Beyond NJ 9842

by Nitin A Gokhale

  “I particularly remember the case of a young officer, of the Dogra Regiment, that occurred in 2005. This officer was stationed at an altitude above 18,000 ft on the glacier when, within days of arrival, he developed clots in the veins of his brain, both legs and one arm. Bad weather on the glacier prevented his evacuation for a number of days. He was brought comatose to Army Hospital (R&R), Delhi, where I first saw him. I had never seen such extensive clots in anybody before! The delay in evacuation must have been responsible for allowing the clots to grow. It took us, a team of doctors, weeks to bring this officer back, as he battled for his life. Repeated surgeries and weeks of clot busting drug therapy later, this officer all of 30 years of age, survived, but in the bargain both his legs and the left arm had to be amputated. It was such a tragedy, especially for one so young. But like a true soldier and hero, he has overcome his loss to lead a near normal life today, but his case highlights the health risks that may strike the unsuspecting combatant as he ascends to extreme altitudes and the cold of the glacier, wilfully, to defend his motherland. (See box)

  Doctors say clotting of blood in the veins is a very rare event at the sea-level, and almost always occurs with the setting in of other comorbidities such as cancers, polycythaemia (excessive red blood cell formation) or dehydration and prolonged inactivity. Thus, the occurrence of clots in the veins of the legs, lungs, brain and other organs in healthy people at high altitudes is indeed surprising. Early research in India and abroad could not identify much that was wrong with the clotting system of the body at extreme heights. It was therefore natural that this was blamed on known factors such as inactivity due to bad weather, dehydration due to the excessively dry atmosphere and thickening of the blood caused by an increase in RBC counts. An increased RBC number is a mechanism of the body to combat the low oxygen at high altitudes.

  The HAPO bag saves precious lives

  Intrigued by the phenomenon, in 2009 a team of doctors were finally tasked with studying venous thrombosis (clotting of the blood in veins) at high altitudes. The commanders were worried about the number of soldiers getting afflicted by this ailment and the effects it had on their life, as also on the morale of their colleagues.

  Says the leader of this team:“I grabbed the opportunity with vengeance, being determined to do something to prevent this disease and/or reduce its impact on the lives of our brave soldiers on the glacier. We found that health data from 1987 onwards showed that a large number of soldiers were referred to various Armed Forces Hospitals from high altitude areas because of blood clotting. The largest number of these, it came as little surprise, were from the extreme altitudes of the Siachen glacier.

  “I, along with some colleagues, therefore set about designing and conducting a study. In the beginning, the one thing we were very sure of was, that the study must be done in actual ground conditions. We would never be able to simulate the multiple effects of altitude ascent and stay, in any laboratory. Therefore we designed a ‘prospective longitudinal cohort’ study to elucidate the mechanisms of blood clotting at high altitudes, and the risk factors that predispose a healthy soldier to develop a clot at high altitudes. The idea, so to say, was to unravel the plot behind the clot!”

  The study entailed repeat examinations and tests on hundreds of soldiers at every stage, starting from the plains to extreme altitudes and back over a duration of more than two years. No such study had been done anywhere in the world till then. The logistics challenge itself was mind boggling.

  The very first problem was to build a team of doctors and scientists who would not only have the requisite expertise but, perhaps more importantly, the passion and endurance to go through with the project involving as it would multiple visits, each spanning weeks, to various locations in the plains and at high altitudes.

  With the full backing of the Armed Forces Medical Service (AFMS) the team leader was given total freedom to choose a large number of specialists from the many hospitals that the AFMS runs across the country. There was one condition: Each specialist needed to have spent at least one tenure at high altitudes, not necessarily on Siachen. Eventually, a team that included specialists in blood diseases, pathologists, physiologists, medical specialists, radiologists as well as scientists from the DRDO, was put together. It had doctors from Army Hospital (R&R), Delhi, AFMC, Pune, Command Hospital, Chandimandir, 153 General Hospital, Leh, the High Altitude Medical Research Centre, Leh, a number of field hospitals of the Army in Ladakh and the DRDO’s Defence Institute of Physiology and Allied Sciences (DIPAS) in Delhi.

  The study was, however, easier designed than done. The next problem area was to find the right subjects, i.e. a multi-ethnic group of otherwise healthy soldiers scheduled for induction to high altitudes and the glacier. The need for a multi-ethnic group was prompted by stray reports of ethnic pre-disposition to ailments at high altitudes.

  Study team members with soldiers freshly descended from the glacier

  Says the team leader: “We found the ‘ideal’ subject group in a battalion of infantry soldiers in the Grenadiers Regiment. This battalion is composed of Jats, Rajputs, Gujars and Hindustani Muslims hailing from the states of Rajasthan, Haryana, UP, MP and Bihar.”

  The study hinged around analysis of blood samples by various tests of coagulation and proteomic and genomic studies. Blood had to be drawn repeatedly from the same soldiers first at their plains location, Jammu, and then as they proceeded through various stages of their stay at high altitudes.

  “Since we conduct a large number of tests every time on every soldier, a fairly large sample of blood (40-50ml) had to be drawn at every contact. As we know, in India blood donation, or removal of any blood from the body generates unimaginable fears of ills ranging from loss of strength and stamina to decrease in libido!! Thus, a structured educational initiative had to be undertaken which involved lectures as well as individual counselling. The initiative was successful, and today our subjects not only voluntarily allow us to repeatedly (3-6 months apart) draw blood, but have also become a force multiplier spreading the word that removal of small amounts of blood from the body does no harm to health at all! The first time we had drawn blood samples, in spite of our education initiative, the hospital fruit vendor would run out of his daily stock of pomegranate (Anar – traditionally considered to be a health food) well before the day was over, selling Anar juice to our subjects,” the team leader remembers.

  Blood testing posed some more problems. A number of the tests require sophisticated equipment which was too unwieldy to be taken to field areas, or be used in any conditions other than the exactingly controlled conditions of a high tech laboratory. The laboratories are based in Delhi at the Army Hospital (R&R) and DIPAS. So thousands of samples collected from Jammu, or the two high altitude locations (Tsang Tse and Base Camp in Ladakh) had to be carried to Delhi by road and by air. There was an additional problem: the samples need to be stored at minus 40°C. For short periods, minus 20°C temperature is tolerated. To overcome that problem, a portable deep freezer named “Bevena”, capable of maintaining temperatures at –20°C was designed to carry the samples.

  However, since it had no battery back-up, it needed to be plugged into a power supply every 3-4 hours for temperatures to be maintained. The biggest test for this device was the time when the samples had to be taken by road from Jammu to Delhi in the peak summer months of June and July 2012.

  Doppler examination of the legs being performed at the ADS in TsangTse

  Remembers the team leader: “Our passionate pathologist friend, not ready to trust his precious cargo to anyone else, travelled in a mini-truck carrying the deep freezer twice from Jammu to Delhi, plugging the device into the power supply at toll posts and once even at a police station in a small town. His hard work paid rich dividends and the samples reached Delhi safely!”

  But the sword cuts two ways. Where the cold of high altitudes helped store blood samples with ease, the low pressures at high altitudes disabled two portable semi-automated blood anal
yzers the team carried to do simple blood tests, such as measurement of haemoglobin and blood cell counts! The machines which analyze small samples of blood through a micro-tube, would not develop sufficient vacuum to suck in the blood samples. The equipment manufacturers’ engineers were dumbfounded when asked to suggest a way around this problem, not having encountered such a problem before.

  Once again it was the pathologist who came to the team’s rescue. That, in a way, is characteristic of working at high altitudes. Most equipment is meant for temperatures and pressure conditions found at sea-levels, usually in controlled environments of a laboratory or hospital. Whether it will work in a field setting at high altitudes is anybody’s guess, till it is actually used in such a setting. Constant innovation becomes a way of life in the challenging environment.

  Recording a routine ECG in a pre-fabricated fibreglass hut, for example, can be a problem. A fully dressed individual is comfortable inside these huts. But, recording an ECG requires removing the clothing, and suddenly one has a shivering subject whose ECG trace resembles a jagged sawtooth rather than the organized ‘P’ ‘QRS’ and ‘T’ waves caused by electrical impulses of the heart, that a doctor is looking for.

  “We warmed the huts and buildings with all manner of bukharis, stoves and kerosene heaters. We allowed people to crowd inside so that the heating devices and body heat in closed spaces warmed the temperatures till people actually felt warm enough to take off their clothes for the ECG! Quite a feat at subzero temperatures and rather unconventional, considering the strict concern for individual privacy that we doctors practice at all times. But, the soldier is not squeamish about partial nudity amongst colleagues, and as I said before ‘innovation is the name of the game.’ Of course, the smoke from all the heating devices was causing discomfort which none minded. Warmth was paramount,” the team leader tells me.

  Every trip to Ladakh entailed carrying more than a thousand kilograms of equipment. For this and for transporting blood samples from Leh to Delhi the staff of Indian Airlines was most helpful and accommodating. Repeated exposure of the research team members to the high altitude environment brought up issues of acclimatization too. Working on tight schedules, the team had to make do with a minimum safe period for acclimatization at Leh before ascending higher. A few doctors did suffer AMS (acute mountain sickness) in the first few visits, but as is typical of high altitudes, their illness decreased in severity with subsequent visits.

  Recalls the team leader: “As per our study protocol, we have studied soldiers in four different phases. The first phase involved baseline studies when the soldiers were healthy in the plains at Jammu. The second phase entailed studies at high altitudes after a month or so of acclimatization at Tsang Tse and at the Base Camp. Shortly (within days, often, the very next day) after this phase, the soldiers ascended the glaciers. All going to posts in excess of 17,000 ft and many to posts as high as 20 to 22,000ft. We again examined the soldiers as they came down after spending between 90 and120 days at extreme altitudes. This third phase of our study helped us to determine the effects of stay at extreme altitudes on the clotting system of the body and other physiological parameters. In the fourth phase, in Tsang Tse again, we examined the soldiers approximately six months after descent from the glacier, to elucidate the residual effects of stay at EHA. The final, fifth phase of the study is yet to come when we shall examine them after descent to near sea-level. We hope to study the residual effects, and the time taken for the body to return to normal after a gruelling two years at HA and EHA.”

  Speaking to the team of doctors at Leh’s Army Hospital

  The main aim of the study is to find markers to identify an “at risk” group, if any, who are pre-disposed to clotting of blood at HA or EHA. The study will also define how long the clotting tendency induced by HA lasts. At the moment no data exists.

  Interestingly, the doctors during their regular interaction with the soldiers, found a number of other health related issues cropping up. A few common complaints they had after returning from the glacier were loss of weight, excessive sleepiness, a tendency to be forgetful and for some, a loss of libido too. Weight loss appears to be a universal problem with decrease in fat as well as muscle mass. Most soldiers report altered sleep patterns on the glacier, with a general decrease in the number of hours they slept daily. What is remarkable about the sleep deficit, however, is that at extreme altitudes the decreased sleep appears not to translate into excessive daytime sleepiness!! It was only after they descended, that the soldiers started feeling excessively sleepy, and this continued for some days at Base Camp as if catching up on lost sleep.

  Soldiers undergoing a crucial test

  Forgetfulness was the most common malady that affects almost all those who have descended from EHA. Doctors say: “This appears to involve immediate tasks at hand. For example, one commonly forgets where one has put down an object say a torch, a few moments ago. Most of these phenomena are anecdotally known to reverse with time at low altitudes or at the sea-level, but their exact time course and permanent residue if any is yet to be studied.”

  The study is far from complete, but its range and scope was wide, and through its conclusions the team of doctors are hoping to unravel a few of the mysteries about venous thrombosis at high altitudes, and offer succour in some form to the heroic soldiers. As the team leader told me: “The amazing spirit of the battalion that has volunteered to a man, to become the subject of our study is just another example of the selfless nature of the common soldier who leaves the comforts of home and hearth with not a complaint, indeed with a cheerful smile, to defend his land and his people at any cost to his own self.”

  MEMORIES OF A REGIMENTAL MEDICAL OFFICER ON THE SIACHEN GLACIER

  My ascent to the “Chandan” post on the central glacier complex began in early March 1995. After the customary prayer ceremony at the Base Camp in early morning, we slowly started climbing the 30° incline up the valley floor, till a spur put us out of sight of those watching and waving to us from below.

  A week earlier, on reporting to the ADS (Advance Dressing Station) at Base Camp I was greeted by Capt Srinivas, three years my senior in college. A generous and cheerful man he guided me through the nuances of early diagnosis of high altitude ailments especially the dreaded HAPO and frost bite. “Remember, being at high altitudes does not mean that the patient shall suffer only high altitude ailments. Always consider all likely disorders before you diagnose a HA ailment and do not panic if you have a patient of HAPO or HACO. Just send them down to me! If evacuation to Base Camp is not an option for any reason, a little bit of descent and oxygen will do a world of good to them and in fact to anybody with any ailment on the glacier,” was his first basic advice which stood me in good stead many a time in the next five months or so that I spent on the glacier.

  Nima Norbu lost three limbs after being stuck in a crevasse for 25 hours

  While training in the Siachen Battle School, I met my classmate from school. So SBS training and my stay in Base Camp turned into an enjoyable experience. We worked hard through the days and partied harder at nights! The number of friends I made in that one month is more than I made in the next 19 years of service.

  We started climbing under a bright sun, and the sky remained clear till we reached the first staging camp within three hours of starting the ascent. But, then to my utter surprise, in a matter of minutes, the azure blue skies were covered in clouds. It snowed for the next 10 days. So I stayed at 14,000 ft for the duration of the bad weather and felt lucky to have got so much time to acclimatize.

  The next ascent would be a cake walk I thought, and eagerly set off. But the snow was waist deep and we were wading through it rather than walking. My breath was coming in short bursts. I had to stop and rest every 4-5 steps and my throat felt parched and my legs heavy. Soon it was clear to me that this would be far from a cakewalk. Having commenced the ascent at 9 am, we finally arrived at the half-link point at 1 pm, a four hour walk for a two km stretch!


  I was ascending with a group of highland native soldiers who had been at those altitudes for 2-3 months by then, and were fleet footed at those and higher altitudes as the deer in the Rajaji national park!

  The obvious impatience displayed by some of them at my slow climb embarrassed me, and after a half hour stop for rest and lunch half way to the next post, I decided to move faster. But my intentions were scuttled almost as soon as we started. For, within a few hundred yards of where we had rested, we had to walk on a path along the mountainside which came to a stretch where it undulated 4-5 feet some 7-8 times over the next 50 meters or so. Here due to the heavy snowfall in the last 10 days, and it being the hottest hour of the day, snow fell in the form of small avalanches at regular intervals. Therefore, our group leader, a young Naik, decided that we must run across this stretch with him in the lead, keeping an eye out for an avalanche. He was good. He got us across, stopping twice to avoid small avalanches. That turned out to be the last straw for me. As soon as the others stopped to take a breather, I sat down heavily in the snow and thereafter refused to budge. I told my fellow soldiers that they should carry on as I would sleep the night there and join them the next day!!

  I do not know if they were bemused or angry. What I do know is that at that moment, I was being totally honest, for I had a headache of gargantuan proportions; the mother of all headaches. The sort I have never had before and after, and pray to never get again in my life or would never wish upon anybody. They spent the next hour feeding me Frooti, tea and biscuits and gently convincing me to come along. Then, all but one carried on.