptly to ensure quick recovery.

  A ‘field’ laboratory set up at TsangTse

  According to a number of doctors in the AMC, a more serious health concern during the first week at high altitudes is pulmonary edema or fluid accumulation in the lungs, and cerebral edema or fluid accumulation in the brain. These two conditions can be fatal if not recognised and treated promptly.

  It is a tribute to the efforts of AMC doctors and nursing assistants – who also brave high altitude hardships with other soldiers – that high altitude pulmonary edema (HAPE), which once afflicted on an average 15 out of 100 soldiers who served on Siachen, now affects less one soldier per 100 soldiers stationed there today.

  Such an impressive reduction in morbidity due to high altitude illness, is largely due to the focussed approach of the AMC teams who have spent months on the Siachen glacier, shoulder to shoulder with their fighting counterparts.

  The first-hand experience of having served on Siachen has motivated these brave doctors in uniform to research the physiological effects of high altitudes, and suggest methods to improve survival and physical performance at such heights. Today, in fact, deaths due to pulmonary edema and cerebral edema are a rarity on the glacier.

  Doctors on Siachen are indeed a rare breed of professionals. No medical school in the world prepares doctors to serve in conditions that prevail on Siachen. Isolated on Siachen, with a body of troops that rely on you to save their life in any eventuality, with the most elementary medical equipment which can malfunction in the exacting environmental conditions, the young medical officer faces the test of his life. Where intravenous fluids freeze, and the normally simple act of hearing patients’ heart and breath sounds with a stethoscope means asking him to disrobe in sub-zero temperatures, the doctor faces an arduous task.

  Nothing that he learnt in medical school would apply in such circumstances. No blood tests, X rays, ECGs or fancy investigations are possible. Often, the toughest decision to take is whether to evacuate the soldier to Base Camp, or to hold on and treat him on the glacier itself. Evacuation by air, although an easy option, is often at the mercy of the weather gods and terrain conditions. Helicopters do not land on every post, and carrying a medical casualty across the crevasse ridden glacier on foot is a daunting and often impossible task, when some time one needs to climb near vertical ice walls, and when every step in the rarefied atmosphere makes the lungs scream out for oxygen.

  As a senior doctor, who has spent time on the glacier remembers: “Improvisations and presence of mind makes the difference between life and death. As a young medical officer, I recall the day we suffered three casualties due to enemy shelling. As we watched our OP (observation post) come under artillery fire, there was little we could do but hope for the best. A call on the radio set confirmed our worst fears. Three soldiers were wounded with multiple splinter injuries. The wait for the shelling to stop was agonizing. I was desperate to know how much was the blood loss. As night fell and we were permitted to move, we asked a neighbouring post to begin evacuating the wounded down towards us, and we set off towards them trying to meet the wounded halfway, so that they could be treated as quickly as possible. We met an hour later, on the vast desolate openness of the glacier. Under muffled torch lights, a quick examination of the wounded revealed that they needed pain relief on priority. It was perhaps the most difficult injection that I have ever administered to a patient. At 17,000 feet, and sub-zero temperature, the vast emptiness of the glacier, the sky as our roof and the threat of fresh enemy fire, that was the place where I treated the injured! We brought the casualties to the company base using skid boards, as ice sleighs and parachute strings as harnesses, sliding them over the glacier, taking turns every few minutes to ensure we did not tire ourselves. The night was spent in our tent using kerosene stoves to provide warmth. We sang songs to keep our wounded friends awake, joking how they would have pretty nurses looking after them in a few hours’ time. Silently we prayed for clear weather the next morning to permit an early evacuation.”

  The HAPO bag: A life saver

  So have things changed over the last three decades?

  Yes, they have. The vast experience gained by the Army Medical Corps in the field of High Altitude Medicine and Physiology has translated into improved practices on the ground. Acclimatisation
schedules for troops inducted at high altitudes have been refined, modified, experimented with and implemented meticulously. The results are plainly evident from the mortality and morbidity data of the last three decades. Though the glacier still claims lives, many of these deaths are accidental. The focus of the high altitude medical researchers has thus shifted from prevention of high altitude illnesses, to areas such as improvement of physical and mental performance of the soldier at those heights. Strategies for rapid induction of troops in those areas, and molecular and genetic studies to identify soldiers who may be genetically susceptible to high altitude illnesses are in place now. Therefore, such individuals are screened at the sea level and not deployed at high altitudes. The DRDO (Defence Research and Development Organisation) has partnered the AMC in these ventures, providing both human and material resources to ensure optimal benefits to the soldiers on the ground.

  Talking to the AMC soldiers at the Leh’s Army Hospital

  A STUDY OF VENOUS THROMBOSIS AT HIGH ALTITUDES

  The field of high altitude medicine is, however, still young. Even today, new effects of high altitudes, on the human body are being discovered. In the last 30 years, sporadic instances of clotting of blood in the veins of previously healthy young soldiers at high altitudes have been reported internationally. With the large presence of our army at high and extreme high altitudes (EHA is above 18,000 ft), such cases have been occurring with regularity.

  A specialist doctor tells me: “As a haematologist (specialist in disorders of the blood) I have personally treated a number of soldiers afflicted by this malady, both in the eastern and northern theatre. The consequences of blood clots in the veins of a living human can be disastrous.