D"; MARINEMEDICAL SOCIETY

n n*; d"; MARINEMEDICAL SOCIETY

(RegdF-361l)

presiclent Surg V Adm Yogendra Singh VSM

Vice presiclents Surg R Adm VS Dixit VSM Surg R Adm VK SaxenaVSM

Executive Conmittee Surg Cmde SK Mohanty SM VSM Surg Cmde BS Rathore VSM Surg Cmde MJ John Surg Cmde SK Satsangi Surg Capt S Nangpal Surg Capt YP Monga Surg Cdr G Verghese Surg Capt PK Singh

Secretary Surg Cdr R Chopra

Treasurer Surg Cdr VK Goyle

Arldress for Corre sportdenc. e Secretary Marine Medical Society INHSAsvini Colaba,Murnbai 400 005.India Website: http://www.mmsindia. net Printed,p Bhavan,l JOURNAL OF MARINEMEDICAL

PublishedBiannually

Editor-in-Chief Surg R Adm VS Dixit VSM

Editor Surg Capt AA Pawar

Addres s fo r Corre sp ondenc e Secretary Marine Medical Society INHS Asvini Colaba.Mumbai 400 005. India Website: http://www.mmsindia.net

published I Printed, andowned by DirectorGeneral of Medical Services(Navy), Sena i Bhavan,New Delhi 110011. Printed on hisbehalf atTypo Graphics, Mumbai 400 103. JOURNAL OF MARINE MEDICAL SOCIBTY

CONTENTS I I I i DITORIAL I OccupationalStress 59 lr Surg Capt AA Pawar I Thermal Physiologyin HyperbaricEnvironment I Dr Brinda Venkatraman SubmarineEscape and RescueWorking Group Meeting2006 - lstanbul,Turkey 65 SurgCdr HBS Chaudhry BiochemicalDecompression 72 Fig.5 : Rer SurgCdr CVSNRao ins FacilitiesOnboard USNS Mercy 14 on Surg Cdr Diviya Gautant Respiri PsychologicalEffects ofLong Sailingon Submariners 80 capeof bc SurB Capt AA Pawar Surg Cdr DK Ghosh, SurgLt B Sotti, Surg Cdr A Tripathi, Ms J Ratlrcd, Col S Chaudhuri is cooler. - The EustachianTube in Diving: Ear Barotraumaand Middle Ear Auto-inflationTechniques in Naval Divers 84 enduranc( Original ResearchPaper It is si Surg Cdr Padma Ramesh including 93 Evaluationof IDA 59(M) ',vhichwc Surg lt Cdr Kamal Mishra t expiredgi The Importanceof Effective and PromisingBehavioul Change Interventions to PreventHIV Infections l0l gas.In de Surg Cdr Saugat Ray I ratorygas A Clinical Trial Evaluatinga New Method of Fore-headPulse-oximetry with ConventionalLimb Pulse-oximetry 108 blockseri in Term Neonates feet, breat Surg Capt G Gupta, Surg Cdr S Narayan, Surg Cdr A K Yadav,A Bableshwar havea res ' ShipboardDermatology l13 WEIGHT Surg Cdr J Sridhar Inexpl; Multislice CT Imaging of SinonasalInflammatory Diseases in the Era of Fess I l8 comfortat Surg Cdr Pradipta C Hande, Surg Capt J D'Souzq Surg Capt E Janres couldbe - Intra Ocular Tension Recording Is Latest the Best? t20 in divers' Surg Cdr Tarun Choudhary concomit Hematological Changesin Alcohol Dependence t22 In the S Chaudhury,M Pawar, D Bahattacharyya, D Saldanha gas feels sensedas CASEREFORTS daysand During Report 127 DecompressionSickness SaturationDiving: A Case that therr Vivek Verma T Surg Lt Cdr bolic hee Lessonsfor Mental Health From 26 July Deluge : Mumbai 130 out shiv( Surg Cdr AI Ahmed PROGR] Management of Partial Anodontia -A ProsthodonticApproach IJJ TIYPOTI Surg Cdr (D) Archana Khanna Deve

-58 Jour Marinc Medical Society,2406, Vol.8, No. 2 Jour.Mat pothermiain cold hyperbaricconditions is of in- creasingconcern now. It involvesvarying degrees of unconsciousnessor mental incompetenceal- though respilatorydifficulties, unsteadinessand weaknessare also common. Insensible respiratory I heatloss is the main factorin suchoccurrences. I Variousstudies have shown that subjective thermal comfortis relatedto fall in coretemperature. ),et. the diver's respiratoryheat lossesand the conse- 60 quent inceptionof hypothermia,a diver's assessmentof comfort is notalways related to physr- 65 trnrro ologicaltemperature changes. c^{cn|t ourrttt (ri.l.0) 72 DTVBRITYPERTITERMIA Fig. : Respiratoryheat loss mildactivity while 5 during Respiratorygas heatingcan lead to hyperther- inspiringgases at severaltemperatures. Based 1t mia in divers,which could be alarming. Respiratory onTaubcr et al.15and Webb and Annis.rT burnsare seen very commonly.Use of gasheaters Respiratoryheat loss is a sizableavenue for es- with hot water suit technologycan result in heat 80 capeofbody heatespecially when the environment stressin waterexposures and divers will encounter is cooler.It is a major factorlimiting survivaland heatsyncope on re-enteringa bell. Faintingoccurs 8,1 endurancein cold hyperbaricchamber. due to heat syncope.Blood pooling in the lorver It is simple to reducerespiratory heat loss by regionsof the body can leadto unconsciousness. includingin breathingequipment; a heatexchanger, 93 PREVENTIONOF TTIER,\4ALEFFECTS IN rvhichwould retainsome of the heatin the warm HYPERBARICCONDITIONS expiredgas and deliver it backto the cold inspired l: Divermonitoring: This is very importantin bounce l0r gas.In deepdives, it is necessaryto heatthe respi- diving.It ensuresdiver safety by determiningif the t ratory gas.Around 250 watts would be neededto diverbecomes hypothermic or if hisperformance is r08 block seriousrespiratory tract drain in a diver at 650 gettingimpaired. Parameters for monitoringare sub- feet, breathingHe-O, and working hard enoughto jective verbal measurement havea respiratoryminute volume of 25 l/min. comments, of deepbody temperatureand skin temperature,heart rate meas- I 13 WEIGHTLOSS INDIVERS urement,direct heat flow measurementetc. No one Inexplicableweight loss in parameteralone is an accurateand a completelyre- lr8 occurs diversduring comfortabledeep hyperbaric chamber exposures. It liableindicator of a decrementin diver performance could be due to an increasedheat loss that occurs or a developmentof a thermalproblem. The single t20 in divers with no decreasein body temperatureor a mostuseful and easily implemented diver-monitor- concomitantincrease in metabolism. ing parameteris direct verbalcontact. t22 In the hyperbaricenvironment, where the warm Giving rigorousattention to automaticregula- gas feels comfortable,the high heat loss is not tion of respiratoryheating and hot water suit entry sensedas cold. When the extra drain continuesfor temperaturescan preventhypothermia. daysand weeks,it would seementirely reasonable Hyperthermiacan be alleviatedby the useof ad- t27 l that there should be a matching increasein meta- equatecooling measures involving shadeor spray bolic heatproduction. This can occurwith or with cooling. r30 out shivering. CONCLUSION PROGRESSIVESYMPTOMLESS IJJ Men who spenddays in underseahyperbaric TIYPOTIIERMIA environmentrequire warm gas temperature, typically Developmentof progressivesymptomless hy- above29'C(85'F). il.8.No.2 Jour.Marine Medical Societv, 2006. Vol. 8. No.2 63 Editorial OCCUPATIONALSTRESS

Surg CaptAAPawar.

is associated.withmodern life. Qtress However,rn youngerpeople are more stressed.This emphasises tJthe Armed Forces setting,stress is usually as- the need of targeting the young population by sociatedwith combatignoring the fact that service educatingand imparting stressinoculation personnelare not different in their mentalmake up techniques.Carrier battle groups of the US Navy from their civilian counterpartsand are equally vul- usually carry a psychologist and psychiatric nerableto stressesof modernliving. techniciansto monitor mentalhealth among the crew. A survey of occupational stressesundertaken Suchdeployments have been found to be effective by Department of Psychiatry,INHS Asvini in [4]. In our setting,the task could be performedby WesternNaval Command three years earlier had havinga seniorsailor who is qualifiedas a clinical revealedthat29Vo of the personnelhad significant psychologistafier doing the proposedBachelor of occupationalstress [1]. Stresswas more common in MedicalTechnology (Clinical Psychology) course junior sailorscompared to seniorsailors and officers. underthe aegisof MaharashtraUniversity of Health Personnelat shorereported greaterstress compared Sciences. to their counterpartsin ship or submarine.Issues Experienceof developedcountries thus brings suchas role conflict, role ambiguity,powerlessness to us the need to update our services in keeping were significant. Also younger people reported with the timesas well asthe needto regularly monitor greatermarital stress. stressparameters in thesechanging times. Institute of Naval Medicine United Kingdom has REFERENCES publisheda recent study in which they have I . Bridger R, Kilminster S, Slaven G. Occupational str.ess comparedthe results of a surveys carried out by and strain in the naval service: 1999 and 2004. Ocruu themin 1999and repeated in 2004 [2]. They measured Med 200'7 57 (2\ : 92-7. a factor called as occupationalstrain. As per the 2. Pawar AA, Rathod J. A survey of occupationalstless study more femalesthan men were stressed.Also, in naval personnel.Article accepted for publication stresswas more in people serving afloat which is by Medical JournalArmed ForcesIndia. contradictory to our study. Factors noted were 3. Ikin Jfl McKenzie DP, Creamer MC. War zone stress without direct combat: the Australian naval experience reducedorganizational commitment, dissatisfaction 'Nar. of the Gulf J Traunta Stress 20!5:1 8 (3) : with the physical work environment,role conflict 193-204. andwork-family conflict which wasassociated with 4. Wood DP, Walker E, Moses K, Gilleran L. Treatment strain in males.The strain prevalencewas 32Voin of psychiatric disorders onboard an aircraft carrier 1999and33Vo in2OO4. Findings from theAusrrahan assistedwith psychotropic medicaton : a retrospective review describing one aspect Navy [3] also indicatethat in times of conflict, of Navy Force Health Protection.Mil Med 20O6: 17l (4\ : 3t6-20.

'Senior Adviser (Psychiatry), INHS Asvini, Colaba, Mumbai

Jour. Marirc Medical Society, 2006, Vol. 8, No. 2 59 THERMAL PHYSIOLOGYIN HYPERBARICENVIRONMENT

Dr Brinda Venkatraman'

Key Words : Thermal physiology hyperbaric

errrc,nrrrurprart . t -,r-r-nnuoO f.fumans are homoeothermic. We normally keep I f I .lour core temperature within the narrow range of 36-38' C despitelarge fluctuationsin the environmental temperature. Homeothermy is dependent upon continuous thermo regulation. Specifically, a stable core temperature requiresa balancebetween heat productlon by our body and heat lost to the environment from our body. Thermoneutral zone refers to a rangeof environmental temperaturesover which it is relatively easy to maintain a stablecore temperature.It is 27-3I'C for a naked70 kg man. Metabolism is at the lowest in temperature within the this zone. The lowest vatwilritkn ol dm blood vce$b thermoneutralzone is known ascritical temperature. It is 27'C. Within the thermoneutralzone minor changes in body temperature are compensatedby simple constriction or dilatation of peripheral blood vessels.Since blood flow in the skin can be regu-

t.tfidgrtl|I|arsr,t bnqrtd

Fig.2 : Homeostaticcontrol systemreducing heat loss by peripheralvasoconstriction following a decreased environmentaltemperature.

lated in the rangeof l-150 ml/ min/ 100 g of skin, sucha mechanismis extremelyeffective. If ambient temperature falls below the thermo neutral zone, heat lossesfrom the body increase, outweighingheat production. Thermal balance will be lost and core temperaturebegins to fall. A Fig. I : Thehit balanceequation. M - metalichit produc- thus tion; E - evaporation(ofsweat); Cd -conduction; seriesof homeostaticresponses is very rapidly C - convection;R - radiation. broughtin to play which returnthe body to normal.

'Associate Professor of Physiology, TNMC, Mumbai

60 Jour.Marine Medical Society,2M6, Vol.8, No.2 A central body temperature equal to or less than 35"C (95'F) is called hypothermia. At the upper end of the thermo neutral zone,thermal balance is threatenedagain and heat gains outweigh heat lossesand core temperaturebegins to rise. Evaporativeheat loss mechanisms,mainly sweatingis important in thermoregulationabove the thermo neutral zone. Hyperthermia is a deep body temperatureof40'C or above. The humanbody is betterdesigned to face high temperatureenvironments rather than low temperature becauseskin nervesprovide the connectionof high temperatureto the feeling of pain. Body pro- tectionis usuallyineffective in a cold environment. When men are confined at severaltimes atmos- Fig. 3 : The increasein convectionconduction (h"with pheric pressurein environmentsthat are typically pressurein helium atmospheresdiffprs with the high in helium content,they are far more closely methodof analysis.Values of h. obServedfrom divers are compared with data from coupled thermally to their environmentthan men 1-o-) physical (A) and mathematical(R) analysefor living in air at I Ata. This closethermal connection small. changesthe usual modes of body heat loss and it producesa mild but sustainedincrease in metabolic C = h.A(T,-T,) rate. Where C = corvective heattransfer = THERMAL STRESSIN IIYPERBARIC CHAMBER h. conuectiveheat transferco-efficient or convectiveconductance Partitionalcalorimetric studies at 4 Ata heliox at = various environmental temperaturesshowed that A body surface area there is an increasein convectiveand radiatrve T, = skin temperature lossesand a decreasein evaporation.In a thermally T" = ambient temperature neutralenvironment for air, both surfaceand core The valueofh" dependsupon the physicalprop- temperaturein man are lower when he is immersedin ertiesofconvecting surface and the enveloping fluid He-O, rather than air. This greaterbody cooling is - density,specific heat, con{ptivity, viscosity,ve- not a resultof loweredmetabolism. Helium promotes locity etc. A combination of such factors could greaterloss of body heatby virtue of its 6 fold larger increasethe h" of He to suchan extentthat it would thermalconductivity, relative to Nr. However,due approachthe h" of water which is 25 times that of air to differencesin densityand viscositybetween He- undernormal conditions. Orand air, the convectiveco-efficient increasesby 55o/ofrom that in air. High valuesof h" are favored by the high thermal conductivity of helium, increaseddensity of CONVECTIVEHEAT LOSS hyperbaricafrnospheres and atmosphericmovement. Under seashelters have extremelyhigh humid- As a generalrule, it appearsthat more stronglycon- ity. Convectiveheat loss bedomesthe main avenue vective the environment,the smaller is the skin to for surfaceheat loss, even in dry chambers.There is fluid gradient.Whether physiological changes are increasedconvective heat transfer as a naturalcon- causedby exposureto environmentof high helium sequenceof the physical propertiesof hyperbaric dependsmainly on ambienttemperature and expo- heliumatmospheres. sure duration. In such environments,skrn temperaturetends to approachambient temperature. To explain this phenomQnonalgebraically, an By merelyproviding a warrnambient, core tempera- equationis employed: turewill bervell maintained in thehvoerbaric helium

.lour MarineMedical Society, 2(il6, Vol.8, No.2 (tl atmosphereand no increasein restingmetabolism shown that skin conductanceis reducedby Va't'at is seen.No shiveringand no other forms of adven- the highestpressure. titious muscle activity are observed.Subjects Therefore,the hyperbarichelium atmosphereof generallyfeel cool but not uncomfortable.If thetem- a permanentdeep ocean habitat will require a high peratureis loweredas in personaltransfer chambers ambienttemperature, especially if atmosphericve- in water temperaturesaround {'C at a depthof 600 locity is significant.This is becausethe high feetone would loseabout 740 k.cal./hour(more than convectiveconductance of pressurizedhelium will 7 times the restingmetabolic level) by free convec- not permit the normal skin to gasthermal gradient, tion alone. This occurs even though the men are which affordsman a liberalcomfort zonein thecon- wearing two 2'/"'foamed neoprenewet suits. ventionalatmosphere. The increasein convectionis concomitantwith a reduction in skin temperaturein hyperbariche- RESPIRATORYHEAT LOSS lium, eventhough the environmentaltemperature is There is unusuallyhigh heat loss from respira- warmer during the chamberdives. The skin to gas tory tract which hyperbaricenvironment would thermalgradient is reducedat the highestpressure. impose. The lowered skin temperaturetends to minimize heat The heat neededto warm the air and to evapo- transferby radiationto the relativelywarm chamber rate moisture from the lining of the upper airway walls contributingto the reductionin radiation. determinesthe lossof heatin warming cool dry in- Skin cooling also minimizesevaporative heat spiredair at I Ata. As gasdensity and specific heat transfer.Core temperatureis not greatlyreduced at increase,the warmingof the gasbecomes the domr- any pressuredespite the lower valuesof skin tem- nant elementespecially since under seahyperbaric perature.The maintenanceof normal over all environmentsare humid. The quantityof respira- metabolismand core temperatureare probably at- tory heat loss dependson the coolnessof air, the tributableto peripheralvaso-constriction. It hasbeen densenessof air, specificheat and the diver's respiratory minute volume.The basic"expressionis H...0=V" rCp (T.- T,) + Ve0.058 (W.- Wi) O.tRAL L l!t. TAmt|sx Where H,..o= rate of respiratory heat loss in k.callmin Ve = respiratoryminute volume rn liters/ min (cAL = E-l :o r Density of gasin gr$sll = P€i Cp specificheat of the gasin k.cal 8n, 20 T. = temperatureof expiredgas Ti = temperatureof inspiredgas 0.058 = latent heat of vaoorizationin k.cal/gram W. = water content of expired gas in

ot[a grams/l PR€SsI.RE,ATrl. I8S. Wi = woter content of inspired gas Fig. 4 : Metabolic balancein Hc-O, underpressure. The in grams/l over-all metabolic rate of divers seatedin a hyperbaric,helium-rich atmosphereis not strikingly The productof densityand specific heat is seen higher than normal. Changesin the relative to directlydetermine respiratory heat loss / unit quan- amounts of heat transfer by evaporation and ra- tity of air breathed.This calculftion is on the diation offset the large increasein convectrve assumptionthat the gasis expired out at body tem- surfacecooling. peratureand that it is inspireddry.

',2 Jour.Marine Medical Sociery, 2006, Vol.8, No.2 pothermiain cold hyperbaricconditions is of rn- id{ I*f.ft |r.at lbrht'n creasingconcern now. It involvesvarying degrees of unconsciousnessor mentalincompetence although respiratorydifficulties, unsteadinessand I weaknessare also common. lnsensible respiratory t heatloss is themain factorin suchoccurrences. t have 59 Variclusstudies shownthat subjective thermal comfortis relatedto fall in coretemperature. ),et. the diver's respiratoryheat lossesand the conse- 60 quent inceptionof hypothermia.a diver"s assessmentof comfort is notalways related to physr- 65 ologicaltemperature changes.

12 DTVBRIIYPERTIIERMIA Fig. : Respiratoryheat loss mildactivity while 5 during Respiratorygas heatingcan lead to hyperther- inspiringgases at severaltemperatures. Based mia in divers,which could be alarming. Respiratory 74 onTauber et al.15and Webb and Annis.rT burns are seenvery commonly.Use of gas heaters Respiratoryheat loss is a sizableavenue for es- with hot water suit technologycan result in heat 80 capeof bodyheat especially when the environment stressin waterexposures and divers will encounter is cooler.It is a major factorlimiting survivaland heatsyncope on re-enteringa bell. Faintingoccurs 84 endurancein cold hyperbaricchamber. due to heat syncope.Blood pooling in the lower It is simple to reduce respiratory heat loss by regionsof the body can lead to unconsciousness. includingin breathingequipment; a heatexchanger, 93 PREVENTIONOFTHER,\{AL EFFECTSIN I rvhichwould retainsome of the heatin the warm HYPERBARICCONDITIONS t\ expiredgas and deliver it backto thecold inspired t Diver monitoring:This is very importantin bounce l0l gas.In deepdives, it is necessaryto heatthe respi- a diving.It ensuresdiver safety by determiningif the ratory gas.Around 250 watts would be neededto diverbecomes hypothermic or if his performanceis 108 block seriousrespiratory tract drain in a diver at 650 gettingimpaired. Parameters for monitoringare sub- feet, breathingHe-O" and working hard enoughto jective verbal measurement havea respiratoryminute volume of 25 l/min. comments, of deepbody temperatureand skin temperature,heart rate meas- r 13 WEIGHT LOSSINDIVERS urement,direct heat flow measerementetc. No one Inexplicableweight loss parameteralone is an accurateand a completelyre- lr8 occursin diversduring comfortabledeep hyperbaric chamber exposures. It liableindicator of a decrementin diver performance could be due to an increasedheat loss that occurs or a developmentof a thermalproblem. The single t20 in diverswith no decreasein body temperatureor a mostuseful and easily implemented diver-monitor- concomitantincrease in metabolism. ing parameteris direct verbalcontact. t22 In the hyperbaricenvironment, where the warm Giving rigorousattention to automaticregula- gas feels comfortable,the high heat loss is not tion of respiratoryheating and hot watersuit entry sensedas cold. When the extra drain continuesfor temperaturescan preventhypothermia. days and weeks,it would seementirely reasonable Hyperthermiacan be alleviatedby the useof ad- 127 l that there should be a matching increasein meta- equatecooling measures involving shadeor spray bolic heatproduction. This can occur with or with cooling. 130 out shivering. CONCLUSION r33 PROGRESSIVESYMPTOMLESS Men who spenddays in underseahyperbaric TIYPOTIIERMIA environmentrequire warm gastemperature, typically Developmentof progressivesymptomless hy- above29"C(85"F). l.8. No.2 Jour.Marine Medical Society, 2006. Vol. 8. No.2 6-l They lose heat mostly by convection despite a Folk, JR, Ph.D SUBI narow skin to fluid temperaturegradient 2. Body tempemtuleand meabolism in hyperbaric helium atmosphi:res.J Appl Plrysiol 1968; 24(5): 678-84. Respiratory heat loss is greatly increasedwhen 2006 Body heat loss in underseagaseous environment. gas. breathing hyperbaric AerospaceMedicine 1970; 4l(ll): 1282-88. Thermally conductive heliox aggravatedby hy- 4. Humanphysiology: Age, stressand the environment SurgCt perbaric pressureconditions may limitman's ultimate by R.M. Caseand J.M.Waterhouse. hyperbaric exposure,as does FIPNS. Metabolicand thermalresponses of man in various He-Orandair environmenrs.J Appl Physiol 1967'.23 REIIERENCES (4):561-65. Key Wo l. Textbook of environmental Physiology by G.Edgar

INTRO m^l

I. ()I, submal tries to commc to Subr ing is I additic presenl addexr to deli' tionsar that nc succes velopir indivic fore a develo SMER ,/ sronsv out fel basisit the rer Tht meetit meetil andth forma countl generi inclus the nr Presei

'Submi

64 Jour Marirw Medical Society, 2N6 Vol. 8, No. 2 Jourlr helium SUBMARINEESCAPE AND RESCUEWORKING GROUPMEETING '8-84. 2006- ISTANBUL.TURKEY Imen [.

Inment SurgCdr HBSChaudhry- arious 61:23 Key Words : Submarine,Escape, Rescue

INTRODUCTION India andis responsiblefor coordinatingall actions uhe Submarineescape and rescue working group with rcgardsto the SMERWG rqeeting. I (SMERWG) meeting is an annual meeting of The SMERWG was held from26 to 30 Jun 06 at submarineoperating NATO and non-NATO coun- the Military Museum at Istanbul, Turkey. Two tries to discussand implement as far as possible officersfrom theSubmarine Cadre namely, Surg Cdr commonstandards and operating procedures related HBS Chaudhry(75563H) and Lt Cdr PallavPrakash to Submarineescape and rescue (SMER). The meet- (04494N) were selectedto representIndia at the ing is held in the month of Jun/Jul each year. In SMERWG 06 meetat Istanbul,Turkey. A total of 26 addition to the above, countries are invited to countrieswith representativesof ISMERLO attended presentvarious research and developmental actions the meet. and exercisesunder taken in supportof SMER and to deliberateon various lessonslearnt. These ac- SMERWGMEETING-2006 tionsare considered inescapable, as it is amply clear" The main purposeof the meet was to streamhne that no country in the world today can guarantee and further standardizethe NATO proceduresrn successfulSMER through its own resources.De- terms of SMER. There was also a need to develop velopingor procuringassets available offthe shelf interoperabilityin orderto meetnew challengessuch individually is alsonot costeffective, there is there- as combatingterrorism and for other tactical fore a need to pool in the resourcesavailable, purposesrelated to SMER. In addition, the needto developa common operatingphilosophy, perfect enhancemultinational operations through formatron SMER relatedissues through exercises and discus- of smallunits/panels was alsoemphasised. sionswith all submarineoperating nations and carry Various panels were seJy'up under the out researchand developmenton a cost sharing chairmanshipof one of the NATO delegates.The basisinvolving civil entrepreneurs/firmswhich have delegatesattending the meet were offered a choice the requisitetechnology. to attendany of the following panelson completlon The agendapoints for the succeedingSMERWG of the openingremarks. The various panelsset up meeting are decided before the closure of the for theSMERWG 06 meetinswere as follows:- meeting.Various countriesthen work theseupon (a) Medicalpanel. and the resultsare brought out at the plenary by a (b) The OperationalPanel Doctrine(OPD) panel. formal presentation.Through presently a NATO country chairs the nreetingand the presentersare (c) Submarineescape equipment (SEE) panel. generallyfrom the NATO nations barring an odd (d) RescueEquipment panel. inclusionthere is a consciousdecision to bring in After the initial plenarymeeting, the panelswere the non-NATO countries for active participation. set up for the first two days to conductthe work in PresentlyGreat Britain is the sponsornation for smallerunits. Subsequently,the plenary met again

'Submarine Escape and Rescue Working Group (Smerwg) Meeting 26- 30 Jun 05 at lstanbul, Turkey i, No.2 Jour Marine Medical Society, 2006, Vol.8, No.2 65 for witnessingthe variouspresentations and finally appropriatechanges were recommendedto be the chairpersonof the panels updatedthe plenary includedin the medicalpanel report to SMERWG. as to the pointsdiscussed and actiontaken. Someof theseare as follows:

Medical Panel AMedP-lI (A) - NATO Handbookon Maritime . The SMERWG medical panel is responsibleto MedicineChapter 7, SectionsIV STANAG 1269 Med (Editionl) their respective.MilitaryCommittees for Maritime StandardizationBoard (MCSBs) through their The chapterof Diving andSubmarine Escape and respectiveWorking Groups (WGs) for the Rescuewas movedand reformatted.Itwas decided developmentof maritimeoperational standardization that sincethis aspectis an ongoingprocess, this documentswithin their respectiveareas of expertrse. chapterwill be reviewedevery two to threeyears. SMERWG medicalpanel is alsoresponsible for the ADivP-2MDIVP-2Allied Guideto diving Medicine developmentof new medicalstandardization issues -Study1432, Ref NSA(Navy) 0136-UD/1432 of I initiated within the SMERWG. A meeting of the Feb01 (Edition2) medical panel was conductedon 27 Jun 2006 and Referencefor AcceleratedDecompression Tables was attendedby all medical membersof the in ADivP-2 has been submittedto the UK for conferenceunder the chairmanshipof Capt Dr Volker inclusionin the abovepublication. Warninghoff of Germany.Around 23 delegates attendedthis meeting. STANAGf319 SMER (Edition3) (No ratification The following issueswere discussed: status)- Minimum RequirementsFor Medical StoresLocated on Board SubrnarinesIn Support of Separate Medical Meeting : The delegateswere escape/Rescue.(CU: USA) informed that a separatemedical meetingwas held The conceptionof this STANAG was a direct earlier in the year in the month of January.The taskingfrom theprevious SMERWG meetings.After importanceof this earliermeeting was that it wasthe much deliberation,it was howeverdecided that it main forum for most of the discussionsabout rnedical would be impracticalto be prescriptivein medical issues.It was stressedthat as many membersas onboard suppliesfor every nation. In lieu of a possible attend this meeting in future as it is the STANAG theMedical Panel strongly recommended main meetingin which all medicalaspects of escape posting national lists of medical stores on the andrescue are discussed in detail.The next medical ISMERLO website.In caseof accident.individual panelmeeting ltentatively scheduledto be held in nationsare to submitan up to datelist of their stores Januarv2OO7 d|lsrael. for postingon theISMERLO website.This will allow Use of a common diving tabte by all Navies : There readyaccess to accurateinformation in the caseof a was a discussionon the merits of different tables DISSUB accident. being used by different Navies and the need for Attendingnations were asked to conductdetailed interoperability between national platforms, analyseson the requirementsof their individual especiallyduring timesof Internationalincidents/S/ submarinesto be performedby appropriatemedical M disasterswhere more than one Navy's rescue personnel.They wererequested to preparethe inputs assistancewould be sought.This issue was prior to thenext Medical Panel meeting in Jan07 and discussedin quite detail. It was concludedthat it forwardthe sameto ISMERLO. would be too difficult to addressinternational operationrequirements with specific tablesat this Reviewof ATP l0 (Search& RescueManual) time. However the importance of this issue was AIP l0 now henceforthbe knownasATP3.3.9.2 stressedupon and was decidedto take it up in the chapter6 of STANAG 3552.NATO memberswere next meeting inJan200'l . askedto review the submarinesection ofATP l0 for Publications : Various publications and discussionat thenext medical panel meeting. If any STANAGS were discussedmainly by NATO medicalchanges would be neededthe samewould delegates and after reaching an agreement, be takenup for discussionin thenext meeting.

66 Jour MarineMedical Society,2006, VoL 8, No.2 I

ATP-57(AYIVITP.s7 (A) - SUBMARINERESCUE d. SurfaceMedical Supportto a DISSUB MANUAL. STANAG I39OSMER GDITION 5 e. EnvironmentalProblems within aDISSUB RATIFICATTONDRAFT) (CU: NL) f. SurfaceEnvironmentalSupport to a DISSUB Delegateswere informed that Updateof ATP 57 is underwayand part 3 needsupdating to coincide VIL Rescue with the ratification.The cunent format is a combined a. RescireAssets and their Capability documentregarding survivability, escape and (to a b. MedicalProblems from Rescue lesserextent), rescue, and it wasdecided that it would c. Medical Organisationfor Rescue be much more effectiveto divide this documentup into shorter and more focussedparts. It was also i.MOSHIP informed that this documentwould now be called ii.DMTT MTP 57 and be availableto all membernations on d. Casualtyhandling (from DISSUB to getting request.It was discussedand agreedupon that this ' aghore) document be so drafted so that at times of e. Medical Careof Rescuees emergenciesit could be usedas a standalone rescue - manual and understoodby even those doctors at f. RescueDecompression Tables Availability sitewith little or no knowledgeof diving/submarine and Choice medicine. MII.Triage Proposedchapters were: D(. Casualtyrecording and management I. Combineddefinitions and glossary X Logisticsand command il. Mobilisationto a SUBSUNK )C. Managementof Radiological and other - Call out, pre-deploymentchecks, liaison with contamination(i.e. petrochemicals) othernations / ISMERLO, briefsof OSC / CRF A lengthydiscussion was held with ISMERLO Itr. SubmarineParachute Assistance Group - representativeson theproposed new format of ATP/ MedicalInput MTP57. N Surfaceabandonment It was decidedthat the Medical Panel should preparea documentwhich is suitablefor their needs, a. Hazardsof SA injuries leaving submarine, and this would then be incorporatedinto ATP 57. thermaleffects, SA equipment The chapterneeds to be a comprehensivechapter, b. Medical Problemsof Surface with appropriatereference to otherchapters, SMER, SurvivalHypo / hyperthermia,sea sickness, and NAIO documents.The aigrfs to have a final drowning draft to discussat Medical Panelmeeting by Jan07. c. SurfaceSurvivability Data Survival times in Medical Aspects of Logistics : There were life-rafts suits, etc. deliberationson what would essentiallyconstitute V Escape the first and secondreaction stores since various a. Hazardsf.o escapees navieshad different store inventories. It wasdecided that the definitions of Reaction stores need to be b. MedicalProblems from Escape clarifiedby editorsof therevised edition of AfP- 57. c. Medical Organisationfor Escape All countrieswere requested to provide information d. Medical Careof Escapees on their medicalcapability and stores to ISMERLO. e. PostEscape Recompression Treatment DecompressionTable Choices : The choice of Vl DISSUB Survival decompressiontables (cunently US, UK, or air desat) was discussed.Considerations were the chain of a. Hazardswithin aDISSIIB command,foreign DISSUB rescuees,and distinction b. MedicalProblems of DISSUB Survival betweenguidance versus recommendation. It was c. EnvironmentalHygiene in theDISSUB felt that it would be difficult to lay down specific

Jour MarineMedical Societ r-, 2006, Vol. 8, No.2 67 -t

orders for the particular decompressiontable to be Escapeand Rescue Liaison Office (ISMERLO) is a adopted.The owner of the rescue system may group of retired or civilian personnelwho are influence the choice of tables.However it was contractedand billetedwithin an establishedNATO decidedthat this is an ongoing issuewhich will be command/HQworking exclusively for SMER.The discussedboth off-line and at upcoming meetings. ISMERLO works towards provisior.ringof SMER Decompression Research : Member nation were advice round the clock to render assistancern askedto furnish detailsof any new resedrchcarried responseto an alert in respectof a disabled out over recent time. However there was no new submarine(DISSUB) anywherein the world. The information. It was stressedthat any new research SupremeAllied Commandfor operationsdesi gnated carriedout shouldbe sharedamong various member Allied SubmarineCommand to establishand maintain nationsand alsoa mention be madeon the ISMERLO theISMERLO in Norfolk,Virginia(USA). Theoffice website. monitors SMER related activities and provides a worldwidecoordination capability and database for Incident Reports : Turkey reportedan incident escapeand rescueassets available. ISMERLO of CAGE after a pressurisedcompartment escape reportsto the SMERWG via the ISMERLO panel. and the managementby immediaterecompression. ISMERLO Web siie : The ISMERLO organizahon SubmarineEscape Tlaining Tank (SETT) Incident operatesthrough their web site.The delegateswere Reporting to the SMERWG Medical Panel. requestedto make suggestionsin order to make While there was consensusthat there is a need ISMERLO more responsiveto their needsin terms for SMERWG reportingsystem for SETT incidents, of SMER. All delegatesand member nation were howevera point was raisedwhether meetings of the invited to registerat the web site and were assured medical panel are the appropriateplace to report.US of providing passwordsto enable accessto suggestedthat the ISMERLO websitemight be the passwordenabled Iinks. Nations were also askedto appropriatsplace to record incidentsbut it would providetheir escapeand rescue facilities and escape need a standardizedform. Privacy and sensitivity and training proceduresto be incorporatedinto the issuesalso need to be considered. web site. The definition of the term "incident" also needs Goals envisagedfor ISMERLO : There were to be determined.It was decided that by the next severaltasks being pursued by the ISMERLO. Some meetingit shall be clarified which "incidents" need of the goalshighlighted were: to be reported upon. (a) Declassificationof AIlied SubmarineRescue Manual(ATP-57)and it berenamed as MTP57. Medical standard for Submarine Escapetraining Tank Candidates:Proposal for a new study (b) Ensureinformation is readilyfvailableto affect It was felt that there should be some SMER at all times including accurate standardizationon the basic medical standardsbeing mobilizationtime for rescueassets. adoptedby variousnations for traineesundergoing (c) Integratecivilian SAR to AIP 57. SubmarineEscape Training and it was deliberated (d) Have provision to ensurebetter coordinatron upon and suggestedthat this should become the amongstvarious submarine rescue coordination basis for a STANAG Details of this study will be cenhes(SRCC). promulgatedfor comment by nations conducting (e) Includehospitals and other facilitiesinto the SETT. A draft STANAG will be presented for web site. discussionat the Medical panelmeeting in Jan07. It (D was noted that the STANAG may result in SETT FormaliseSOPs and standardizeequipment nationsaccepting foreign candidateswith different basedon US certificationin termsof SMER the standardsthan they acceptin their own nationals. world over. (g) Bring SMER community to table using Operational Doctrine Panel (ODP) ISMERLO asa facilitator. ISMERLO Panel : The InternationalSubmarine (h) Evaluatevarious escape and rescueexercises. 68 Jour.Marine Medical Societv, 2006. Vol. 8, No.2 T

Coordination with operational authorities o SEIE (MKl0) Hood Design Issue (visor Although contactingISMERLO in theevent of a material)RN/USN Refurbishment Protocols submarinedisaster was voluntary, ISMERLO could r Life Rafts Internaland Under CasingEfTorts provideassistance in timesof needto variousnavres o FutureTesting and ResearchAreas including non NATO countries.It was broughtout r Royal that at the momentthe capability of ISMERLO web Navv SurfaceAbandonment (T-Class) site to carry out SMER was almost completeand o SurfaceAbandonmentProcedures and Conquct that it should not be neglectedby submarine of AbandonmentExercise (worst case) operatingnations. The exchangeof information o DISSUB Lighting and PersonalLocator during the Chicoutimi ,the San Franciscoincident BeaconsBriefings andthe Russian Priz AS 28 broughtout the strengths o SubmarineEscapeTraining'Iowerlnformation of the system.. inpurtoISMERLO SubmarineEscape Equipment (SEE) Panel . FutureEvents and Recent Changes, Equipment The purposeof setting up of the panel was to Issuesand GeneralDiscussion provideescape equipment usage and training input Indiandelegatesjust briefly visitedthis panel. as to the SMERWG regardingall aspectsof submarine they wereobservers at the OPD and medicalpanels escape.The missionof the panelwas to:- and the above information was gatheredfrom the (a) Provide a forum for minor and major usersof discussionsof the SEEpanel was highlighted later submarineescape community. duringthe plenarysession. (b) Facilitatethe exchangeof informationbetween Surface abandonment : The issue of surface escapeequipment users. abandonmentwas discussed in detail.There was a generalagreetnent to have a rapidly deployable (c) Identify escapeequipment problems and appliancefor surface abandonment. panel solutions. The membersalso agreed that there was a needto revlew (d) Monitoring of equipmentdefects. the abandonmentphilosophy and carry out checks (e) Designreview. for shortfallsand equipment.As more training was (f) Shareproposals for equipmentmodifications required in this aspect,the Royal Navy agreedto betweenuser countries. conducttlials to help defineissues. (g) Provide an avenue for customerfeedback to The next SEEPanel meeting has been scheduled manufacturers. for Montreal,Canada forApril2ffiT .It will be ajoinr Canadian/UnitedStates spqt#ored meqting. (h) Identify country point of contact. 0 Identify tower and air systeminterface issues. RescueEquipment Panel (k) Identify training issuesand capabilities. This panel for the rescueassets was set up to provide Specificareas of review includedthe following: rescueasset operators, users and potential usersinputs to SMERWG regardingall aspectsof o Analox MKIIPAnalyzers andAnalox Submarine submarinerescue asset ownership, capability EscapeAid(SEA) manlgementand operation.Whilst delegatesfrom o CanadianElectrical ReverseOsmosis Device NAIO countriesparticipating in theSMERWG were (eROD) (DISSUB water production) to be membersof this panel, delegatesfrom o FrenchNavy Testingon CO?absorbent material partnershipfor peace(Pfp) nations,Mediterranean andPODs dlalogue and sponsorednon-NATO nations were permittedto o NorwegianNavy liferaft, HIS Testingand CO, attendthe panelmeeting as observers. Absorbent Testing The following missionswere assignedto this panel:- o Royal Navy 02 candleignition issuesand CO, absorbentmaterial testins (a) Facilitatethe exchange of informationbetween

Jour.Marine Medical Society, 2006, Vol. 8, No.2 69 owners, operatorsand potential users of e. AS-28"Priz" rescue-USA/BRITAIN/RUSSIA/ submarinerescue assets. JAPAN (b) Identifyrescue asset problems and solutions. f. AS-28"Priz" Actions& Lessonsldentified - (c.) Shareproposal for equipmentmodification presentationSMER betweenuser countries. c. SurfaceAbandonment Trial Report- SERPC - (d) Consider and where appropriate,develop or recommendationBRITAIN revise standardi4ationproposals, STANAGS h. VENTILEX& SURVTVEX- FRANCE andrelated publications to rescueasset aspects .1. SURWVEX06 - I\ETHERLAND of SMER. i EXERCISEBLACK CARILLON 06 - (e) Establishand maintain liaison with otherNATO AUSTRALIA and internationalbodies and groupsconcerned with rescueactivities related to SMER. NATIONAL/SC REPORTSON RESEARCH & -DEVELOPMENT (f) Monitoring of industry developmentof rescue assetsand supportingequipment technology. a. Update on the CHICOUTIMI incident with iol respectto observationson the effectsof smoke \ Identifytraining issues and capabilities. b/ inhalationon the crew.- CANADA Presentationsby Various Countries/Agencies b. Presentationon the first SubmarineDiesel The salient presentationson various SMER MedicineCourse conducted in Halifax.Canada. relatedexercises/issues presented to the plenaryby -EANADA various nations/agenciesare enumeratedin the SCHEDULEDSMER EXERCISES succeedingparagraphs. '08: ' a. Bold Monarch IPC scheduledin October. a. The useof air-bagsin main ballasttanks for emergencysurfacing -GERMAI{Y b. RESCUEX'06:Location-SanDiego. '06: b. Effect of ambientpressure and temperatureon c. ESCAPEX Escapefrom 688-classsubmarine sodalime "passive"CO, absorption- NORWAY in June06. c. Seatcertification LL and STANAG 1297 way d. NSRS'trialsincluding patient transfer exercises '06. ahead-USA/ISMERLO in late '07: d. Pre-engineeringwork on current ships rescue e. PACREACH Currentlyscheduled for Nov systems- BRITAIN 2W7. '08: e. Updateon ventilationsystems - FRANCE f. Bold Minotaur Dates to b/cletermined. LocationBergen, Norway. f. Presentation& practical demonstrationof Canada'sSubmarine Surface Abandonment Suit Recommendations : The following -CANADA recommendationswere forwarded for consideration:- g. Russianassesment of thecurrent NAIO-Russia (a) Presentlythe Indian delegationattends the cooperationin the SMER domain - RUSSIA SMERWG as observers.However, given our long submarineeringexperience and India's SUBMARINE ESCAPEAND RESCUEEXERCISES escapeand rescue assets,we need to assert ANDOPERATIONS itself in forums of such importance.It is a. Report on exercise NORTHERN SUN - thereforerecommended that the service must BRITAIMNORWAY/ISWEDET{ endeavortoactively participate in SMER related b. StrategicAirlift Support to RescueOperations - joirit exercisesand become a member of the USA SMERWG at theearliest c. RESCUEX05-USA (b) As only two delegateswere sent to the meet it was not possible to attend all the panel d. Exercise"BoldMonarch"-UK discussions.In order to sain to most from such

70 Jour MarineMedical Society, 2N6, Vol.8,No.2 dedto be annual meetings, it is recommendedthat there (d) The discussionsheld in the medical panel were iMERWG. must be at least three delegates for future very useful and infact it was recognized as one SMERWGmgetings. of the main panelsof the meeting. However, in (c) ISMERLO website is an excellent tool to gain the main SMERWG meeting, only l-11/2 days itime are allotted for separatepanel meeting and here tG 1269 rapid information on the availability of rescue ready assetsallover the world. The ISMERLO the points discussed in detail in the pre- provisioning SMERWG meeting are only briefly elaborated iscapeand works towards of SMER advice upon. In view of this it is recommended that asdecided round the clock to render assistance in India should also send its delegatefor the pre- )cess,this response to an alert in respect of a disabled SMERWG medical panel meeting which 'eeyears. submarine(DISSUB) anywherein the world. As .submariningis a risky professionthere is a need deliberates in detail on medical aspects of Medicine to anticipate and.be ready for any eventuality. escapeand rescuefor the entire duration ofthe 32ofl The use of the website during SMASIIEX is conference. therefore recommended. ;ionTables e UK for ification dical iupport of m a direct :ings.After ded that it in medical lieu of a lmmended 'es on the individual heir stores ;willallow / LeCaSe of a rctdetailed individual .temedical : the inputs Jan07 and rual) \TP3.3.9.2 nberswere AIP l0for rting.If any amewould eeting.

VoL8, No.2 Jour MarincMedical Society,2N6,VoL8, No.2 '7' BIOCHEMICALDECOMPRES SION ar a( dr Surg Cdr CVSN Rao. st al di ABSTRACT 'fo Biochemical decompression is a ternr used for the protective effect against decompression sickness achieved by removing by biochemical means some of the inert gas dissolved in tissues after a hypcrbaric exposure. This is H a novel approach that involves increasing the tissue washout rate of inert gas to decrease the risk of decompression H sickness, was tested in animals during simulated Hydrogen dives. To increase the washout ratc of Hydrogen a TI Hydrogen metabolizing microbe, Methanobrevibacter srnithii was used that converts Hydrogen to H,O and CH.' ln di Key Words : Biochemical Decompression SU w( H. INTRODUCTION the pressure.To a,voidthis problem,Helium is thi commonly substitutedfbr Nitrogen during J fnderwaterexploration involves stressful expo deep ris LJ rur. to elevated pressures,and the return to divesbecause Helium is 4 timesless narcotic than normobaricenvironment has been recognized as one Nitrogen.However, the low narcoticpotency of co of themost dangerous part of diving dueto therisk Helium allows the expressionof High Pressure hy of DecompressionSickness (DCS). DCS is notonly NervousSyndrome (HPNS), a conditionmalked by wa limitedto diving, but is alsoa problemfor caisson tremor,nausea and sometimes convulsions and death workers and during aerospaceflights, or any other at depthsbeyond 200 meters. (a) exposureto changing atmosphericpressures. For For dives exceeding100 meters,Hydrogen rs free diving marineanimals. physiological adapta- currentlybeing investigated as an alternativeinert (b) tionssuch as atelactic lungs are part ofthe solutton gas.There are some disadvantages with Hydrogen thatenable them to performrepetitive dives without as a diving gas. The most obvious being is apparentproblems. flammability.However, Hydrogen is notexplosive if theOxygen concentration of thegas mixture is 47o During exposureto elevatedpressure. increased ofI levels gas or less.Another potential problem with Hydrogen of inert dissolvein the tissuesof air- ofi asa diving gasis thehigh thermalconductivity and breathing aniri(s. The tissuetension of dissolved wh heatcapacity compared to Helium,which suggests gascontinues to increaseuntil equilibriumwith the wo that heat losses in hyperbaric Hydrogen environmentoccurs, at which time the organismis injr said to be saturated.If hyperbaricexposure is long environmentwill behigh. enough,the elevated level will exceedthe solubility Thereare several advantages to usingHydrogen of the of the inert gas during the decompression as the inert componentof a breathinggas. The phase,a term calledsupersaturation. When thegases densityof Hydrogenis lower thanthat of Helium, becomesupersaturated in the tissues,they begin to andconsequently Hydrogen is easierto ventilateat come out of the solution.DCS is believedto be elevatedpressures. Hydrogen can also be easily causedby an excessivelyrapid pressuredecrease madefrom HrO by hydrolysis,where as Helium is leadingto the evolutionof gasbubbles. expensiveand sometimesdifficult to obtain. Gasesused in diving : Air is commonly usedas Hydrogen also has a slight narcotic potency that gasfor shallowdives. For divesexceeding 40 meters, may helpalleviate HPNS at higherpressures. Nitrogen has a narcotic effect that increaseswith Avoiding DCS : Currently the only method of

'Graded Specialist Marine Medicine, INS Satavahana.

72 Jour Marine Medical Societv,2M6 VoL8, No. 2 Jou avoiding DCS is to carefully control the ascent causea systemic immune response,as would for accordingto published guidelinesfor dive depth, exampleinto the blood stream. duration,and rate of decompressionto avoidcritical The study showedthat DCS incidencecould be supersatulation.Nevertheless, this strategyis not reducedconsiderably without harmful effectson the always successfuleven when tablesare followed, animalby themicrobes. Removal of smallfraction of diverssometimes get DCS. inert gashas a surprisinglylarge impact on the DCS Biochemical Decompression : A novel approach risk. rved by for safer decompressionfrom dives that employ The resultsof theseexperiments show that This is Hydrogen as the inert gas involves the use of removinga relativelysmall fraction of the tissue rression Hydrogen metabolizing microbes (methanogens). burden of inert gas can potentially have a rogen a The conceptwas first postulatedby Dr Lutz Kiesow surprisingly large effect on the DCS outcome. ,0 and in 1963.The theory was basedon the idea that the However the use of Hydrogen as a diving gas is diver breathingHydrogen would in somemanner be limitedto deepdiving. Biochemical decompression suppliedwith a hydrogenase.The Hydrogenase fiom divesusing Nitrogen, as the inert gaswould be would convertsome of the dissolvedHydrogen into themost useful, given its potentialwide application HrO and CHo,which would result in a reductionof lum ts for professionaland recreationaldiving and the tissueHydrogen tension there by reducingthe g deep aerospaceflight. riskof DCS. ic than However due to stable conformation of the )ncyol Theseexperiments were carried out on pigs, using Nitrogen molecule,reactions that break down ressure colonic microbe Methanobrevibactersmithii as Nitrogen require an energy source for complete 'kedby hydrogenase.The rationale for using this species conversioninto NH' nitratesand nitrites.Therefore d death was: eventhough variousmicrobes are capableof using (a) First this methanogenis native to the human Nitrogen,they morecommonly utilize othersources )genrs gut flora and is non-pathogenic. of Nitrogen than the gaseousmolecule. In addition reinert (b) The hydrogenaseused by this methanogen the end productsof Nitrogen metabolism are not drogen catalysesthe reaction gaseousand would stayin the intestines,in contrast .ino is to CH" andmost are toxic. ""c '" 4H,+CO + CI{+2H,O osiveif Theseorganisms were placed in large intestine CONCLUSION e is1'7 of pigs, sincethis location is anaerobic,a requirement Geneticengineering in the future may create drogen of M. smithii. The intestineis alsohighly perfused, enzymesthat are able to metgbdliseNitrogen more 'ityand which would guaranteethat high levelsof Hydrogen efficiently and that can convert any toxic end lggests would be transportedto this location.Further more products into innocuous to make lrrrtrcn compounds ".'b"" iniection of a microbe into the intestinewould not Nitrogenbiochemical decompression possible. drogen rs.The lelium. Iilateat easill, :liumis lbtain. cy that S. thod of

8, No.2 Jour Marine Medical Society,2006, Vol.8, No.2 73 FACILITMS ONBOARDUSNSMERCY

SurgCdrDiviyaGautam.

Key Words : Facilities Onboard USNS Mercy

ROLEOFMERCY Mercy which is basedat San Diago and other sister pimary nole : To provide mobile, fl exible, rapidly ship USNS Comfort (T-AH 20) which is based at I responsive afloat medical capability for acute Baltimore,Maryland. medical and surgical care in supportof United States T-AH 19 is a converted SAN CLEMENTE oil Marine Air/Ground Task Forces deployed ashore, tanker (SS WORTH), which was delivered to the Army and Air Force forces deployed ashore, and Navy December19, 1986and assignedto the Mili- Navy amphibioustask forces and battle forcesafloat. tary sealift Command (MSC) (Refer Appendix -II). SecondaryRole : To provide mobile surgicalhos- In conversion processa top oftanker was removed pital servicefor useby appropriateU.S. Government and Medical TreafrnentFacility (MliF) modules were agenciesin disasteror humanitarianrelief or limited constructedup-side down on pier which were flipped humanitarian care incident to these missions or into hull and then welded into place. peacetimemilitary operations. Ship's Statistics General Information Ship's Statistics: USNS Mercy (T-AHI9) is the third ship bearing a. Displacement :69,360tons the nameMercy. Earlier ships namedAR 4 MERCY full load served in World war(WW) - I and AH 8 MERCY b. Draft :33 feet served in WW-II. The T-AH 19 of mercy means Tanker, Auxiliary Hospital, l9'h hospital ship com- c. Length :984 feet missionedby the Navy (For detail ReferAppendix d. Ream :106feet -I). PresentlyUS navy have two hospital.shipsUSNS e. Propulsion :Singlescrew, geared steam turbine,two boilers,single shaft f. Shaft horsepower :245C0

o b' Sustained speed 17.5knots h. Fuel tankage 1.7million gallons i. Fuel consumption ll0gaUmile L} j. Range l3.420miles

k Diesel generators : Three2000KW ter L Fresh water tanks :300,000gallons m Air conditioningplants : Three400 ton each by Fig. 1 n. Waterdistilling plants : Four each 8-l( (qut Patir 'Medical Olhur Fleet Medical Centre, Mumbai. area getfir 74 Jour Marine Medical Society, 2006, VoL8, No. 2 Jour, producing 75,000gallons/ day o. Ballast : l1 milliongallons (Fresh water) p. Incinerators :Two

Departments The MTF(Medical TreatmentFacility) has the following departments a) Executive Officer and Command Master Chief assist the commanding officer in chain of Fig.2 command for smooth functioning of MTF Eachlift hold 25 patients b) Admin department has sections as General can individuals or 6 litter (using admin,Personnel admin, Patient admin, Public special bracketsattached to the interior of the The ramp provides route affair and Security.The administrationsection elevator). an alternative for gettingto the Receiving Time by also has the Law Officer who takes care of Casualty area. elevatorto CASREC is 20 time ramp ernigration, power of attorney,etc. secondsand by is approximately2 minutes. c) Supply department with has sections as Flight Deck :- Flight deck have the hanger for Administration,Stock Control, Food Services, helicopter Sales& Services,Disbursing, Medical Repair, two andlanding area. The US Navy H-60 or Army Black Hawk most fre- Clinical Nutrition; Medical Support,Post office. aircrafts are used quentlyfor Medevacflights. They hold 4 litters and d) Nursing departmenthas sectionsas Admin, 2-3 ambulatorypatients. The Navy CH-53E Super Casrec,ICU, Med / Surg wards. Stallionis the largesthelicopter used by the military e) Medical departmentincludes sick call (Staff and holds24 litter patients.The helicoptersare not surgeon/MlRoom) and PreventiveMedicine. only usedfor patientmoment but also for receiving f) SurgeryDepartment consist of surgery,dental, supplyduring Vertical Replenishments (VERTREP) CSSD (CSR) , optometry. whereall typesof goodscan be deliveredi.e. medi- g) Ancillary departmentconsisting of laboratory cal items, food, store items, mail, equipment and parts. including blood bank, pharmacy,physical therapyand radiology. Decontamination Statig6 :- Three stationswith the intendeduse of removiig and h) Opsdept which havesections as OrNr(Oxygen chemical biologi- and Nitrogen plant), communication,IT/ADP, cal warfareagents from casualties.MERCY being a Air Ops. third levelcare facility, it is expectedthat mostcasu- alties would come to the ship already MMOC Dept Includes sectionsas POMI / , decontaminated. However, the necessaryequipment Readinessand Training. and trainedpersonnel are available,ifneeded. LAYOUT : Generallayout of the ship is given below: FACILITIES Bridge :- Which is the domainof the ship'sMas- ter andthe civilian mariners,is at 04 level. l. Casualty Receiving(CASREC): CASREC has fifty emergency treatment beds which are PatientArrival : Patientscan be broughtto Mercy divided into four areasfor receipt and initial by a smallboat from starboardside (pier side)about managementof patients.During a masscasualty 8-10 feet above the water line or on the port side situation,the following applies: (quarterdeck)using a patient litter hoist assembly. Patientsare also brought to ship by helicopter.There a) Speciallydesignated triage officers (one are a total of9 elevatorson board which are usedfor nurseand administrative staf0 would assess gettingthe patientsto casualtyreceiving (CASREC). patientsin front of the elevatorand quickly

Jour.Marine Medical Society, 2006, Vol. 8, No.2 75 I

identify triage category before assigning capabilitiesare availableexcept open heart them a bay and bed number. surgery and transplants although b) Each bay has 4-6 beds which areequipped emergencycardiac surgery could be with everything needed for patient performedon a limited basis. resuscitation.Each bed is monitored and has c) OR's arelarger than conventionaloperating in line oxygen and suction.The immediate rooms so asto accommodatemore thanone areais also specially equippedwith overhead surgicalteam. This was basedon a vital washdown capabilitiesfor rapidcleaning of lessonlearned during VietnamWar where it the patient if needed.The areais equipped wasfound more advantageousto the patient with surgicallights to facilitatesuturing and by surgicallymending all woundsat onetime, minor surgicalprocedures. ratherthan numerous procedures over a long Intensive Care Units periodof time. a) Thereare four IntensiveCare Units (ICU) of d) Further,two minor operationrooms in Dental 20 bedseach, with a total of 80 critical care canbe usedto expandthe OR capabilities. beds. e) There are flash autoclavesfor quick b) ICU is divided into five pods of four beds sterilization(l forevery 2 ORs)and warming each. cabinetsfor blankets.sheets. and fluids. Surroundingcabinets maintain sterile packs, c) All four ICUs are equippedthe same and suturesand othersurgical supplies. can be usedfor medicalor surgicalpatients. Becausethere is high probability of having PACI.J largenumbers of burn patientsin a wartime a) PostAnaesthesia Care Unit (PACU) has20 scenario,a unit is set asidefor burn care. bedswith samesupport systems as ICU with d) Staffing:- one nurse and l-2 hospital additional monitorinsat nurses'station and corpsmen (depending on acuity levels of ventilatorcapability. patients)per pod. b) It can serveas auxiliaryintensive care unit e) Like the other bedson this deck,each bed is making total ICU bedsto 100beds. monitored and has in-line oxygen and Central Sterile Receiving(CSR) suction.Centralized monitoring is available a) Receivessoiled instruments, utensils, linen at the nursing station. and trash from surgeryvia equipmentlitis f) There is small pantry in each ICU and it andcarts from thehospitalrlrcility. includes ice machine, microwave and b) Directlysupports the needfor suppliesand refrigerator. reprocessingin theoperating room complex. g) At nurses' station there are medication Lift systemtransports sterile packs from CSR refrigerators, and cabinets for stocking on 0l Level. Dirty gearis returnedto CSR medicine. via lift in utility room. This establishesa Pre-Operative Holding Area: - It has six to closedsystem between CSR and OR , which twelve bed holding area.Procedures which can is necessaryfor infection control. be undertakeninclude dressingchanges, shave c) Sterilizersuse the ship's steam.Ethylene preps, and starting I.V. lines and patient Oxide is not used.Cold sterilizationis the monitoring at six bays. only otheroption- (soakingin sterilization 4. OperatingRooms (OR) fluid). a) There are 12 operatingrooms, 2 rows of 6 d) CSR has four steamsterilizers and three each,separated by centralsterile core, with washersterilizers. capabilitiesof 120surgeries a day. e) Reissuessame equipment in a reprocessed, b) All surgical specialtiesand procedure sterilizedstate.

76 Jour Marine Medical Society,2006, Vol.8, No.2 '-r

1 PatientWards becauseof which self life of RBC unit post- a) There are 15 patient care wards; 8 are deglycerilizationis 14days at 4qC. Intermediateand 7 areMinimal Care. c) It has eight Blood Bank Refrigerator b) All have elevatoraccess. m4intaining temp at 40C with capacity to store 300 blood units each. c) There are no private or semi-private rooms. Ambulatory patient are berthed on top rack d) Upon activation Blood Bank can store 3,500 non-ambulatoryon bottom. FreshFrozen Plasma units. d) The Nurses' station is centrally located to e) Blood bank also has facility of platelet facilitate visibility of patientsthroughout the agitator, refrigerated centrifuge and blood ward. collectionon board which is rarely used. e) Thereare two freatmentrooms, an equipment f) Blood bank is part of Armed ServicesBlood holding/cleansupply room, a soiled utility Programme. room. a nourishment station and g) Blood units are replenishedas and when nourishmentroom (on the IntermediateCare required by using liquid nitrogen where Ware). transittime can be 48 hrs. ' fl Patientson minimal care wards eat mealson I l. Mainlaboratory the messdeck. a) Laboratory have facility of haematology, 8. StaffSick Call:- It hastwo private exam rooms, biochemistry, clinical chemistry, two observationrooms, and six treatmenttables immunoassay,drug assay,microbiology, providing for the medical needsof the crew. PCR, histopathology,cytology, frozen 9. Radiology Department :-The departmenthas sections. following facilities- b) Provides routine and high priority 'fotal a) of four X-ray rooms with capabilities proceduresfor all generalwards, ICUs and for full radiology / fluoroscopy diagnostic thePACU. studies. c) During FOS, the laboratory has eight b) Five portablex-ray machinesavailable for techniciansprocessing specimens and CASREC, surgeryor wards. samplesand one pathologist. c) Two C-armsfor realtime radiologyviewing; d) The laboratory has following important especially useful for orthopaedics and equipments general surgery. i) Two'COULTERdcTSdiffCPCoulter d) Four automatic film processorsand two dip HaematologyCell Counter (Five part tanks as a back-upfor manualprocessing. differential) e) Ultrasonographywith colour Doppler and ii) Two ACL 9000 Beckman coagulation threeportable ultrsonography machines. analyser f) 16 slice helical CT scanner.It was first CT iii) Onefully automatedhaematology slide scannerto go afloat. stationer t0. Blood Bank iv) Vitrous 5.1 FS a fully automateddry clinical chemistryanalyser a) Stores2500 units of frozen RBC units below minus 650C,with shelf life of ten years. v) Vitros ECIQ Immunodiagnosticsystem b) Thereare six haemoneticsACP 215 machines vi) Urine Strip reader for deglycerilisation of frozen RBC unit. vii) Bactect9120 blood culture system Deglycerilizationof eachunit takesone hour. viii) LaminarAirflow work station Closedsystem is usedfor Deglycerilization ix) Fully automited bacteriaidentification

Jour.Marine Medical Society,2006, Vol.8, No.2 77 --

system material items. It has 60.000 cubic feet of x) Roch Light Cycler- Real time PCR storagespace machine 15. Nitrogen Oxygen Plant D Two ShandonCryostat a) PlantGenerates O, and Nr. xii) Microtome b) Plant has capability to produces200 lbs of xiii) Fully automated Tissue processor liquid O, or N2per hour. e) The lab has adequatefacility for storageof c) Thereare two 500 gallontanks in O"N, plant temperature sensitive reagentswhich for liquid O, or N, storage.Also there are includes walk in refrigerators,deep freezers, high pressureflasks for gasesstorage prior etc. to distribution under high pressure. f) Extensive internal and external quality d) There is High pressurecharging main for control is being used. chargingof O, in cylinders. g) The department has bio-terrorism testing e) Low pressureO" distribution line (light green facility. The laboratoryundertakes external coloured)in PACU, ICU,CASREC, wards, bio-defencequality control programmeon OR's. monthly basis. 16. MH)ICALRPAIR t2. Physical Therapy a) ROS staff of eight biomedicalengineering a) Primary purposeof this unit is for whirlpool techs ensuresthat over 3,000 pieces of debridementof burn patients. medical equipmentis properly checked, maintained,and repaired. b) Major equipment includes 2 full-body immersionHubbard tanks,2 extremity tanks b) They have the capability to repair most of and 2 hand/foot tanks. the equipments. c) Departmenthave the capability of post- c) Naturally,there are no servicecalls at seaby operativerehabilitation, hot and cold pack companyrepresentatives. therapy,soft tissueand joint mobilization. 17. Galley 13.Plrannacy a) Galley is one of the largestafloat. a) The pharmacyis well stockedwith bulk b) It is capableto feed up to 2,500 people in issue,distribution system. two hours threetimes a dav b) It has the capability of Intravenousdrugs c) Galley is common tor bfftr the staff and admixtureby using asepticconditions. patients c) Narcoticsare storedin a vault. d) Non-ambulatory patients have their food d) Extensive facility for storageof temperature preparedin the galley and then brought to sensitivemedicines, vaccines etc. them using portable steam carts. The IntermediateCare wardshave nourishment e) Issuewindow to the outsidepassageway. roomswhere the portablesteam cart can be t4. Logistics pluggedin and the food kept hot. a) Five daysof medicalsupplies maintained on 18. Mess decks board all the time. a) Mess Deck has seating capacity for 500 b) Mercy's Medical inventory is I1,400 items people. valuedat 26 million US $. b) Staff and ambulatorypatients use the mess c) Upon activationorder, ship hasfive daysto deck. receive25 days of supply and crew up the c) It is alsoused for training andentertainment ship and sail. purpose. d) BARN maintainsgeneral supply, and medical 78 Jour MarineMedical Society,2006, Vol. 8. No.2 19. Berthing f) Both males and females have separate a) Theship has berthing for 888junior enlisted, berthingand are not allowedto go in each 54 seniorenlisted and 264 officers. othersberthing. b) Officer's berthing n. Lifeboats personnel D Totalof 264officer berths,I 32 femaleand a) Thereare 12 life boatsto carry I 188 132male on separatelevels. b) Also 82,25man life raftsto carry2050 people ii) Made up of 4, 6, and 8 bunk c) Furtherfour 22 men rigid life rafts for 88 configurations. people r sister c) CPOberthing accommodations for 54 CPOs d) Thus Mercy has total capacity for 3326 medat on 3rddeck. personnelin eventof abandonship. d) Thereare total of'8 enlistedberthing areas. e) Regulartraining is beingheld for abandon TE oil Thereare I I I rackseach. ship,fue andman-over-boat drills. to the e) There is ample the storagefor personal 2r. Miscellaneousfacilities :- The ship is like a rMili- clothing.Accommodations are generally smalltown andprovides services like Library, ix -II). betterthan afloat standards. Gym,Post Office, Chapel, Laundry (ship's and moved self service),Barber shop, and Ship store. )swere flipped

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I, No.2 Jour.Marirc MedicalSociety,2U)6, Vol.8, No.2 79 PSYCHOLOGICALEFFECTS OF LONG SAILING ON SUBMARINERS theindi recorde( The Surg Capt AA Pawar*,Surg Cdr DK Ghosh', Surg Lt B Soni#,Surg CdrA Tripathi--, Ms J Rathodt*, ColS Chaudhuri# RESUL The wereju Abstract averagc

The paper is a pilot project to study the psychological impact on submariners subjected to long sailing.53 5l %,wr sailors of a submarine were studied during a long sailing mission. They were administered the General Health theresl Questionnaire (GHQ) and the Fatigue Impact Scate (FIS). l3.20Va scored above the cut-off of 5 on the GHQ. modera Scores on the FIS were within normal limits. Higher scores on the GHQ were linkcd to alcohol consumption. Similat The study brings out the importance of monitoring and assessing psychological health of crew during long nissions to maintain optimum performance of the personnel. smokec

Key Words : Submarine Sailing, Psychological Health TABLE Socio-d

INTRODUCTION Objectives No. stud tTlhe submarineenvironment is characterisedby To studythe cognitive impact of long sailing Rank I I crampedspaces, hot bunking, stale air andmo- To studythe socialimpact of long sailing Mcan a1 notony of living in a cramped spacewithout To study the levelsof anxiety and depression Marrred exposureto natural environment.Recently the In- afterlong sailing lJn marri dian Navy has increasinglyresorted to prolonged Consum sailing for submarineswherein the submarinere- To studythe fatigue levels after long sailing Non drt mainsundersea without surfacingor touchingany Smoker: MATERIALANDMETHODS base port. Submarinersas a group are known to Non sm havetraits of detachment,propriety, and workaholism A submarinecrew detailedfor long sailingwas studiedduring the period of sailing.A socio-demo- I I ]. They havealso been reported to be havingmore graphicquestionnaire was preparedand the We adventurousness,confidence, group. orientation, to the and self-sentiment As future missionsbecome followingscales were administered. [2]. correla longer,personal aqd psychologicalissues become l. GeneralHealth 28 item version. Questionnaire the GH more importantzfowever, hardly any literaturers The GHQ is a standardisedmeasure accepted 5 whic availableon this topic.An US studyrevealed that in all overthe world asa measureof psychological long health. The 28 item version allows sailings issuessuch as boredom becameim- TABLE portant and attitudes became negative only to categorisationto measurethe cognitive impact, Generi reversepolarity after the submarinereturned to har- the social impact, the levels of anxiety and rank bour [3]. An internetsearch did not revealany other depressionamong the sample. impactof long sailing other than the study outlined 2. Fatigue Impact Scale. This scale is a above.It was,therefore decided to studythe impact standardisedscale to measurethe levels of of long sailing in this pilot study on Indian Naval fatiguein the sample.It is also divided into personnel. physical,social and cognitivecomponents. Means AIMS All the saJnplestudied were sailors.The ques- Numbe tionnairewas administered individually to thesailors allo ve To study the impact of long sailing on the psy- by the Medical Officer. To obtain true levels strict Somati chologicalhealth of submariners confidentialitywas maintainedand only therank of Anxiet Social 'Senior Depres Advisor Psychiatry, INHS Asvini; *BMO INS Vajrabahu;rMedical officer Vajrabahu;"Classified Specialist Psychiatry, INHS Asvini; *Clinical psycholcigist;*Prof of Psychiatry, RINPAS. Total s

80 Jour Marine Medical Society,2M6, Vol.8, tio. 2 .lour h NERS the individuali.e. junior sailoror seniorsailor was We then linked the scoresobtained on the Fatigue recorded.No other recordof identity was maintained. ImpactScale to the rank of the sailors(Table 3). The datawas analysed using SpSS. Therewas no correlationwith the rankand the scores d*, obtainedon the inventorv. RESULTS The sample consistedof 53 submariners.64Vo TABLE3 werejunior sailorsand 367owere senior sailors. The Fatigue Impact Scale scores linked to rank averageagc was28 years.43Vo were unmarried and Junior Senior ailing.5.1 57 7owere married. All marriedpersonnel were MLR, Maln al Sailors Sailors Whirney tl Heatth the rest were in-living.36Voconsumed alcohol in :heGHQ. N=34 N=t9 resr moderation,while umption. therest did notconsume alcohol. signifrcance ring long Similarly,287a did rbt smokewhile the restTZVo Mean smoked(Table l). score obtained 50.29 38.21 p>0.05 Cognitive impact 12.91 8.47 p>0.05 Social impact 25.74 20.63 p>0.05 TABLEI Physicalimpact 11.65 3.1 I p>0.05 Socio-demographic profile of submariners Maximum score 108 Minimum score 45 No. studied 53 tiling Rank Juniorsailors 34 (7o) Seniorsailors I9 (oZ) lo'b We then linked the scoresobtained on the GHe to Mean age 28 the maritalstatus of the saitors(Tabte 4). lresslon Married 30 There was no correlation Unmarried 23 with the marital statusand the scores Consumers obtainedon the GHQ. Seven iling of alcohol l9 sailors scoredabove Non drinkers 34 thecuroff of 5 ivhichfour werejunior sailorsand 3 Smokers 38 weresenior sailors. Non smokers l5 lngwas r-demo- TABLE4 General Hcalth nd We Questionnaire scores linked to the then linked the scoresobtained on the GHe marital status to the rank of the sailors(Table 2). There was no /ersion. correlationwith the rank and the scoresobtained on U nmarried Married Mann N=23 Whitney rcepted the GHQ. Sevensailors scored above the cut-off of 130 U 5 which indicatessignificant psychological lest rlogical distress. significance allows impact, TABLE2 Mean score obtained 2.32 1.84 p>0.05 GeneralHealth Nurnbcr scoring ? (5.61o) (7.5Eo) )ty and Questionnairescores linked to 4 rank ahove cut-off Somatic complaints 28.41 25.73 p>0.05 ) is a Junior Senior Mann Anxiety and Insomnia 28.98 25.48 p>0.05 relsof Sailors Sailors WhirneyU Social dysfunction 28.98 25.48 p>0.05 N=34 N=19 :d into tesr Dcpression 27.00 27.0O p>0.05 significance )nts. Total scorc 29.03 25.72 p>0.05 Mean score ) ques- obtained 2.32 l.g4 p>0.05 Number scoring 4('7.SEo) (5.6%\ 3 We sailors above cut-off then linked the scoresobtained on the Fa- tigue Impact s stnct Somaticcomplaints 2j.21 26.63 p>0.05 Scale to the marital status of the ankof Anxiety and Insomnia 29.46 24.39 p>0.05 sailors(Table 4). There was no correlationwith the Social dysfunction 29.46 24.39 p>0.05 nlarital statusand the scoresobtained on the GHe. chiatry, Depression 2j.00 Z7.OO p>0.05 Sevensailors scored above the cut-off of 5 out of Total score 2'l .69 Z5.jg p>0.05 which four weremaffied and3 were unmarried. i,No.2 Jour Marine Medical Sociery,2006, Vol.g, No.2 8l

) t- TABLE 5 TABLE 7 surv€ Fatigue Impact Scalescores linked to marital Fatigue Impact Scalescores linked to alcohol posul status consumption disso

Unmarried Married Mann Non Drinkers Mann apprt N=23 N=30 Whitney U drinkers N=I9 Whitney U stresl test N=34 test cnter significance significance ston.

Mean score obtained 28.1'7 26.50 p>0.05 Mean score obtained 27.24 26.58 p>0.05 assoc Cognitive impact 28.65 25.73 p>0.05 Cognitive impact 2'7.O3 26.95 p>0.05 subse Social impact 28.37 25.80 p>0.05 Social impact 27.03 26.95 p>0.05 toms Physical impact 27.59 26.55 p>0.05 Physicalimpact 26.'76 27.42 p>0.05 disso Maximum score t08 Maximum score 108 study Minimum score 45 Minimum score 45 traine mighr An attemptwas madeto link the scoresobtained 0able 7). toms. on the GHQ to the habits of the sailorsi.e. whether a mor the personwas consumingalcohol or not (Table6). A similarcomparison with smokersdid notyield sympi rine There was no correlationwith the marital statusand any significantdifference in both the scales. cl the scoresobtained on the subscalesof the GHQ. manOr However,the total scoreon GHQ showeda signifi- DISCUSSION stress cantcorrelation with thealcohol consumption. Seven There has been a substantialincrease in the whoti sailorsscored above the cut-offof more than 5 out numberof peopleliving and operatingin isolated, nelan of which four wereconsumins alcohol and 3 did not confined,and artificially engineered environments. factor consumealcohol. suchas spacecraft,deep diving, weatherstations, psych submarines,and polar outposts. However, no indi- What TABLE6 cationsof a "psychologicallimit" for how long nners General Health Questionnaire linked to alcohol peoplecan tolerate remaining in isolationand con- percer consumption finementhave been found. Issues of psychological offscc healthbecomes important when peoplehave to stay theirp Not Consuming Mann andn( cgsuming alcohol Whitney U for long periodsconfined together. Anecdotal evi- /alcohol N= 19 test denceof people winteringover theAntarctic have llowe' N=34 significance revealedthat incidentssuch as "scapegoating"of helpfr wellin p<0.05* deviantcrew members and displacement of aggres- Mean score 1.65 3.05 hasbe obtained sion to outside personneldoes take place. consur Number scoring 3(5.67o) 4('7.59a\ Individualscharacterized by strongachievement above cut-off motivationcombined with interpersonalsensitivity eventl asmo( Somatic 28.41 25.'73 p>0.05 seemedto adaptbetter than others[4]. A studyof complaints US Navy submarinepersonnel i.e. I389 oftlcersand ing th p>0.05 Anxiety and 28.98 25.48 I1,952enlisted crew members served aboald partici- especii I nsomnia patingsubmarines for 215,086and 1,9-55,521 basis.' Social 28.98 25.48 p>0.05 person-daysat sea were studied.Cases reporting sociate dysfunction person Depression 2'7.OO 2'l.O0 p>0.05 sickwere mainly due to respiratoryillnesses or mus- indicat Total score 29.03 25.1 2 p>0.05 culoskeletalcomplaints. Many had ill defined scored conditions[51. Psychological health was presum- ably not studied.Another study assessed the stress missio When the scoreson the Fatigue Impact Scale reactionsof a submarinecrew tbrcedto abandon to strel were comparedto alcohol consumptionthere was their vesselin high seasafter tlooding andfire dam- reporte groups. no significant difference betweenthe two agedtheir ship. The remainingcrew members werc sumptl

82 JourMarirte Medical Societv. 2006. Vol. I. No.2 Jour.Mt I

surveyed7 months after the incidentregarding ex- the individual and educativeefforts must be made posures,initial emotionalresponses, peritraumatic to increaseawareness of the personnelregarding dissociation,subsequent life events,current safety safelimits of alcohol consumptionand the hazards appraisal,and current symptomsof posttraumatic involved. The study did not involve officers who stressdisorder (PTSD) and depression.9.I7o met may havebeen reluctant to fill out the questionnaire criteriafor PTSD and none met criteria for depres- for reasonsnot known. But if the safetyof the sub- sion. Higher levels of depressivesymptoms were marine and the necessityof the mission are associatedwith previous traumatic exposuresand paramountthen it is important that especially for subsequentlife events.Higher levels of PTSD symp- long sailings,psychological health is monitored to toms were associatedwith greater peritraumatic preventaccidents. It is also important that medical dissociationand initial emotionalresponse. The officers proceeding on these missions are suffi- study concludedthat acute-exposuresof highly ciently sensitisedin the knowledge and treatment trained professionalsto potentially fatal events of mentalhealth problems they arelikely to encoun- might not resultin high levelsof posttraumaticsymp- ter during suchmissions. toms.Previous and subsequent life eventsmay play a more significantrole in the level of post disaster CONCLUSIONS symptoms [6]. In anotherstudy when the subma- The study thougha pilot study hasbeen the first rine crewswere studied 2 to 3 weeksafter peacetime to systematicallystudy the psychologicalhealth manoeuvreaccidents, submarine crew showedless during long submarinemissions. The findings of stresssymptoms than their surfacenavy colleagues the study are being validated by a concurrent re- who tiad facedaccidents. Cohesion among person- searchproject. There is a needto studyofficers also nel and habitualcoping style emergedas resilience as well as families of submarinerswho proceedon factors [7]. Our study is thus the first to focus on suchlong missions. psychologicalhealth of long submarinemissions. REFERENCES What hasemerged from the studythat most subma- rinerscope well with therigors of long sailing.13.20 l. Moes GS, Lall R, Johnson WB. Personality characteristicsof successfulNavy submarinepersonnel. percentofthe sailorsstudied scored above the cut- Mil Med 1996 Apr; 161 (4) : 239-42. off scoresof the GeneralHealth Questionnaire.Thus, 2. Van Wijk C, Waters AH. Personality characteristics their psychologicalhealth may be takenas impaired of South African Navy submarine personnel. Mil Metl and needingfurther assessmentand management. 2000 Sep; 165 (9) : 656-8. However,none of the sailorsreported sick or sought 3. Weybrew BB, Molish HB. Attitude changesduring and help for their symptoms.They were able to cope after long submarine missions. Undersea Biotned Res 1979;6 Suppl :5175-89. well in spiteof havingill health.A significantfactor ,/ 4. SandalGM. The effects of personality and interpersonal has been the consumption of alcohol. Personnel relations on crew performanceduring space simulation consumingalcohol had higher scoreson the GHQ studies. LlZ Support Biosph Sci 1998; 5 (a) : 461-70. eventhough the alcohol consumptionwas reported 5. ThomasTL, Garland FC, Mole D, Cohen BA, Gudewicz as moderate.This brings out the issuesof monitor- TM. Spiro RT, Zahm SH. Health of U.S. Navy ing the psychological health of submariners submarinecrew during periods of isolation.Aviat Spat:e (3) especiallyinvolved in long missions on a regular Environ Med 2O03 Mar:'14 : 260-5. basis.This can be accuratelydone if the stigmaas- 6. Berg JS, Grieger TA, Spira JL. Psychiatric symptoms and cognitive appraisal following the near sinking of a sociatedwith mental symptomsis removbdand such researchsubmarine. Mil Med 2005 Jan; 170 (l) : 44-7. personsare not made unfit unlessthere is a serious 7. Eid J, Johnsen BH. Acute stress reactions after indication.After all in the study the personnelwho submarine accidents.Mil Med 2002 May: 167 (5) : scoredhigh on the GHQ did go on to completethe 427-3t. mission. Betterpsychological health and resilience 8. Pawar AA, Rathod J, Saldanha D, Ryalli VSSR, Das to stressin Indian Navy submarinershas also been RC, SrivastavaK. Environmental stressin Indian Naval personnel.Best Poster presentationon Day two in reportedearlier The secondis that alcoholcon- [8]. XVI Asia Pacific conference on Military Medicine sumption does impair the psychologicalhealth of 25-30 Mar 2006 New Delhi.

Jour.Marine Medical Society,2006, Vol. 8, No. 2 8-l -

THE EUSTACHIANTUBE IN DIVING: EAR BAROTRAUMAAND MIDDLE EAR AUTO-INFLAIION TECHNIQUESIN NAVAL DIVERS - ORIGINAL RESEARCHPAPER

Surg Cdr Padma Ramesh'

ABSTRACT

A survey of 50 naval divers was conducted using a structured questionnaire administered by personal interview to determine the prevalence of ear barotrauma durirrg diving and to study the practice of various middle ear auto-inflation techniques.

All (1007o) of the divers studied considercd pressure cqualization difficulties to be the conrmonest ear problem in diving. 42 (84Vo\ of the studied divers reportcd symptoms of ear barotrauma, of which the conlnlonest symptom was pain (l00Vo), Other symptoms accompanying pain were blocked ear sensation, blocked seusation and tcmporary deafness, and vertigo. 40 (95.27o) of affected divers suffered barotrauma of descent' the comnronest depth being l-5 metres (20,47.69o\. Two divers (4.87o) experienced barotraumas of ascent' 30 (7l.4Va) ear barotraumas were sustained during wet dives, 7 (16,7Vo\ during training and 6 (14.3o/o)during dry (chamber) di ves.

The commonest cause of barotraurna was perceivcd to be diving with an upper rcspiratory infection in 25 divers (59,5Vo1,rapid descent (31 7.l%o), unknown (5, ll.9vo) and others (10,23.8Vo\ including equipment-related causes, repetitive prolonged diving, late auto-inflation, lack of awareness, exposure to cold, and absence from diving of over one month. The commonest outcome of barotrauma symptoms was atrorting dive (14 divers, 33.3Vo). ll divers (26.2Vo) reported for medical treatment and were diagnosed with ear barotrauma which resulted in absencc from diving comprising a few days (2, 4.77o\, wceks (5, ll.9?o), or ntonths (3' 7.lolo), the maximum period being two rnonths.

Of the various middle ear auto-inflation techniques, the most conrmonly uscd primary method was the Toynbce method (21, 42Vo), followed by jaw movement (13, 26Vo\, the Valsalva technique (12, 24qo) and the Frenzel technique (4, 8Vo). Most divers (34, 68Eo) uscd a conrbination of two techniques, the connonest combination being Toynbee plus Valsalva (14,28Vo). However 16 (32Eo) practiced only one technique, of which Valsalva was commonest (7,l4Vo). The large majority ofdivcrs (27,54Va\ performed repeated auto-inflation only at each tinre pressure sensation in the ears was felt during continuing descent, a practice predisposing to middle ear barotrauma.

Recornmendations to reduce the incidence of ear barotrauma in naval divers include empha;,i/on the correct use of middle ear auto-inflation techniques during training, training in more than one tcchnique, and frequcnt refresher cducation programmes.

Key Words : Barotrauma, divers

INTRODUCTION ageresulting from expansionor contractionof en- \ fiddle-ear barotraumais by far the mostcom closedair spacesas a result of such pressure LYlmon barotraumaticotologic injury and has changes,the greatestoccurring near to the water beenexperienced by all diversto someextent Il]. surface.It follorvs failure to equilibratemiddle ear Every 33 feet of depth of sea-waterresults in an andenvironmental pressures via activeopening of added pressureof I atm. Barotraumais an injury the Eustachiantubes during descent.Any condi- that occurs due to the result of rapid or extreme tion which tendsto block the Eustachiantube changesin pressure,and is defined as tissuedam- predisposesto middle ear barotrauma.More com-

"ClassifiedSpecialist ENT, INHS Asvini

84 Jour.Marine Medicul Soc'ierv,2006, Vol.I, No.2 I

monly, it is causedby faulty techniqueof voluntary divers and input from the interviewed divers was middle earauto-inflation [21. Factors leading to block- incorporatedinto thefinal questionnairedesign. The ageof theEustachian tube include upper respiratory refinedquestionnaire was administered by personal infection and allergies,nasal pathology and faulty interviewmethod by the sameworker andcollected techniquese.g. delayedauto-inflation during de- data on diving experience,incidence of symptoms scent,descent to thepoint of locking,and horizontal and managementof ear barotrauma,and practical or head-downposition. useof middleear auto-inflation techniques during Barotraumaproblemsmay contribute to panicand trainingand operational diving. diving deathsin novicedivers, prolonged absence Middle earbarotraumas can be classifiedinto six from diving dutiesor to permanentdisability - tinni- stagesdepending on physicalsigns, ranging from tus, imbalanceand hearing loss. Despite the fact Grade0 (symptomswithout physicalsigns) to Grade that ENT problems are both frequent and may be 5 (free haemorrhageinto middle ear with tympanic life-threatening,it is difficult to find numberson membraneperforation) [2]. However,no documen- morbidity andmortality of ENT problemsin diving tary evidencewas available for corroborationin any [.|. Of the few accessibleinternational studies on ofthe cases.Therefore, for the purposeofthis study, earbarotrauma in divers,most are on thescuba div- reportedbarotrauma was classifiedas mild (diver ing population.To the best of the author's ableto continuedive), moderate(dive abortedand/ knowledge,there is no previousstudy on the prac- or symptomspersisting post-dive for minutesto ticeof middleear auto-inflation techniques in divers. hours)or severe(symptoms lasting days, requiring This study aims at studyingthe prevalenceof medicalmanagement, and/or resulting in absence earbarotrauma, the practice of middleear auto-infla- fiom duty). tion techniques,and possiblecauses of ear RESULTS barotraumain navaldivers. A total of 50 navaldivers were interviewedof OBJECTIVES which most were clearancedivers. the rest being l. To study the prevalenceof ear barotraumain ship'sdivers. The sampleincluded diving instruc- navaldivers tors,technical divers and chariot divers. (32, -30 years 2. To studythe practice of middleear auto-inflation Most divers 640/o)were aged 2 I and (28Vo) -40 (87o) techniques 14 were aged3 I years.4 were aged 4 I -50years. Experience ranged from I I monthsto 19 3. To bring out possiblecauses for earbarotrauma yearswith mostdivers having experience of 6-10 STLIDY DESIGN : A cross-sectionalretrospec- years(23, 46Vo).Maximum of diving ranged $Fth tive descriptivestudy carried out on naval divers from 35 to 160metres with most (32,647a)in the from May to October 2006. rangeof 55-60metres. All (1007o)of the interviewed SUBJECTS : 50 navaldivers involved in actrve divers consideredproblems with middle ear auto- diving duties. inflationto be thecommonest ear problem aft-ecting EXCLUSION CRITERIA : Diverswho hadless divers. thansix monthsexperience following dive qualifica- l. Ear Barotrauma tion (SD) coursewere not includedin thestudy. (a) Prevalence z 42 (84Vo) had personally METHODS experiencedproblems with middle ear auto- This cross-sectionalstudy used a structured inflation and symptoms of barotrauma(pain, questionnairecontaining a range of self-reported tinnitus,hearing loss or vertigo)at onetime or outcomemeasures related to symptomsassociated the other. with earbarotrauma and practice of middleear auto- (b) Severity, Frequency and Symptoms : 14 ear inflation techniques.A pilot study for the barotraumasreported were severe(33.39a),13 questionnairewas conducted on a smallnumber of mild (317,.)and l5 moderate(35.7Vo), (Fig l).

Jour MarineMedical Society, 2006, VoL. 8, No.2 8-s a--

The majority of affected divers (16, 38.17o) (d) Outcome of symptoms: The occurrenceof reported barotrauma on an occasional basis symptomsof earbarotrauma resulted in one of with 4 (9.57o)each having experiencedit the following outcomes:dive abortedinl4 frequentlyor mosttimes,5 (Ll.gEo) rarely, and (33.37o),graded slow descentin 7 ( 16.77r,),use 13 (3lVo) once respectively,(Fig 2). The of yo-yo ascent(l 1,26.2 Vo),use of another commonestsymptom was pain (42,loOo/o\.Pain auto-inflationtechnique (4,9.5Va) or use of was the sole symptom in 26 (6l.9Vo).Other fbrcrbleValsalva (3,7.|Vo), (Fig 3).One diver symptomsaccompanying pain wereblocked ear resortedto both yo-yo ascentand forcible sensation(l l, 26.2Vo),blocked sensation wi th Valsafva (2.4qo).One diver continued to temporarydeafness (2,4.87o), and vertigo(2, descenddespite increasing otalgia (2.4Vp). ll 4.8Vo).Two(4.8Vo) divers had only blockedear (26.2Vo)of aft'ecteddivers sought medical advice sensationwithout pain. The majority of ear and were diagnosedto have sustained barotraumawas unilateral(38, 90.57o).Of the barotrauma. diverswho reportedear barotrauma symptoms, (e) Absencefrom diving duties: l0 divers(23.88a) only two (4.8 7o)reported symptoms suggestive with ear barotraumasymptoms were certified of middle ear infection.of which one was temporarily unfit for diving. The period of unrelatedto diving. absencewas a few days(2 divers,4.7Vo),weeks (c) Setting, depth and timing: The majority of (5 divers,Ll.97o),or months (3 divers, T .l7o).Of reportedbarotrauma occurred during wet dives thoseexcused diving for a month or more, two (30,7 1.47o). 7 (l 6.7Vo) occurred duri n g traini n g gave a history of tympanic membrane periods.Only 6 (14.67o)occurred during dry perforation(Grade 5 barotrauma). (chamber)dives (one diver reportedoccunence (f) Causesfor ear barotrauma: Perceivedcauses of barotraumain both wet anddry dives).Most for barotraumaas statedby the affecteddivers reported barotraumasoccurred at l-5 metre includeddiving with-an upperrespiratory depth (20, 41.6Vo)and the remainingat 6-10 infection(commonestl6use) in 25 (59.57r').rapid metres(15,35.1Vo), I l- 15metres (3,7 .lVo) and descentin3 (7.l%o), unknown in 5 (l1.97o),and l6-20 metres(3,7.IVo) with one unspecified equipment-related(ill-fitting nose-clip,tight (2.4Vo).Almost all barotraumasoccurred during hood, heavy set (3 divers,T.l%o)). Only one descent(40,95.2Vo) except two (4.87o)which diver reported barotrauma associatedwith a occurred at l-5 and 6-10 metresrespectively tight hood (2.4Va).Various other cited causes durins ascent. weredelay in first auto-inflation,repetitive short dives in a few hours,absence from diving for sa/ere more than a month, exposureto cold, lack of 110t- rsq/ere exercise('warm-up') immediatelyprior to dive, I nDderatei and lack of awareness(7, 16.77o).One diver : reported two causes(URTI and repetitive diving). npderate %o/o

. ^g. I : Severity of barotrauma 40 30 cnce s20 I occasional 310/o 10 lrmsttims 0 rJfreguently E rarely rarely is f requently trDst tin€s once ;€ I EE ,"1 € €$t$ 10olo 1006

Fig.2 : Frequencyof symptoms Fig. 3 : Outcome of symptoms

86 Jour Marinc Medical Society, 2N6, Vol.8, No.2 2. Middle ear auto-inflationtechniques time pressuresensation in the ears was t-elt (a) Techniquesin use: The most commonly used during continuing descent,a practice primary methodof middle earauto-inflation was predisposingto middleear barotrauma. rnn theToynbeemethod (21 divers,42Vo),followed (c) Efficacy of middle ear auto-inflation with rey u by jaw movement(13, 267o),the Valsalva respectto head position : Attempting to auto- e5l (12,24Vo) cance technique and the Frenzeltechnique inflate while in the horizontalor head-down (4, 8Vo).Most divers (34, 687o) used a _ postureis more difficult due to increased I.t)5 combinationof two techniques,with the venouscongestion of the Eustachiantube. a r.0 5 secondarymethod being used if the primary finding which was corroboratedby 8 (16%) 05 wasunsuccessful. However. a sizeablenumber divers. 22 (44Vo) f'elt no difference in easeof .05 of divers (16, 32Vo)practiced only one in body posture. )8 middleear auto-inflation any technique,of which Valsalvawas commonest 5 The remaining20 divers(407o) however, could (n=7,l47o).No diversreported use of theBTV notspecify as most diving is donein thevertical or the Edmond'stechniques, which are positionwith head-upon thedescent line (shot describedin dive literature. rope). (i) Primary method: The most common (d) Useofyo-yo ascentsas an aid to auto-inflation yield methodwas theToynbee (swallowing with : The useof the yo-yo ascent(ascent by l-2 closednostrils) (21,42%,), followed by jaw metresafter a failed auto-inflationattempt and movement(13, 267o)and the Valsalva repeatattempt) is discouragedby diving (blowingout cheekswith closednostrils) physiciansas this practicepredisposes t

to. ! Jour. Marine Medical Society,2006. Vol.8. No.2 87 (i) Upper respiratory infection : This wasthe of middleear auto-inflation, 5 (3I .37oof this single commonestassociated causative group) sustainedsevere barotrauma, vis- factor occurring in 25 (59.5Vo)divers i-vis 8 (23.5Vo)of the 34 divers who sustainingear barotrauma. employedtwo techniques.Within the (ii) Nasal atlergr and use ofdecongestant nasal singletechnique group, 7 divers(43.8%) drops : Nasal allergy symptoms were reported occurrenceof barotraumaon reported by 7 (L6.7Vo)of the divers fiequent/ most times basis.Of the divers experiencingbarotrauma symptoms. Divers who employed two techniques,only 2 with nasalallergy had both more incidence (5.9Vo)reported barotrauma on frequent/ of severe barotrauma symptoms (3/7, mosttimes basis, (Fig 6). 42.9Vo)and frequentsymptoms (217 ,28.6 (ii) Timing and frequency of auto-inflation : 7o)than the non-allergic group (lO/35,28.6Vo While only 4 divers performed auto- and 5/35, l4.3Vo respectively).Of the l0 inflationat surfaceprior to dive, 3 (75Vo)of divers who reporteduse ofnasal dropson them sufferedsevere barotrauma vis-)r-vis occasional or frequent basis, 4 (40Vo) l0 divers(10146,21.77o\ in thosewho did developedsevere barotrauma as compared not auto-inflate at surface.One diver of to five (5/40, 12.5Vo) in the group who did the first group (257o)had barotraumaon not usenasal drops or had usedthem only frequent/ most timesbasis as compared to once. Symptoms were more frequent in the 6 (139o)in thesecond group. first group (4llO,4O7o) experiencingthe Consideringthe timing of subsequent same on frequent / most times basis as auto-inflation,of the 24 diverswho did so comparedto the secondgroup(3140,7 .57o), at 0-l metre,9 (37.SVo)suffered severe (Fies). barotraumaas compared to only 4/26 (iii) Smoking : Of the 42 divers reportingear (15.47o)of thosewho auto-inflatedafter I barotraumasymptoms, 12 (28.6Vo)were metredepth. However, only one diver ( l/ smokers.This group of smokershad less 24, 4.2Vo)of thoseauto-inflating at 0-l t incidenceof severebarotrauma symptoms metre had barotraumaon frequent/ most j (3112,25Vo)than the non-smokinggroup rimesbasis as compared to 6 (6126,23.1%') t (10132,3l.3%o), however reported more of thosewho auto-inflatedabove I metre. barotraumasymptoms (2112,16.'l Vo)on Of the27 diverswho repeatedsucceeding s; frequentor most times basisas compared auto-inflationsonly on perceivingpressure : to non-smokers(5 132, l 5.6 Vo). in theears,4 ( l4.8Vo)had severebarotrauma i (9123,39.17c)who O) Diving and auto-inllation techniques ascompared to 9 divers T auto-inflatedafter every breath or 3-4 (i) Single vs. two techniques : Of the l6 divers breaths.However,5 divers (5/27, 18.57r,)of (32Vo)who employedonly one technique the first group had barotraumasymptoms 45 Fig & 50 45 35 40 30 Fs"** 35 25 barotrauma 30 i I8e\€re :e I ! barotrauma 20 rfrequent $25 I frequent 20 I r 15 I barotrauma I barotrauma 10 15 10 5 t 0 o freq/occas once/nenr singletechnique two techniques Fir Fig.5 : Useof nasaldrops Fig. 6 : Single vs two techniques

Jot 88 Jour MarineMedical Society,2006,VoL8, No.2 -l7cof this on a frequent/ most times basis as first group(5129,l7 .2Vo) experiencing the uma.vls- comparedto 2 (2123, 8.7Vo) in the second same on frequent/most times basis) as rerswho group. comparedto 212I,9.5Voin the second ithinthe (iii) Use of j'o-yo ascents : Of the 7 divers who group,(Fig 8). ; (43.8Vo) employed yo-yo ascentson a frequent (v)'End-of-the-day' barotrauma : Two divers aumaon basis as an aid to clearingtheir ears,2 reportedmoderate barotrauma symptoms .hedivers (28.6Vo\suffered severe ear barotrauma and following repetitive dives in a short time s,only 2 5 ('71.47o)had barotraumasymptoms on period(4.87o). fiequent/ frequent/most times basis. Of the l6 divers (c) The role of experience: Of the I I divers who who employed the yo-yo occasionally,8 hadexperience offive yearsor less,3 (27.3Vo) nflation: (507o)experienced severe barotrauma, and reported severe barotrauma symptoms, ed auto- one (6.3Vo)had barotraumasymptoms on comparedto l0 (10/39, 25.6Vo)of those who (75o/o)of frequent/ mosttimes basis. Contrastingly, had more than five yearsexperience. None (07o) vis-d-vis in the 27 divers who did not use yo-yo of the first group reported symptoms on : whodid ascentsor used the yo-yo only rarely or frequent/ most times basisvis-i-vis 7 (7139, diverof once, severebarotrauma occurred in 3 (3/ l87o) inthe secondgroup, (Fig 9). 'aumaon 27 , I I .IVo)with only onediver in thisgroup (3.7Vo) nparedto having symptomson frequent/ DISCUSSION mosttimes basis, (Fig 7). In this study,84Vo of divers reportedsymptoms (w) of ear barotrauma,confirming the high prevalence Ssequent Use of the forcible Valsalva manoeuvre : of the condition in the naval diving population. hodid so Of the 29 divers who practiced forcible :d severe Valsalvamanoeuvre as an aid to clearing Mawle and Jacksonin a survey of 142 British nly 4126 ears, IO (34.5Vo)sustained severe diversfound thatl I.IVo hadexperienced equalizing edafter I barotraumaas compared to 3 (3121,14.297o) problemswhile diviny'and 64Voof divers reported diver( l/ in those who did not. Barotrauma symptomsof earbarofrauma [3]. In their study,507o I,Sat 0-I symptomswere also more frequentin the of diverssuffered clearing difficulties I - l07o of the nt / most 80 time. ll%o of diversin their studystated having been t,n.tqd 70 diagnosedwith barotraumapreviously. In a ques- 60 : I metre. tionnaire-basedretrospective study among diving il.;;;-- l cceeding instructorsand dive mastersin recreationaldiving. s 40 i barotrauma: Ornhagenand Hagberg found 6.5%oear related I pressure 30 ilfrequenl i [4] rrorauma LbarorJsumaj problemsamong malesand 8.97oproblems among I 7c)who 10 females.This studyhowever, dealt with very experi- h or 3-4 o enced divers of two categories.Taylor et al 8.5%,)of frequenl occasional no use conductedan internationalpostal survey of 709 ex- /mptoms use use periencedrecreational scuba divers in 2003 and Fig.7 Use of yoyo ascents 30 4A 25 - e\rerg 2A f j F*** arotrauma 25 I severe barotraumal I barolrauma ee 15 I eguenl s20 frequent fr"quunt lI : arotrauma 15 ll barotrauma' r ...9"119!rl"tTi I 1A 5 o 0 usars non-us€rs less than 5 yrs more than 5 Yrs

Fig. 8 : Use of forcible Valsalva Fig. 9 : The role ofexperience t.8,No.2 Jour Marine Medical Society,2006, Vol.8, No.2 89 tbund that earbarotrauma had beenexperienced on descentassociated with unsuccessfulauto-intla- oneor moreoccasion by 369 (52.lEo)with tympanic tion. Uzun et al documented0.46 7o incidenceof achieve[51. membranerupture and round./ovalwindow rupture alternobaricvertigo in 1086scuba dives In con- [7]. the Swedisl beingexperienced by 38 (5.4Vo) and 8 ( I . I 7o)respec- trast,Lundgren et al reported17 .lVo of recreational tion of the tively. l6 divers (2.37o)reported permanent divers to have experiencedalternobaric vertigo at tubeopenin disabilities(hearing loss, tinnitus and imbalance)[5]. leastonce during their diving career [8]. passivecler ENT problems in diving are usually minor and In Mawle andJackson's study [2], the incidence 39.7cm ol thus not reported,since the diver aborts the dlve of middleear infectionwas high at 38 9oas com- man [9]. becauseof pain beforeany damageis caused.Even pared to only 4.8 Voin our study.Reasons for the Surprisi more severeENT problems are most likely under- sameare unclear. verebarotra reported since there is no real incentive for Despitethe fact that URTI is well recognizedby five or less reporting [6]. divers as a causeof ear barotrauma,it remainsthe with moret 'In our study,the majorityof divers(16,38.17o) commonestassociated cause in our settingat59.59o. ever,the reportedoccurrence of ear barotraumaon an occa- Possiblereasons for the sameinclude dismissal of experience 'minor' sional basis.Most barotraumawas moderatein thenasal symptoms as a'normal' or cold.an on frequen severity(35.7Vo) and occurredat shallowdepths (l- attitudewhich was commonin many of the inter- l87cof mo 5 metres,47.6Vo), in conformity with the principles viewed divers. Other causeswere operational asbrought of Boyle's law. The majority occurredduring wet commitmentsin which the affected diver did not divers,cou dives (7l.4Vo) and affected one ear (90.57o).Only notify his superiorsabout being medically unfit to promptlyr( 26.27oof diversin our study soughtmedical advice dive and training dives during courseswhen the same)and' and were diagnosedto have barotrauma,the much traineesare under self-compulsionto completethe toms.In co larger majority not reporting milder symptomsto qualifying divesin the stipulatedtime period.Apart psychologi 'divir medical personnel.Factors leading to non-report- from othercited causeswhich are known to predrs- their ing are likely to be acceptanceof the problem as a poseto barotraumae.g. rapid descent,repetitive WithURTI routinepart of diving, non-availabilityof a system problems, diving and equipment-related the inter- Useof of immediatepost-dive feedback/questionnaire re- vieweddivers considered exposure to cold,lack of is condem garding symptoms and importantly in our setting, pre-diveexercise and prolonged absence from div- onlyin mir the apprehensionof being downgradedin medical ing predisposing to be factors. permitting category,a factorwhich is directlylinked to diving Mawle and Jacksonfound that divers who wore trauma.Al pay and allowances.27.3Vo of the diverswho re- a hood all the time had significantly more severe reduced,E portedsick were absentfrom diving dutiesfor over andmore frequent barotrauma symptoms than those and cause a month. who wore a hood only in cold water [3]. Ornhagen double-bli Occurrenceof ear barotraumasymptoms often and Hagbergreported as many as l.9Voof instluc- drineand t resultedin the dive being aborted(33.3Vo), a prac- torsand dive-masters to haveproblems during diving barotraum tice which is recommendedin medical literatureto with mouthpiece and full facemask which may pre- nasalspra avoid further ear pathology.To abort safely,due to clude effectiveuse of jaw movementsas an ear reducing, technicalconsiderations of gassupply etc, on many clearingmethod [4]. Barotraumadue to equipment changing occasions,the dive buddy fso has to surfaceand relatedcauses (ill-fitting nose-clip,tight hood,heavy etalinari may then be sentback intolthe water aloneto com- set)constitutes 7.lVo in our study,with only one trolledst plete the task at hand.The practicalimplications of diver reporting barotraumaassociated with a tight decongesl the samein operationalmilitary diving areobvious. hood(2.4Vo\. dren with The incidenceof vertigo associatedwith earclear- Lack of experienceis often cited as a common otitismed ing difficulties in our study was low in 2 divers, predisposingcause for earbarotrauma since to avoid nosedrop 4.97o,onecase being a diver who sustainedGrade 5 separationfrom other divers, many inexperienced protectlv( barotrauma(perforated eardrum) on free diving to 3- diverscontinue to descenddespite ear pressure and Theinr 4 metres with a common cold. The other diver pain []. Also, pressureequilibration is not always surels a c experiencedrotatory vertigo at l5 metre depth of passive,but requiresskills that take sometime to one techt sallyrecot 90 JourMarine Medical Societv,2006, Vol.8, No. 2 JourMari - I

achieve[5]. A six-monthtraining in scubadiving in that the Frenzel manoeuvreis safer than the Val- the SwedishNavy resultedin a significant reduc- salva since it does not causean increasein either tion of the active forcing pressurefor Eustachian intra-thoracicor intra-cranialpressure with the added tubeopening from 43.8to 31.3cm of HrO, while the advantageof a hands-free approach. Ornhagen, passiveclearing remained almost the same43.0 to (UHMS Workshop2004 on MedicalAspects of Div- 39.7 cm of H,O according to Ornhagen and Ro- ing Safety) stated it to be the most effective man [9]. technique[6].The disadvantageis that it is more Surprisingly,in our study,the incidenceof se- difficult to teachand learn.This is alsoborne out by verebarotrauma was comparable between divers with our surveywhich showsthat only 87oofnaval divers five or less yearsof experience(27.37o) and those usethe Frenzelas a primary techniqueand none as with morethan five yearsexperience(25.6Vo).How- a secondarytechnique. ever, the divers with less than five years of The useof the forcible Valsalvamanoeuvre as an experiencereported no occurrenceof barotrauma aidto difficultiesin auto-inflationis contra-indicated. on frequent/ most times basis(07o) as compared to Apart from producingpain and dizziness,it is also I 87oof more experienceddivers. Possible reasons, an importantcause in itself of middle and inner ear asbrought out during interactionswith experienced barotrauma.In this survey,it was found that most divers,could be thatnovice divers are more likely to (587o)of the divers practicedit on unsuccessful promptly report URTI (thereforenot diving with the auto-inflation.In addition, 4l.4Voof divers who re- same)and to abortdive on experiencingmild symp- sorted to it did so in the presenceof URTI, a toms. In contrast,experienced divers areoften under combinationof two predisposingfactors for baro- 'perform' psychologicalcompulsion to andkeep up trauma. 'diving their reputation' and may undertakediving Use of a singletechnique of auto-inflation,re- with URTI thoughaware of thedangers of the same. duced frequencyof auto-inflation,use of yo-yo Use of decongestantnasal drops prior to diving ascentsand forcibleplsalva manoeuvrewere all is condemnedin medical literatureas being useful found to be associatddwith more severeand more only in minimalEustachian tube block andeven then, frequentbarotrauma. permitting slow descentwith somedegree of barotrauma.Although symptomsduring descentmay be RECOMMENDATIONS reduced,Eustachian tube block will occuron ascent The following measuresmay serveto reducethe and causefurther barotrauma[2]. Joneset al in a incidenceof earbarotrauma in navaldivers: double-blindcomparison between oral pseudoephe- (a) Basic dive trainingand indoctrinationshould drineand topical oxymetazoline in theprevention of includemore emphasis and detail regardingthe barotraumaduring air navel found that oxymetazoline correct use of middle ear auto-inflation nasalspray is little more effective than placeboin techniques. reducing ear pain and discomfort associatedwith (b) Training in more than one techniquewould changingambient pressures Van HeerbeekN [10]. appearto be useful. et al in a randomized,double-blinded, placebo-con- (c) refreshereducation programmes on trolled study to assessthe effect of a topical Frequent of decongestanton Eustachiantube function in chil- auto-inflationtechniques and causes indicated. dren with ventilation tubes (becauseof persistent barotraumaappear to be otitis mediawith effusion) found that xylometazoline REFERENCES ventilatory the nosedrops had no effect on the or l. Becker Gary D, Parell G Joseph.Barotrauma of the protectivefunction of the Eustachiantube I I I ]. ears and sinuses after scuba diving, Eur Arch The incorrectuse of methodsto equalizeear pres- Otorhinolaryngol(2001) 258:159-163 @ Springer- Verlag 2001. sureis a commoncause of barotrauma[]. No single 2. Edmonds C, Lowry C, and Pennefather,J. Ear, sinus one techniqueof auto-inflation has been univer- and other barotrauma.Diving and SubaquaticMedicine. sallyrecomniended. It is generallyaccepted, however, Fourth ed. (2002) Arnold Publishers, London.

Jour MarineMedica! Society,ZOOi, Uot. 8, No.2 9I I

Mawle SE, JacksonCA. An investigationof ear trauma risk factors.The Journal of laryngology and otology, in divers including ear barotraumasand ear infection. 2003,vol. ll7, no. ll, pp. 854-60. EuropeanJ UnderwaterHyperbaric Med 2OO21'3(l): Lundgren CEG, Tjernstr0m O, Ornhagen H. 47-50. Alternobaric vertigo and hearing disturbanciesin 4. OrnhagenH, Hagberg M. Olycksfallsskadorvid connectionwith diving: an epidemiologicstudy. sportdykningI Sverige.l,akartidningen 2fi)4; l0l (9): I|nderseaBiomed Res1974l' l(3) : 251-8. 774-9. 9. OmhagenH, RomanM. Ear clearingcapacity in divers. 5. Taylor DM, O'Toole KS, Ryan CM. Experiencedscuba In Proceedingsfrom the sthAnnual Scientific meeting divers in Australia and the United States suffer of EUBS 1979.J Grimstaded. NUl, Bergen,Norway. considerableinjury and morbidity. Wilderness Environ t0. JonesJS, SheffieldW White LI, Bloom MA. A double- (2) Med. 2fi)3 Summer; 14 : 83-8. blind comparisonbetween oral ps€udoephedrineand 6. OrnhagenH. Ear Nose and Throat problems in Diving, topical oxymetazolinein the preventionof barotrauma UHMS Workshop, Medical aspectsof diving safety, during air tlavel. An J Emerg Med 1998 May; 16 (3) Atami, Japan,2OO4-ll -O2. : 262-4. Uzun Cem,YagizRecep, T:is Abdullah,Adali Mustafa Van HeerbeekN, Ingels KJ, Zielhuis GA. No effect of K, Inan Nurkan, Koten Muhsin, KarasalihogluAhmet a nasaldecongestant on eustachiantube function in R. Alrcrnobaric vertigo in sport SCUBA divers and the children with ventilation tubes, Laryngoscope.2002 Junll12 (6) : lll5-8.

92 Jour.Marine Medical Society,2006, Vol.8, No.2 - I

EVALUATTONOF rDA 59(M)

Surg Lt Cdr Kamal Mishra-

ABSTRACT

A submarine on surface is more likely to sink than a surface vesselbecause of smaller reserve buoyancy. Submarine lossesin war and in peace have been very heavy.About 1150submarines were sunk during the World War II, amounting to almost half the total number of subrnarinesoperated by the warring nations. About 170 submarineswere lost in peacetimein the last century.On the 12 August 2000 K-f41 'Kursk' of the Russian Federation Navy sank in approximately ll0 msw following two explosionsin the torpedo compartment. This was the most recent naval loss at sea. There were no survivors.

The Indian Navy is operating submarines for the past three decadesand has an enviable track record till date. This can be attributed to meticulous training, attention to detail and professionalismof the submariners.A study was conductedat the Institute of Naval Medicine/INHS Asvini to study the safety of the IDA 59 escapeset at escapedepths of 100m using the tables laid in the Russian escapeBR. Type CX22H 1800-30bar Chamber by Comex industries of France which was installed in INM / Asvini in 1984 was used along with the IDA 59 submarineescape set. Resultshave shown that new submarineescape table are safe for depth 40m, 60m, 80m. HoweYer,as three out of four divers developedO, toxicity, only one diver could complete the l00m escapesafely on the safety of 100m escapetable could not be established.It is recommendedthat further studies are required to validate the safety of the escapetable for depth of 100m. Key Words: Sunken submarine, escape

INTRODUCTION causeOz toxicity at depth and as the escapee l. In eventof a submarinemishap where a disabled approachesth{surface, O, partial pressure submarineis unableto surface,and detoriating should increaseto preventDCS & hypoxia. microclimate& lack of timely surfacesupport, Therefore one breathing medium in the bag makes the option of rescue foolhardy, shouldbe l00%oO, and the other gasesadded submarinershave to dependon individual wet to the breathingbag from mixture bottle should escape.Conventionally the submarinerscan not causeInert gas Narcosisor dilutional effect individual escapefrom 100mtrs and 120 hypoxia. mtrs (in spec,alcircumstances). AIM 2. When abandoningship all that a sailor needs This projectaims to to have is swimming capability and an aid to float, till being rescued.But a submariner l. Test the safetyof Decompressionschedule in requiresa breathingmedium which should be relativesafety of compressionchamber. dynamic i.e. pressureand compositionof the 2. Evaluatethe safetyof IDA 59(M). medium should vary according to depth. Duration of stay at depth, and rate of ascent OBJECTIVEAND SCOPE can causeDCS & pulmonary barotrauma,if To study the safety of IDA59(M) and the proper procedure is not followed. After prescribedSoviet Submarine decompression surfacingthe escapeeneeds positive buoyancy schedulein terms of protection it offers against till being rescued. Decompressionsickness (DCS), Oxygen toxicity, 3. O, partial pressurein breathingbag shouldnot PulmonaryBarotrauma, Hypoxia andHypercapnla.

'Medical Officer, INS Abhimanyu.

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BACKGROUND asagainst varying timings with theearlier table. l. Shoulda submarinebecome disabled; there are At thesedepths of 40M, 60M, 80M and l00M two main methodsof evacuationof survivors.If for different duration of bottom time, the the depth of the distressedsubmarine is decompressiontime was shortercompared to sufficiently shallow the survivors can escape. the olderRussian escape table. However, in escapingsubjects the escaperto 5. In view of thesedifferences in this table, as sea pressureequivalent to the depth of the comparedto the older table,a researchproject distressedsubmarine, and this can causea 313012002was takenup underaegis of Armed variety of seriousphysiological problems. Forces Medical ResearchCommittee in Despiteongoing research a realisticmaximum controlledcondition in chambercomplex, INHS escapeIimit of 200meters is all thatis likely to Asvini. be achieved.The escaper'sproblem is further During individualescape one hasto go through complicatedby the variousgas concentrations the following four stagesof escape:- within the distressedsubmarine, before he (a) Pre-fl period. attemptsto escape.In casethe depth of water ooding exceeds180 meters,or for a variety of other (b) Stageof pressureequalisation. considerations,the survivor may be betteroff (c) Ascent. awaitingrescue. (d) Survivalon surface. 2. Where as North Atlantic Treaty Organisation Ascent : Ascent through water is the stageof (NATO) Submarinesfollow a systemof rapid decompressionas the pressureof surrounding compressionfollowed by a decompressionfree waterdiminishes with ascentto surface.There ascentfor individual sur.vivors,Indian Navy are two typesof ascent. follows the Soviet pattern of water (i) FreeAscent. decompressionwhen stipulatedlimits of time t and pressureare exceeded.There has beenno (ii ) Buoy-ropeAscent./ escapefiom a sunken submarinein the entire l. It is not possibleto opena hatchon theDISSUB rangeofsubmarine escape depth and pressure. againstthe weightof waterpressing down on it Hence the decompressionschedule that we without first equalisingthe pressurebelow the follow in Indian Navy has never been fully hatch with that of the seawateroutside. testedas regardsto its safety. Therefore,any escapeattempt will involve 3. Although we have been relying on Soviet exposureof the crewmento the pressureof the literatureprovided to us by the Russians,these sea associatedwith the depth at which the equipmentshave never been used or testedfrom DISSUB hascome to rest.Breathing air for any l00MSW depth.The calculationsare based on lengthy exposureat pressuresof more than a Russiansubject who is moreheavily built with few tensof metersfollowed by direct ascentto more body mass than average Indian thesurface would resultin severeDCI andlikely submariner.How theTableswill affectthe Indran death.Therefore, either the exposure to thishigh sailorin real life situationneeds to be evaluated pressuremust be made sufficiently short such to ascertainthe safetyofthe entire procedure. that the amount of inert gas absorbedby the escaperwhilst at great 4. With inductionof INS Sindhurakshakin Indian depth is not enoughto causeDCI, Navy the Russiansgave a new decompression or, if the exposureis to be long, the escapermust table to help individual escapefrom disabled be able to stop at various points during the ascent wait submarinefrom depth using buoy rope ascent and for the absorbed inert gas method.This table was introducedto make it to leavehis body at a saferate before progressing easy to follow for escapingsubmariners as it toward the surface.As broughtout earlier, the first type of escape,with out had standardfixed stoppagesat various depths 'escape whilst escapingfrom a fixed depthof submarine, stoppages,is called by free ascent'or

94 Jour MarineMedical Society, 2006, Vol. 8, No.2 I

to-infla- rush escape.The secondtype of escape,with 9. On arrival at the surface,the escapesuits provide denceof stoppages,is made with the aid of a float rope required buoyancy for effortlessflodting and 'buoy . In con- and is called rope ascent'. protection againstrapid loss of body heat rn 'escape reational 8. In by buoy rope ascent',to avoid DCI contact with water.The orange colour of the ertigoat the escapermust perform severalstops on his suit helpsin easyspotting from a distance.The way to the surface.In order to achievethis he submarinersshould attach themselves with one rcidence ascendsto the surface following a rope with anotherwith the help of the hook provided on ascom- knots to indicatehis depth.Depths at which he the suitsand should wait in cluster.Individual s for the needsto stop and the duration of the stops to drifting will thusbe preventedand spottingand allow gas to safely leave his body must be rescuewould be easier. calculatedusing tablesbased on initial escape nizedby MATERIALSANDMETHODS rainsthe depth and time at depth. ComexDecompression Chamber ft59.5Vo. a) Free Ascent : Free ascentis desirableas it Insulatedbreathing apparatus IDA-59(M) nissalof quickly bringsthe submarinerto the surface. 'cold, The rate an average of free ascent,with the Selectioncriteria he inter- escapeset and suit on, is I metre/second. 1. A panel of volunteersselected as subject for rational Free ascentis, however,indicated only when the study was medically screenedfor diving did not the stay under pressureis short and the fitnessusing standard laid down by NO (spl)l/ ' unfit to body saturationwith inert gasis so lessthat 1999and17lzW. rhenthe no decompressionstops are necessary. pletethe Maximum stay under pressurefor various 2. Personnelused were either clearancedivers rd.Apart depths,which allows free ascent,is given in (who are trainedto dive more than 35m depth) r predis- Table2. or shipsdivers (who are trainedto dive to dive opetitive till 35 mdepth;. . b) Buoy-rope Ascent. When the stay under r he inter- pressureexceeds the limit, which is safefor Exclusion critefia: l, lackof free ascent,decompression stops on the way URN romdiv- to surfacebecome necessary to avoid bends. IVo Epilepsy/Fits,IHD, PulmonaryTB, Asthma A buoy with a buoy-rope attachedto High fever 'howore submarineis released.The escaping e severe submarinersascend along the buoy-ropeand On medicationslike Steroids,insulin, thyroxine, ranthose havedecompression stops of 4-8 minutesat theophyline, analgesics, salicylates rrnhagen the mousingsfixed on the buoy-rope. antineoplastic, anticonvulsants, 'instruc- TABLEI rgdiving Maximum allowable time of stay under pressure for escape by free ascent maypre- s an ear Depth Max time Remarks Max time Remarks ulpment in msw with IDA 59 with compt air ,d,heavy l0 2.5hrs Endurance of set Unlimited rnly one 20 20 min 45 min h a tight 30 20 min 02 Toxicity 30 min 40 20 min 20 min Decompression 30mmon 50 20 min 12min Sickness ;toavoid 60 12 min 8 min IU 7 min erienced 80 5 min Decompression Nitrogen sureand 90 3 min sickness Narcosis t always 100 2 min ) tlme to

'1.8,No.2 Jour Marine Medical Society,2006, VoL8, No. 2 95 antihypertensive,sulfonamides, amino- introducestwo fixed time 4min/Smin at the glycoside heparin, digitalis, disulfiram. mousingdepending on thedepth and time under 2806 acetazolamide,lVo DCS, PulmonaryBarotrauma pressure.So in emergencythe submariner only CDI] chan Inclusion Criteria: keepstwo figures in his mind a) depth of first stop b) time of stay at first and subsequent man l. The diver should have 100 hrs divins stop. cam experience. prob A On conclusionof eachdive thesubjects will be 2. He shouldbe in MedicalCategory SlAl. sequ clinicallyexamined for evidenceof DCS with wer( 3. He shouldnot be exposedto any diving in specialemphasis on neurological,chest and previous72 hrs. CVS examinations.Doppler bubble detector is On Initially all personnelwere trained in useof IDA usedto detectsilent bubbles. carri prot 59 (M) which includedsurface trial andworkup ENT examinationis doneto seethat tympanic new dives. Three points are impressedupon the membraneis mobileand has no pertbration. volunteers. The ECG is doneto seethat there is no arrhythmic Dec L No hyperventilationis allowed. focus. On 2. Bottom drill, which includesbreathing in 7. Clinicalneurological assessment and EEG will carl from set and breathingout into atmosphere be carriedout to ruleout oxygentoxicity. dov thrice,is doneto preventdilutional hypoxia. Chestexamination and PFT will be carriedout usll 3. No holdingof breathwhile ascending to rule out pulmonarypathology con In compressionchamber diver is initially ABG analysisofpo2, pco2,pH ofI breathingchamber air while beingpressurized. SerialEEG after0.02. 24 hrs 1 Ho' For dives and surfacingfrom beyond50 MSW div i.e. 6kg/cm2 pressurethe subjectis advisedto OBSERVATIONAND RESULTS prc be on mask.Hence the diver is advisedto put l. The detailsof the simulatedescape from 100 the on themask on beingpressurized beyond 6Kg/ metersdepth under controlled c

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Jerret et al demonstratedthat hyperbaric oxygen oxygen,the fbllowing sat'elimits can be extrapolated; augmented tissue concentrationsof hydrogen 1. PO,- l.7ATA- 7 hours. peroxide.Simet et al, demonstratedthat hydrogen z. PO,- l.8ATA- 3 hours. peroxideproduction increases linearly in rats exposedto 0.6 AIA, I ATA and 3 ATA of oxygen POr- 2ATA- 50minutes. comparedto rats exposedto 0.2 AIA. Yusa et al A PO,- 3 ATA- 30minutes. provided strongerevidence when they reportedthat It hasbeen found that certainconditions hasten SOD and catalase increasedthe latency time to the onsetof symptoms.These include increased convulsionsin rats exposedto oxygen at 6 ATA. carbondioxide, fatigue, stress, cold. The toxicity These resultsclearly show that hyperbaric canr.rotbe preventedby anti-convulsantsor oxygenexposures leads to formationof freeradicals anesthetics.These drugs can avoid convulsions but in the brain and that they are involved in the not the underlyingtissue damage. Antioxidants, pathogenesisof convulsions.The free radicalsare particularlyvitamin E, magnesiumhave shown to be thoughtto act by; of benefit. l. At thecell membranecausing lipo-oxidation. An interestingfeature mentioned is that the 2. Nuclearfunction inhibition. hyperoxiaCNS injury,by mediationof sympathetic system,determines a vasoconstrictionof the 3. On decreasedprotein synthesisleading to cell pulmonarymicrocirculation leading pulmonary death. to hypertension.Therefore, a neurogenicacute The selectivity of CNS lesionson autopsycould pulmonaryedema can occur concomitantto be due to: hyperoxiaseizures. When seizuresare repetitive, l. Reeionalcell vulnerability. irreversiblepulmonary damage can be induced. 2. Regional CO, retention secondary to Protectiontiom hyperoxiaconvulsions also prevents maldistributionof cerebralblood flow during the associrtedpulmTnary manifestations. I hyperoxia. Pulnronary toxicity - "J Lorrain Smith effect" 3. Regionalimpairment of oxidativemetabolism Oneof themysteries of PaulBert's work is that with accumulationof acidmetabolites in some he did not discoverthe toxic effectsof oxygenon areas. the lungs.It was J. Lorrain Smith, in 1899,when Otherbasic mechanisms not related to fi'eeradical attemptingto determinethe lowest levels of productionare surely responsiblefor oxygen hyperoxianeeded to producethe Bert's effect, who neuronaltoxicity andthe encompass; discoveredand described the existence of pulmonary l. Non-radicaldependent enzyme inhibition. oxygento.\icity in therats after continuous exposure - 2. Cerebralmetabolismmodification. to PO, at 0.41 3.6 atm. Pr. and without any neurologicalsymptoms. He noted a progressive Many cerebralenzymes are susceptibleto dyspneathat led to death,without convulsions, after inhibitionby hyperoxia,which leads to alterationof an averageof 4 daysunder a PO, of 0.74- 0.8 atm. cerebralmetabolism. Two fundamentalpathways Pr. ol in 5-10 hoursunder 2.7 - 3.6 atm. Pr. The areinvolved; pulmonaryoxygen toxicity is thus often referredto l. Oxidativephosphorylation may be inhibited asthe Lorrain Smith effect. andhence ATP productionblocked. Presentlywe know that pulmonarytoxicity of 2. Inhibitionof glutamicacid decarboxylase blocks oxygencan arise from prolongedexposure to PO, > the synthesisof GABA. 0.6atm. Pr andthat this is themain limiting factor in The ocurrenceof seizuresat 3 ATA, is the therapeuticuse of hyperbaric oxygen. The concomitantwith a drop of GABA cerebral symptomsappear after a latentasymptomatic period, concentration. whoseduration decreases with the increasein PO,. If one plots a graphof neurologicaltolerance tcl In a normal human,the first sisns of tracheal

Jour MaritrcMedical Society, 2A06, Vol.8, No.2 99 - I

bronchial irritation appearafter about l0 hours of SUMMARYAND CONCLUSION inhalation of oxygen at one atmosphere,and after Thoughno caseof Decompressionsickness was 24-48 hoursunder similar conditionsif sufferingfrom noticedduring these dives, there was unusually high ARDS. The symptomscan be divided into three incidenceof Oxygentoxicity during the use of IDA stages: 59 M, due to excessamount of oxygen in mixture l. Tracheobronchitis - relativelyearly, even at a bottle.The laid down procedureas given in Russian low PO' It is not seriousand easily reversed. It BR andthe new submarineescape table are safe tbr is an important warning that should not be depth40m, 60m, 80m but asthree out of four divers undervaluedto avoid further and more serious developedO" toxicity,only onediver couldcomplete damage. the l00m escapesafely. Hence further studiesare 2. Second stage,ARDS, is typified by acute requiredto validate the safety of the escapetable respiratory insufficiency, pulmonary edema, for depthof l00m.The subjectsfor the l00m escape reductionof the pulmonary spacesand serious were kept for observationfor four days after the alveolardamage. If this stageis exceeded; accidentduring which they were medically investigated.They werereturned to theirunits only 3. Interstitialpulmonary fibrosis results. atierall investigationparameters reverted to normal. It is a moot point whether the responsibilityfcrr It is pertinentto note that EEG changeswele pulmonaryoxygen toxicity is the high PO, in direct observedin all threedivers but weretemporary in contactwith the alveolusor the increasein pressure nature(due to O, toxicity) and revertedback to of the plasmaoxygen. The former hypothesisseems normalin 04 days. feasible in the case of exposureto PO, of up to I Further,comparison of variousparameters (rate atmospheresand the latter is consideredtrue for of regenerationclf Oxygen, rate of absorptionof exposuresat higher pressures. Carbondioxide and total regeneration capacity etc.) From the histological point of view, the of the indigenouschemical O-. with RussianO. is mechanismsof pulmonary oxygentoxicity seems alsowarranted. t basicallycellular and at a membranelevel. It is rn / fact, the cellular membranesthat areconfronted with REFI,RDNCES the highest level of PO, and that are undefended I . Bove and Davis. Divins Medicine -3rd Edition. from attacksby free oxygen radicals. 2. INBR 2806. 3. Physiologyand Medicineof Diving, Bennetand Elliot- Free radical theory of oxygen toxicity 5th Edition. This theory assumesthat the oxidative injury is 4. Edmonds Lowry and Pennfather,Divingand Subaquatic caused by highly reactive metabolic products of Medicine-4th Edition. oxygen,which may 5. Manual of medical and dental administration-2O04. 6. Best of Alert Diver, Peter B Elliot. L lnhibit cellularenzymes. '7 . HyperbaricMedicine, Hunt and Davis-lst Edition. 2. DamageDNA. 8. Textbook of Hyperbaric Medicine. KK Jain.3rd 3. Destroylipid membranes. Edition. Free radicals of oxygen are productsresulting 9. Textbook of Hyperbaric Medicine Practice. EP Kindwal-2nd Edition. fi'om the normal oxi-reductiveprocesses of the cell. In hyperoxic conditions, their production notably 10. INBR on escapefrom sunkensubmarine. increases.

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THE IMPOKTANCEOF EFFECTIVEAND PROMISINGBEHAVIOUR CHANGE INTERVENTIONSTO PREVENTHIV INFECTIONS

SurgCdr SaugatRay'

Key Words : Bahviour change, HIV Infection

INTRODUCTION andspreading HIV. They alsolive and interactfreely l. Globally,an estimated40 million'peoplewere with civilian populationand are potential bridging living with HIV/AIDS at theend of 2005.More than groupfor disseminatingHIV into the generalpopu- I 0 million of ttremare young pmple aged1 5-24 y eus. lation [4]. DeployedNaval personneltravel between Therewere a total of 4.9 million peoplein theworld, home & various ports, increasingthe opportunity newly infectedin 2005and 3.1 million peopledied of for thoseengaging in risky sexualbehaviour to be AIDS in theyear []. exposedto and spreadHIV and STDs at home and abroad. 2. The National AIDS Control Organization (NACO) estimatesthat5.2l million peoplewere liv- 6. HIV/AIDS hasits rootsin a rangeof problems ing with HIV in 2005 in India, giving an adult that underminepeople's health and human rights, prevalenceof O.9l%oI2l. suchas inequity and discrimination, poverty. social unreStand migration, exploitation and abuse. Chang- 3. The incidenceof HIV/AIDS in theArmed forces and specially in the Navy is showing a plateauing TABLEI effect in the last few years.There were2J , I I and I 3 Incidenccof HIV Infecy'onsfor the year 2005till casesof HIV in 2003,2004& 2005respectively and Jun 2006 r 05 casestill Jul 06 (Table 1) [3]. Thereare a total of 327 casesof HIV +ve individuals servingin theNavy Month Army Navy Air Force presently, population which is O.625Voof the total Jan05 49 02 03 whereas the prevalence isO.9lvo in India and0.067o Feb 05 -tz 0l in the US Navy. Mar 05 38 02 4. It is observedfrom the surveillancereports Apr 05 45 that 6O7oof those infected with HIV in the Armed May 05 25 ; ; June05 54 0t 0l Forces have acquired infection from exposure to July 05 ll 02 commercialsex workers.However, there is a large Aug 05 29 0l 0t chunk ofpersonnel (307o)who were detectedto be Sep05 64 0l HIV+ve but in whom the probablesource of con- Oct 05 32 0l 0l tracting the diseasecould not be ascertained. Nov 05 )t 0l Anotherdisconcerting trend is thatofthe incidences Dec 05 z-) 0l or new casesof STD infections,which still contin- Jan06 JI ; Feb 06 29 02 uesunabated (Table 2) [3]. Mar 06 39 ; 0l 5. Naval Personnelreport participatingin high- Apr 06 28 0l risk behaviour,because oftheir youth and frequent May 06 23 0l deploymentsat important city ports in India and June06 4l ; 0l abroadand thereby increasethe risk of acquiring

'Officer in charge, SHO, Visakhapatnam.

Jour. Marine Medical Society, 2006, Vol. 8, No. 2 t0l I -

TABLE 2 also emphasizesthe senseof urgencythat should Decadal trend STDs (All forms) (Rate per 1000) accompanythe drive to achievethese goals, as well as the needfor a specificemphasis on prevention. Year Army Navy Air Force and within that,a fbcuson the young sailorswho 1994 0.53 0.66 0.t9 remainat the centreof the HIV pandemic.It alstr I 995 0.46 082 0.l5 tries to explore the need to have a better under- I 996 0.55 0.55 0.10 standingof theevidence base for makingdecisions t997 0.49 0.62 0.09 as to the natureof interventionsneeded for a posi- I 998 0.55 0.6'7 0.00 tive behaviourchange amongst our naval l 999 0.35 0.6'7 0.03 2000 0.20 0.32 0.10 community. 200l 0.19 0.64 0.04 Methodology 2002 0.22 0.r8 0.04 2003 0.r3 0.l0 0.04 The study has tried to review the efficacy and 2004 0.14 0.32 0.04 effectivenessof a range of preventionapproaches that areat variousstages of research.The intention wasto illustratethe landscapeof interventionsthat ing thesestructural, socioeconomic and contextual havebeen developed and evaluated in dift'erentset- determinants will be fundamentalto making the [5] tings and that have the potentialfor widespread preventionof HIV sustainable. applicationin our setting. 7. Preventionstrategies in theNavy primarily fb- cus on Health Education strategiesfor the service DISCUSSION personneland their families through symposiums, , Undcrstanding the Typcs of IIIV Epidemic workshopsand peer group education.An attempt l. Threetypes of HIV epidemicsare described: to measurethe changesin behaviourhas not been undertakenso far. Enumeratedbelow are a few of Low Level Epidemics - In low-levelepidemrcs the newerstrategies ofbehaviour change interven- HIV may havebeln recordedfor many years, tion being researchedat different partsof the wolld but prevalencehas never consistently exceeded with different groupsof people. 5Voin anysubpopulation [8]. 8. In theface of increasingrates of HIV infection Concentrated epidemics - In concentrated aroundthe world, there are peoplewho doubt that epidemics.HIV is well establishedin HIV preventionstrategies work, despiteextensive subpopulationswith behavioursknown to put evidenceof the effectivenessof the severalinter- themat high risk, suchas injecting drug users, ventions[6]. Despitethese challenges, the field of sexworkers or menwho havesex with men.In HIV preventionis aliveand well. In thecourse of the concentratedepidemics, HIV prevalence past 20 yrs, many approachesfor stemmingthe consistentlyexceeds 59o in atleastone of these spreadof HIV have been developed,tested and groups,but there is no sign of substantiai evaluatedin different populationand settings,and spreadbeyond thesegroups [91. a numberhave been widely adopted[7]. The follow- GeneralizedEpidemics - Countrieswhere I{lV ing study is a brief overview of a range of has spreadto the generalpopulation - with interventionsthat has attemptedto induce behav- morethan IVoHIY prevalenceamong pregnant ioural change,apply technologiesand strategiesto women-are saidto havegeneralized epidemics. nlodify the psychosocialenvironment prevalent In generalizedepidemics the main modeof HIV amongstthe generalpopulation in differentparts of transmission is through penetrative theworld. heterosexualsex in the generalpopulation. Suchepidemics are currently tbund mainly in Obj ectives sub-SaharanAfrica and in some countriesrn This evidencebased overview focuseson ways the Caribbean.Generalized epidemics are also of meetingthe global goalsof preventionof HIV. It driven by youngpeople I I 0- I 2].

t02 Jour.Marine Medical Society,2406, Vol.8, No.2 lnslenl llchaviour Changc Intcrvcntions. beento demonstrateto patientsthat the xygen. l. The goal of interventionsaimed at changing medicalcare they are receiving is safe. rlaise. behavioursis to reducethe risk of HIV-related Managing STIs - A largebody of evidence lrse ol' sexual behaviour. Behaviour change accumulatedfrom epidemiologicaland nas to interventionsseek to delaythe onset of sexual clinicalstudies has shown that the risk of 'ith the- intercourse,reduce the number of sexual sexual transmissionof HIV is partnersa personhas and reduce the incidence substantiallyincreased in the presence use' ,vhic h. of unprotectedsex by increasedcondom of otherSTIs [5]. The evidenceshorvs - t tli the Interventionsaimed at changingbehaviour thatSTIs particularlythose associated groupsby - ()lI tng focus on'individualsor small with genitalulceration canenhance the rillnot conductingworkshops or proglammesthat infectiousnessof people who are HIV lmood provideinforrnation; develop skills on how to positiveas well as the susceptibilityof ielerc use condoms; social marketing and peoplewho areHIV negative.Therefore. media tingto interpersonalcommunications and mass thediagnosis and treatment of STIshave and :ly.the campaignsI I 3]. Severalsystematic reviews the potential to be effective prevention fiom mprete metaanalyses have summarized findings strategiesby reducingSTI prevalencein few published rSATC these studies.There are a couples whose HIV status is nolIcc experimentalstudies testing the effectiveness discordant[6,17]. risk rt.frew of an interventionto reducebehavioural Antiretrovirals to prevent HIV infection end ln tne using both behaviouraland biomedical - Preventing mother to child or both) and visulI points (irrcidenceof STD or HIV transmission - One of the most For example, llcatea thesehave found mixed results. significant developmentsin HIV among ringo1' two multisiteintervention studies preventionis the finding that certain found tsnelt', heterosexualmen and women in the US antiretroviraldrugscould be adm i nistered outcomes Thesc significantpositive effects both on t., pr.gn.n/*omen and their newborns incidence ly first ofbehaviouralchanges and STI [14] in sucha way as to significantlyreduce protocols(Pr

8.No. l Jour MarineMedical Society, 2006, Vol. 8, No.2 10.1 adherence to HAART regimens emergesinthe nearfuture will beclose to contributesto the sustainedsuppression 1007oeffe'ctive. Only one product of virus.Some data indicate that the risk (AIDSVAX gpl20) so far hascompleted of HIV transmissionis directlyassociated phaseIII' testing- in the Netherlands. with the infectedindividual's viral Thailandand the United States- and it load [20]. Mathematicalmodels have showedno efficacy[251. demonstratedthat at thepopulation level, Microbicides- A microbicideis a chemical the beneficial effect of HAART on .compounddesigned to block the sexual reducingsexual transmission of HIV transmissionof HIV by killirrg or could be offset by an increasein the inactivatingthe virus, blocking the entry circulationof drug-resistantstrains of HIV ofthe virusinto tdrgetcells or interrupting and increasesin risky sexualbehaviour the viral lif'e cycle once it has enteled that might occur if people believe HIV targetcells. Microbicidesare being transmissionis unlikelyor if HIV infection developedchiefly for vaginal use. becomesless feared becausetreatment althoughresearch on productsfor rectal is available[21,22]. useis alsounder way. The drive behind Male circumcision - Numerousstudies microbicidedevelopment is the urge tt', havefound evidencethat uncircumcised providewomen with an HIV prevention men have higher ratesof HIV infection technologythat doesnot dependon male thantheir circumcisedcounterparts [22]. cooperation.The earliest randomized It has been hypothesizedthat male trialswere conducted with non-oxynol-9, circumcision protectsagainst HIV whichhas been used as a spermicidebut infection chiefly becausethe foreskin, has also shown anti-HIV activity in which containsa high densityof HIV- vitro [26,27]. specific cellular targets,has been Social interventions - Social removed [23]. Accordingto a studydone arrangements,institutions, laws, policies in the US Navy, the proportion of and customscan influencegreatly the circumcisedmen did not significantly ability of individualsto engagein differ betweencases (84.9Vo) and controls protective behaviours and to use (81.87o). After adjustment for biomedical technologiesto avoid demographicand behavioralrisk factors becoming inf'ectedwith HIV. In recent lack of circumcisionwas not found to be years,increased attention has been paid a risk factor for HIV [24]. to the possibilitiesof modifying social Vaccines - There is generalconsensus arrangementsthat affect HIV prevention. that the HIV preventionstrategy with the Whether they are called "social potential to have the greatestimpact strategies" t2), "structural would be an HIV vaccine.Unfortunately. interventions"t28] or "environmental no effectif vaccineexists, nor is one interventions"[29], efforts to createsocial expecteds6on. The complexityof HIV, the conditionsthat facilitate health promotion multiplicityof its variants,the ability of and risk reduction have proven to be the virus to mutate,the lack of validated effectivein a numberof locales. - correlatesof protection not to mention o l00Vo condom use - Perhapsthe most thecosts and logisticsof mountinglarge- notableexample of a socialintervention - scale clinical trials have made it aimedat preventingthe spreadof HIV is extremely difficult to develop and test theThai "lNVo condom"use programme. candidatevaccines. Moreover, there is The promotion of condom use was little expectationthat any vaccine that coupledwith an emphasison decreasing

104 Jour.Marine Medical Societv,2M6, Vol.8, No.2 visits to sex workers and other non- videos,films. pamphlets,billboar-ds. ll beclose to regularpartners, particularly among Thar postersand interactiveweb sites. re product military recruits.But the Thai national (c) scomplered Behavioural and social issuesin developing response,like that in Uganda,also - letherlands. and implementing Interventions There are included national sentinel surveilliince, a numberof interrelatedissues that cut tes- and it massmedia campaigns,community acrossvirtually all interventionsdesigned mobilization and interaction between to preventthe spreadof HIV andthese must sa chemical nongovernmental organizations, be attended to in developing and l thesexual community-basedorganizations and implementingsuch interventions. killingor industry, as well as strong public Economic empowerment interventions 1gthe entry statementsand resourcecommitments for women - Recruihnentto and retention rnten'uptlng made by political leadersand policy in studies- The requirementsof rigorous rasenteled makersat thehighest levels [30,31]. randomizedcontrolled trials, the range arebeing o Economicempowermentinterventions and number of HIV prevention ginaluse. - for women Many women and girls do technologiesunder study,and HIV :sfor rectal not have basic infbrmation about their incidencelevels necessaryto enable 'ivebehind bodies,sex or sexuality,and do not know researchersto detecttrue effectsfrom an theur.ee tt; how to preventHIV andother STIs; they prevention interventionmean that large numbersof cannot demand that male partners use peoplemust recruitedand retainedin ndon male be condoms; they cannot refuse sex; they lndomized multisitestudies over many years.This are often forced to sell sex; and if they r-oxynol-9, is logisticallychallenging and also inject drugs they often are given a dirty micide expensive[33]. but needleto useafter their male partner. rctivityin Economic emDowerment interventions - t- o Effectivenessof Mass media Given that for womerf - Adherence to prevention adolescentsare so attunedto massmedia - protocol - Oncerecruited and retained, it Sociai for information and cues about how to ''s.policies is essentialthat studyparticipants adhere behave,the media have tremendous to the prevention protocol if the full rreatlythe potential for reaching them with )ngage effectivenessofthe interventionis to be ln messagesabout HIV and AIDS. Mass d to use captured.For some technologiesand in mediacampaigns may complementother to avoid somesocial and familial circumstances, programmes(for example,the trainingof prove In recent this may impossiblefor study personnel or the distribution of participants beenpaid [34]. condoms)designed to stop the spreadof rng Economic empowerment interventions social HIV. The evidence in the published revenhon. for women - Behavioural disinhibition - literature on the effectiveness of "sociaI It is possiblethat when peopleperceive communicationprogrammes is sparsebut tructural that a particularHIV preventionmethod therehave beenseveral rigorous studies

Jour MarineMedical Society, 2006, Vol.8, No.2 t05 il.8.No.2 to tackle the HIV/AIDS epidemic.It is medicaland social strategies, particularly when they essentialthat we should diligently occur together. promote behavioural change and REFERENCES communicatethe need to continue to engagein risk reductionor avoidance l. UNAIDS. AIDS epidcnic updatc 200.5.Gcne va. LJNAIDS.WHO, 2005: http://www.unaids.org/epi/ evenas new prevention methodsemerge. 2005 ldoclEPlupdate 2005_html_en/ o Economicempowermentinterventions epi05_02_en.htm#TopOf Pase for women - Partial efficacy and partial National AIDS Control Organisation(NACO): http:// effectiveness-No single prevention ww w.nacoon line.org method is 1007oeffective. Even sexual Office of the DGAFMS. ReDorton the Health of thc Armed Forces: 2004 abstinence,which may be theoretically Nwokoji Ajuwon AJ. Knowledgc effective, is imperfectly practised.The UA, of AIDS and HIV risk related sexual behavioursamong Nigerian naval most effective preventiontechnology is personnel. BMC Public Llealth 2O04.4:24. the male latex condom, which has an 5. Dehnc K, et al. The HIV/AIDS epidemicin eastern estimated8O-90Vo level of expectedrisk Europe: reccnt patterns and lrcnds rnd their reductionwith correctand consistent use. implications for policy-rnaking.AlDS 1999; I .l : -9. Based on the outcomes of the first 74l randomizedcontrolled trial of male StonerJ, et al. Can we revcrsethe HIV/AIDS panclcmic with an expanded response?Lanrtt 2002: 360 . 13-1. circumcision,that intervention appears to Justin D. Auerbaen,Richard J Hayes, Sonia M havethe next highestlevel ofefficacy, at Kondathil. C)verview of effective and promisrng 65-7O7ofor a single procedure[35]. intervention to prevent HIV infection. WIlO TRS Additional methodsunder study (such 2006: 938: 43-78. as vaccines,microbicides, pre-exposure LINAIDS/Wtf O. Second ganaratiottsurvcillanct .lltr antiretroviralprophylaxis) are estimated HIV: lha next derade.Ceneva.UNAIDS. 2000. to have only a 25-507o level of UNAIDS. Populatiott rrrobilitt' and AIDS. UNAII)S effectivenessusing currentstudy-design rtrhniral updatc. Geneva,UNAIDS, 2001. calculations.This meansthat researchers, t0 UNDP, South East Asia HIV and DevelopInent Programme. TIrc impact,r ol nappitrg o.\.\(.\stn(trt.\on providers, service programmemanagers, prtpulation noy(ilrc,il and IIIV t,ulnarabiliD' in Soutlt policy-makersand community advocates East Asia. Bangkok, UNOPS,UNDP. 2001. must not promise too much for any ll Lurie MN. et al. Who infects whom? HIV- I particular method; they must be clear concordanceand discordanceamong migrant and non- about the need to use a combined migrant couplcs in South Africa. A/DS 2003: l1:2245-52. approachto preventing the spreadof t2. Lydic N, HIV; and they must emphasizethe et al. Mobility, sexuallrchavior'. and HIV Infection in an urban population in Camcloon. Journul importanceof adherenceto behavioural ol Acquired lununt De.fiticncv Syndrornc.s2004: 35 changes. : 6'7-74.

l-) AuerbaechJ D . CoatesTJ. HIV prevcntiouRcscarch: CONCLUSION accomplishmentsand challen_qesfor the third decade This reviewof the/IV preventionstrategies tells of AIDS. Arncriran Journal of Public Hcalth 2O00: 90 : 1029-1032,3.4. us a numberof thin$. First,we havea greatdeal of IA Kamb ML et al. Efficacy risk-redustion evidencefrom researchstudies - both experimental of counseling to prevent human - immunodeficiency virus and sexually and observational and from practicalexperience transmitteddiseases: a randomizedcontlolled trial. to make the casefor the eff'ectivenessof a nurnber Jourrtal of lhe Anerirott Mediral As.sotiatittn,1998, of interventionsto prevent the spreadof HIV. Al- 280:l l6l-l l(r7. ( ProjectRESPECT Study Group) though not all researchhas been rigorous,and not l5 Fleming DT. WasserheitJN. From epidemiological all interventionshave shown significant results, we synergy lo public health policy and practicc: thc contributionof other sexually transmitteddiseascs to do know that reductions in risk and ratesof HIV sexual transmission of HI\/ infcction. .Sz.tra1h' infectioncan be achievedthroueh behavioural. bro- Transnitted Irtl?rtiott.s1999. 75:3-17. t06 Jorrr:Marirrc Mcdical Society. 2006. Vol. 8. No. 2 JOI I

l6 Grosskurth H, et al. A community trial of the impact 27. Van Damme L, et al. Effectivenessof COL-1492, a of improved sexually transmitted diseasetreatment nonoxynol-9 vaginal gel, on HIV-l transmission in on the HIV epidemic in rural Tanzania. 2: baseline female sex workers: a randomised controlled survey results. AIDS 1995, 9:927-934. trial.Lancet 2002: 360 : 97 l-77. t7 Mayaud P, et al. lmproved treatment services 28 Sumartojo E. Structural factors in HIV prevention: significantly reduce the prevalence of sexually concepts, examples, and implications for research. transmitted diseasesin rural Tanzania: results of a AID,2000: l4 Suppl l:53-10. randomizedcontrolled trial. A/DS 1997, I l:1873- 29 Sweat MD, Denison JA. Reducing HIV incidence in 1880.) developing countries with structural and environmental l8 Connor EM, et al. Reduction of maternal-infant interventions.AIDS 1995; 9 Suppl A:S251-257. transmission human immunodeficiency of virus type -)u Blankenship KM, Bray SJ, Merson MH. Structural I with zidovudine treatment. New England Journal of interventionsin public health. A/DS 2000; l4 Suppl (Pediatric Medicine. 1994. 331:I 173-l180. AIDS l:SI l-2l. Clinical Trials Group Protocol 076 Study Group.) 3l PhoolcharoenW et al. Thailand: lessonsfrom a strong l9 Cardo DM, et al. A case-control study of HIV nationalresponse to HIV/AIDS. A/DS 1998, l2 Suppl seroconversion in health care workers after B:S123-135. percutaneous exposure. New England Journal o.l' -)l Newman PA, Medicne, 1997, 337:1485-1490. (Centers for Disease et al. Challenges for HIV vaccine disseminationand clinical Control and Prevention Needlestick Surveillance trial recruitment: if we build it, will they come? A/DS Patient Care and STDS 2OO4: Group,) l8:69l-701. 20. Quinn TC, et al. Viral load and heterosexual transmissionof human immunodeficiencyvirus type 33 Mantell JE, et al. Microbicide acceptability research: 1. New England Journal of Medicine 2O0O,342:921- current approaches and future directions. Sor'ial Scienre Medicine 29. (Rakai Project Study Croup.) and 2005; 60:319-330 Cassell MM 2l Blower S et al. Predicting the impact of antiretroviral 34. et al. Risk compensation:the Achilles' heel innovations prevention2 in resource-poorsettings: preventing HIV infections of in HIV BMJ, 2OO6, 2:605-607. whilst controlling drug resistance.Current Drug 33 Target s. I nfe ctious Disorde rs 2003, 3:345-53. 35 Auvert B, et al. Randomized, controlled intervention trial male 22. Velasco-HernandezJX, GershengornHB, Blower SM. <-rf circytfncisionfor reduction of HIV infection Could widespread use of combination antiretroviral risk: the ANRS tZOS trial. PLoS Matlirinc. f inejournal] therapy eradicate HIV epidemics? ktncet Infectious IOn 2005,2:e298.http: / / Diseases 2002: 2 : 487-93. medi cine.plosjournals.org/perlserv/ ?reque51=getdocument&doi=10. I 37 l/ 23. Reynolds SJ, et al. Male circumcision and risk of HIV- journal. pmed.0020298 ). I and other sexually transmitted infections in India. Lanret. 2004:363 : 1039-40. 36 Scalway T, Deane J. Critical rlmllenge ,; itt HIV (onunutti('atiotr.London. Panos lnstitute. 2002. 1i Thomas AG Bakhireva LN, Brodine SK, Shaffer RA. Bertrand Prevalenceof male circumcision and its association JT, et al. Systematic review of the effectiveness mass programmes with HIV and sexually transmitted infections in a U.S. of communication to V/Af navy populatiot. lnternational AIDS Society 2O04. change H I DS-related behaviors. H ealtlt Edur at ion and Behavior. press. http : //w w w. i asoci ety. ot gl abstract/ 2006. In show.asp?abstra,ct_id=217 6OO2 38 PeersmanG, Grimley Evans J. Interventions for preventing HIV infection in young people in t5 AIDS VaccineAdvocacy Coalition. AIDS vaccinefails to shov) e.ffk'acy in Tlni trial, (http://www.avac.org/ developing countries. Cochrane Database of Systenmtir AIDSVAXthai.htm). Rcvieu,s,2002, (2):CD003649. (Protocol.) 26. Wilkinson D, et al. Nonoxynol-9 for preventing 39 Brieger WR, et al. West African Youth Initiative: vaginal acquisition of HIV infection by women from outcome of a reproductive health education program. men. Cot'ltrane Databa.se of Systenntk Reviews 2OO2: Jounnl of Adole.trent Health 2OOl:. 29:436-46. 4:CD003936.

Jour Marine Medical Society,dn1, Uot.8, No.2 t07 I

A CLINICALTRIAL EVALUATINGA NEW METHODOF FORE-HEAD PULSE-OXIMETRYWITH CONVENTIONALLIMB PULSE-OXIMETRY IN TERM NEONATES

SurgCapt G Gupta',Surg Cdr S Narayan*,Surg CdrA KYadad,A Bableshwar--

ABSTRACT

Objectives: To comparatively evaluate the use of the conventional transducer probe attached to the forehead against the limb probe and to detect the strength of agreement belween the readings obtained from the two sites.

Design: Clinical trial.

Setting: NICU/ Maternity ward

Subjects: 89 asymptomatic term neonates.

Methods: Iwo similar pulse-oximeters (Oxylife, Meditrin Instruments, Mumbai) were used for all measurements. 'fhe sensors of one of the probes was placed over centre of the forehead with a Velcro fixed head band , the other Y probe was attached to the limb in conventional manner. The simultaneous readings from both pulse- oximeters were taken on the euthermic neonates at 2, 5, f0 & 15 minutcs. Probes were interchanged after the first set of readings to eliminate probe bias. A third sct of readings were taken after the switching probes at the machine end to eliminate machine bias. The Bland and Altman Statistical analysis method was used to evahratc the strength of agreement between the readings of both the pulse-oximeters.

Results: The readings of saturations taken at 10 mins and 15 nrins showed a narrower SD of 0.8 to 0.9 and limits of agreement of l.|Vo to l.9%a i.e the values from the forchead probe fetl within the limil( of 1.57o below and 1.99o above the limb probe readings. The readings of heart rates takcn at l0 mins and 15 l6ins showed a narrorver SD of 0.8 to 0.9 and good agreement with the variation in heart rate between the two probes being between 1.86 beats/ min and 0.74 beats/min.

Conclusion: We conclude that the readily available transducer pulse-oximeter probe can be used to obtain reliable SpO, and heart rate readings from the more stable forehead site in term infants without any illness.

Kev Words : Forehead. Pulse Oximeter. Neonates

INTRODUCTION saturation and heart rate in neonates,and in par- |Jhe mostwidely usednon-invasive method of de ticularfor ensuringthat correct levels of arterialO, I terminingthe blood oxygenationis pulseoxi- sustainedduring oxygen therapy . The useof a trans- metry.Pulse-oximetry is a trans-cutaneousoptical ducer probe attachedto a peripheralbody part is techniquefor the non-invasivedetermination of ar- the standardmethod to detectSpO, and is prone to terial oxygen saturation(SaO,). The pulseoximeter erraticreadings in patientswho havea poor periph- measuresSaO, in well vascularisedtissue by calcu- eral circulationdue to any cause[,2]. Movement latingthe ratio of the relativeabsorption of light at artifactsfurther compoundthe problem.especially two wavelengths,one of oxyhemoglobinand the whenlimbs arechosen as probe sites [2,3]. Recently, otherof deoxyhemoglobin. Continuousnon-inva- a few studieshave described the useof a new probe sivepulse oximetry is routinelyused in theNeonatal thatmeasures saturations by analyzingreflected light IntensiveCare Unit (NICU) to monitorthe oxygen fr

'Senior Adviser and Head : *ClassifiedSpecialist (Pediatrics & Neonatology)lrGraded Specialist: "Post GraduateResident Deoartmentof Pediatrics.INHS Asvini. Colaba. Mumbai-400 005.

t08 Jour.Mrtritrc Medical Society,2006, Vol.8, No. 2 : is describedto obviate problems associatedwith the traditionallimb probes. The non-availability of ForeheadReflectance probe in India, prompted us to design a study to answer the research question "Whether the conventionaltransducer probe of the pulse-oximeter be usedeffectively on the foreheadsite in placeof limb?" This clinical trial was designedto comparativelyevaluate the useof the conventional transducer probe attached to the forehead against the limb probe and to detect the strength of agreementbetween the readingsobtained from the two sites. Fig. I : Showsthe photograph of a terminfant with both the probes. SUBJECTANDMETHODS rate were taken at intervals of two, five, ten and After obtaining institutional ethics committee's fifteen minutesfor eachof the modalitiesdescribed approval, in this clinical trial eighty nine neonates above. Babies were also observed for any skrn were recruited over duration of three months from changeson the foreheaddue to head strap. The Jun-Aug 2006.All subjectswere asymptomaticterm Bland andAltman Statistical analysis method was neonates. Birth weights of study subjectsranged usedto evaluatethe strengthof agreementbetween from 2.5 to 3 kgs and postnatal ages from I to 05 the readings of both the pulse-oximetersand to days.Sick and pretermneonates were excludedfrom determine whether forehead pulse oximetry can this study.Informed maternalconsent was obtained replacelimb pulse-oximetry beforerecruiting the subject in to study.Two similar [6]. (Oxylife, pulse-oximeters Meditrin Instruments, RESULTS / Mumbai) were used for all measurements.The t In the study,oxygen saturationand heart rates sensorsof one of the probeswas placedin a newly of 89 consecutiveterm neonatesborn over the three- designed rubber socket with a fixed distance of 5 monthstudy period were taken at intervalsof 2,5,l0 mm betweentwo slots, housing two limbs of the and l5mins for each probe and machine probe, placed over centre of the forehead with a manipulation.Probe and machinebias were Velcrofixed headband with flexibility to adjustto eliminatedby interchangingthe probesat the subject different headsizes. The other Y probe was attached and machineend. Thus, threesets ofreadings each to the limb in conventionalmanner of finger pulse- were obtainedfor SpO, and heart rate. The mean oximetry as shown in Fig. l. The readingswere taken difference and standarddeviation of the SpO, on the euthermic neonates,so as to eliminate readingsand heart rates were calculatedfor each measurementerrors due to cold peripheries.Care measurementinterval for eachof the three modesof was taken to keep pressureapplied on the forehead monitoring. The results were then subjectedto t probe to the barestminimum to avoid faulty readings testand the confidencelimits wereestimated by the due to impairmentof local circulation [4]. If subjects Bland andAltman method. were observedon Day I of life, readingswere taken after at least 30 minutes of birth to minimise the Oxygen saturationsrecorded at 2 mins and 5 mins variationsof heartrateand oxygen saturationseen in all the threesets showed SD t 1.7 with limits of agreementranging from 3.8Vato2.|Vo. The readings normally in the immediate post-natalperiod [5]. Probes were interchanged after the first set of taken at 10 mins and 15 mins showed a narrower - readingsto eliminate probe bias. A third set of SD t 0.8 0.9 and limits of agreement of l.Svo to readings were taken after the switching probes at l.9Vo i.e the values from the forehead probe fell the machineend to eliminate machinebias. Three within the limits of 1.59o below and 1.97o above sets of readings for oxygen saturationand heart the limb probe readings. Thus, the difference

Jour.Marine Medical Society,2006, Vol.8, No.2 109 I

betweenthe readings ofthe foreheadprobe and the ratesat l0 mins. Figures4 & 5 show the difference in limb probe was clinically not significant at any the oxygen saturationand heart rates to the average measurement interval in all three modes of oxygen saturation and heart rates in both forehead monitoring. and limb probes. None of the study subjects Tables-l& 2 show three setsofreadings for the developedany skin changeson the foreheadat the oxygen saturationand heart rates from the forehead end of the study period. and limb pulse oximeters with their corresponding DISCUSSION mean difference, standard deviation, limits of agreementand their confidence intervals. Figures 2 The present study is the first one to test the & 3 show graphs of oxygen saturation and heart effectivenessof forehead pulse-oximetry in OXYGENSATUR/{NOil AT 10 IIINS TABLEI Oxygen saturation 95 Mean Limits of 95% Confidence f i HEAD PROBE Difference (SD) agreement% Limits o 90 r A ir LIMB PROAE a 2mins 0.11(1.7) 3.55-3.25 4.5-2.1 85 5 mins 0.15(t.7) 2.4-2.2 3.9-3.2 l0 mins 0.3(0.8) 1.9-1.3 r.38-t.22 80 0204060E0t(n 15 mins 0.4(0.9) t.8-1.4 r.4-1.24 PROBECHANGED AT SUBJECTEND SAXPLE3IZE 2mins 0.2(1.5) 3.7- 3.4 4.3-2.4 Fig.2:-Showsoxygen saturation of bothprobes.

5 mins 0.13(1.6) 2.3-2.1 J. /-J.J l0 mins 0.2(0.7\ 1.8- I .5 l 4-t. t Hem rote of tnrh prcbes ur l0 nins 15mins 0.3(0.8) 1.8-t.3 |.3-l.2 PROBECHANGED AT MACHINE END 2mins 0.2(1.6) 3.8-3.4 4.7-2.3 5 mins 0.l3(1.5) 2.6-2.3 3.7-3.4 l0 mins 0.1(1.4) t.5-1.4 r.2-l.l I oHead prcbe 15mins 0.2(1.3) 1.6-I .3 r.5- t.3 JnlpPS

TABLE 2 Heart rate O 20 .l{) fl) 80 100 SlnpL.b. Mean diff Limits of Confidence Fig.3 : Showsheart rates for bothprobes. (SD) agreement limits Oxygen Saturrtlon !t 10 mlns 2mins 1.32(4.3) 9.92-3.2 4.8-3.I a ? 1.5 5 mins 0.2(1.6) 7.28-2.8 3.9-2.8 L l0mins 0.03(0.93) | .83-l.7j 1.4-t.2 !t 15 mins 0.1 (0.8) 1.9-1.8 1.5-t .3 E 0., ! PROBECHANGED AT SUBJECTEND a 2mins 0.2(0.86) 9.6-3.2 -3.8 30 iaoqtanS&el 4.7 C 5 mins -7.1 : {.s 0.3(3.7) 7.7 3.6-3.4 o E l0mins 0.01(0.9) l.8l-1.29 1.3-l.l !.r a I 5mins 0.06(I .2) I .86-I .74 t.4-r.2 E o .1.5 PROBECHANGED AT MACHINE END 85 S 95 100 2 mins 1.4(3.6) 9.3-4.5 4.5-3.2 A169.02Srt nilo 5 mins 0.4(1.8) 6.5-3.5 3.4-2.'t | 0 mins 0.05(0.9) 1.8-1.6 1.5-1.3 Fig.4: Shows the difference in the oxygen saturation 15mins 0.07(l.l) 1.9-2.1 1.3-1.2 and the average oxygen saturation in both foreheadand limb probes.

IIO Jour. M arine M edical Soc iety, 2006, Vol. 8, No. 2 H..ft rrb I 10mlm henthey 1.6beats/min lower thanthe readingsfrom the limb probe.The 9570confidence limits for heartrates were ?1 I .5-I .I beats,which is not clinically significant. L' present Gcneva. F o.u In the study,using the regulartransducer c .orglepil oe .IT1rr"- probe,the readingsof the foreheadand limb pulse- nl_en/ i ..u oximetry arein goodagreement in term asymptomatic € neonatesand hencethe foreheadcan safelybe used o )): http:// -1.5 as a sitefor transducerprobe attachment in placeof 0 20 40 60 80 100 120 140 160 the conventionallimb pulseoximetry, as there were' th of the Avemge HR by two methods no changesin the skin of foreheadat the end of the study.There are no studiesavailable in the literature andHIV Fig.5 : Showsthe differencein the heartrates to the ian naval averageheart ratesin both foreheadand limb to compareour study with standardpulse-oximeter probes. probe. n eastern The limitationsof the study include the fact that comparisonwith the limb pulseoximetry using the rd their the study subjectswere term infants without any 991l3 : conventionaltransducer probe in neonates. disordersand hence the findings of this study Very few studies have been conducted on pandemic cannot be extrapolatedto apply to sick/ preterm pulse-oximetry 0 : 73-'7. forehead and all of them involved infants.This limitation is acceptableconsidering the use of the reflectanceprobes, which at presentis ionia M fact that the aim of the present study was to 'omising not availablein India [7]. In fact,an extensivesearch determinewhether the novel method of using the HO TRS of literature failed to reveal any study similar to ours traditionaltransducer probe on the foreheadwould andespecially in neonates,hence the presentstudy give readings akin to the traditional limb probe 'anre.fbr would prove to be an useful alternative to method. )0. conventionallimb oximetry and be cheaperthan use a Weconclude that/Ie readilyavailable transducer U NAIDS of the reflectance probe. pulse-oximeterprobe can be usedto obtain reliable lopment The differences betweenthe two probesfor both SpO, and heartrate readingsfrom the more stable nreillson oxygen saturationand heartrate measurementswere foreheadsite in term infants without any illness. in Soutlr notclinically significant at any measurementinterval Further studiesto evaluatethe effectivenessof the in any mode of monitoring.Though not significant, transducerprobe for foreheadpulse oximetry in sick ] HIV-I the differencewas wider at 2 min and 5 min after and non- and preterm babiesis the next logical step and is s 2003: probe placementin all three modesof monitoring likely to altermonitoring practices in the NICU. this smallgap markedly decreased at l0 and 15mins rnd HIV after probe placement.This finding suggeststhat KEYMESSAGE Journal both the sites can be used to monitor oxygen In term neonatesthe Foreheadpulse oximetry 004: 35 saturationsas well as heartrate, using the traditional with the conventionalprobe can be used as an transducer probe. alternativeto Limb pulseoximetry. iesearch: I decade As seenin Tables I and 2, at l0 and 15 mins A ckno w Ied ge men ts '/r 20001 interval the limits of agreementare very narrow both We gratefully for oxygen saturationand heart rate i.e mean acknowledgethe financial help extended Marine Medical unseling differencein oxygen saturationwas O.l7oto 0.4%' by Societyof India. sexually between the forehead probe and peripheral one; ed trial. REFERENCES ,r, limits of agreementwere within 1.97o 1998. moreor I .37o l. Cooke J. Scharf J. lmproving pulse oximeter ;roup) less than the limb probe at intervalsof l0 and 15 performance, Proceedings of Anaesthesiology rlogicaI minuteswith95Eo Confidence interval between 1.5 conference, Orange County Convention centre, Emory lce:the to I .1. This is clinicallyinsignificant. schoof of medicine,Atlanta,Georgia.2002:96 : A593. easesto 2. Hay WW Jr, Rodden DJ, Collins SM, Melara DL. Hale Similarly, the readingsfor the heart ratesfrom exuallv KA, Fashaw LM, Reliability of conventional and new head probe are between 1.9 beats/minhigher and pulse oximetry in neonatal patients.J.Perinatol 2O02.

8, No. 2 JourMarine Medical Society,2006, Vol.8, No.2 111 22 (5) : 360-6. J Perinatology 2005: 175-6. SHIP Workie FARais-Bahrami K. Clinical use of new 6. Martin J Bland, Douglas G Altman. Statistical methods generation pulse oximeters in the neonatal intensive for assessingagreement between two methods of care. Ant J Perinatol 2005;22 (7\ :357-60. clinical measuremett. The Lancet 1986:l13-6. Reflectance pulse oximetry on the forehead SurgC of New 7. Dassel AC, Graaff R, Aardema M, Zijlstra WG. bom- the influence of varying pressure on probe. the Aarnoudse JG. Effect of location of the sensor on J Neo 1996: 12 (6) : 421-8. reflectance pulse oximetry. Br J Obstet Gynaercl 1997; 5. William T. Basco, Jr, MD. FAAP Healthy Infanrs 104 (8) : 9t0-6. Key Wo Have a Gradual Rise in Oxygen Saturation after Birth.

INTRO (rhipl t Jthe easewl leading Jamesl who id, thedise continr ship'ss bidity,, App on boa several includi andthe itself.I spaces conditi, dermat aggravi canovl Tho andexl in man to test conditi thesen / seriour

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'Graded

I12 Jour Marhe Medical Society, 2006, Vot.8, No.2 Jour. M SHIPBOARDDERMATOLOGY ncthods l0ds o1' '. SurgCdr Sridhar' ra wG. J lsoron ,l 1991. Key Words: Ship Dermatology

INTRODUCTION history-takingis the preferredroute for narrowing dermatology tracesits roots back to the diagnosis. Qhipboard rJthe l8'h century when scurvy,a deficiencydis- The patienthas to be fully bared and viewed in easewith primarily cutaneousmanifestations, was a adequatelight. The four cardinal featuresof type, leadingcause of mortality among mariners.It was shape,distribution and symmetryof the skin lesion JamesLind, a ScottishSurgeon in the Royal Navy must be recorded.The type of a skin lesion may be who identified in 1753 that citrus fruit could treat primaryor secondary,details of which arepresented thedisease I I ]. In this age,dermatologic complaints in TableL Finally,any alterationin the nails,hair, continue to be a common reasonfor visits to the palms,soles, oral cavity andgenitalia must be noted. ship's sickbay.They area significantcause of mor- Evenif final diagnosisis not evident,the Medical bidity, combatineffectiveness and poor morale [2]. Officer can effectively utilise the descriptive Approximately30 percentof the medicalproblems terminologyof skin lesionswhile communicating on board ship are dermatological[3,4]. There are his findingsto thedermatologist. severalfactors that contribute to this high figure, It is recommendedttyf the Sickbay library be includingage group, adverse environmentalfactors updated prior to deploytnent. Handbook of Skin andthe recalcitrant nature of dermatologicaldisease Diseasespublished by AFMC, Pune(2001) as well itself.For much of the Ship's working Company, as one of several Indian colour atlasesof spacesremain as heat stress areas and living dermatologywill assistthe ship's MO in arrivingat conditionsare often crowded.Miliaria, acne,contact a correct diagnosis.Tables 2-5 are suggestedas a dermatitis, fungal infections and bacterial are all treatmentguide for commondermatologic conditions aggravated heat by andhumidity. Scabies infestation encounteredon board ship. can overrunentire messdecks. Though today's ship's Medical Officer hasnew DermatologyMedications and expandedresources at his command,his skills Soaksand compresses in managingdermatologic conditions are often put to test at sea. He must know how to treat minor They can be used to great effect in oozing, conditionsindependently, and also recognisewhen inflamed lesions.Normal saline or potassium theseminor conditionsare a signof somethingmore permanganate100 mg/litre solution are practical serious. agentsfor useon board ship. They reduceirritation and exudation,remove crusts, produce cooling and Approachto diagnosis increasepenetration of subsequentlyapplied The traditionalapproach in medicinehas been to medications.Soaks are given to the extremities,in a take a history before the physical examination[5]. In basin or bucket. Compressesare given by using a dermatology,the advantageis that the abnormalities gamzeepad dipped in compresssohition and placed are visible. Henceinspection, followed by directed over the lesionfor 5-10 minutes,repeated every 2-3 hours.The areais to be dabbedand not rubbed.

'Graded Specialist Dermatology and Venereology, INHS Kalyani, Gandhigram, Visakhapatnam- 530 005.

No.2 Jour. Marinc Medical Society, 2006, VoL 8, No.2 113 TABLE I TA Terminology of skin lesions Co ma Primarv skin lesions Secondaryskin lesions

Bo Macule Flat, circumscribed lesion characterisedby a Crust Dried serum and exudateson the skin o chaoge io colour or texture O Papule Circumscribed, palpable ele,,ation, less than Scale Visible shedding of cornified skin 0.5 cm in diameter Nodule Palpable elevation more than 0.5 cm in Erosion Loss of epidermis,which heals without scarring o diameter, which also has depth o Plaque Raised area more than 0.5 cm in diameter. U lcer Loss in continuity of the skin involving both length more than elevation epidermisand dermis: healswith scarring He Vesicle Elevated lesion less than 0.5 cm in diameter. Scar Replacernentof injured lissue with fibrous a containing fluid ti ssue Pustule Elevated lesion less than 0.5 cm in diameter A trophy Loss of epidermalor dermal tissuc:appcars as a containing pus wrinkling or depression Bulla Elevated lesion less than 0.5 cm in diameter. Excoriation Loss of skin producedby scratching o a-- conmlnlng pus Cyst Closed cavity lined by cells containing fluid or Burrow A small tunnel in the stratumcorneum dug by o semisolid material the scabiesmite Wheal A transient area of dermal or subcutaneous A lopecia Absenceof hair from a normally hairy area oedema o o TABLE 2 Im Common fungal infections and their management a

Tinea cruris Tinea pedis o Expanding erythematous plaque in the groin o Usually startsin the last web spaceand spreadsacross the a O 2ch Miconazole nitrate cream twice dailv for foot. Can involve the sole with scaling or a few large a atleast two weeks. blisters.Rarely involves the dorsum o o Apply till lcm beyond the plaque o Treatment- as for Tinea Cruris o Keep area dry and friction-free; switch to boxer o Dry the feet with a cloth, use cotton socks o shorts o After crrre.powder feet and shoesdaily with clotrimazole Hr o Avoid meticulous over-cleansins dusting powder a Tinea versicolor Onychomycosis a o Diagnosis - hypopigmented macules that appear over Patientswith onychomycosisshould be referred to a sweaty areas - chest, shoulders, neck and sometimes, dermatologistas therapy is prolonged and treatmentlailures the face. They exhibit a cigarette paper type of fine can occur. w scaling, made prominent when scratched with the a little fingernail. ln the later stages, lesions appear darker than the normal skin. a a 2.5 % selenium sulphide lotion applied to involved areas at bedtime and showered off next morning, for 3-4 weeks- t| o Upon treatment,scalid! resolves first: pigmentary a change may take several weeks to improve.

Choice of preparations which prevailin many of the ship's spaces.Gels, Creamsare most often usedfor applicationover solutionand lotions are non-greasy and suitable for l soft skin of folds, scrotum etc. and for acute the face,folds and hairy areas.Over the body folds 1\ inflammatorylesions. Ointments and pastes are best however,calamine lotion and powdersshould be avoideddue to theirabrasive constil.uents. suitedfor the chronic scaly dermatoses,but should t generallybe avoidedin the hot,humid environments It is betterto becomefamiliar with a few drugs I

I14 JotrrMarine Medical Societv, 2006, Vol. 8, No.2 TABLE 3 engine room/ galley or excessive UV glare in the Common bacterial and viral infections and their upper decks can aggravate it. management o Wash face with soap, dry and apply 5% benzoyl peroxide gel twice daily Note: initially, there may be Boil (Furuncle) an irritating effect. a Hot moist compressesfor 15 minutes, t.i.d. O In case there are 10-20 or more inflammatory o A 5-day course of anti-staphylococcal antibiotic papules/pustules, add Cap Doxycycline l(X) mg once (ampicillin-cloxacillin/ erythromycin) 250-500 mg OD (l hr before food with a large glass of water) for 4 q.i.d. weeks. o Incise and drain if abscesshas "pointed." o If the condition is severe, then remove patient from o Remember, the patient is a walking fomite - if a hot, humid, greasy or sun-prone areas. food handler, excuse his duty. o Avoid hair oil. -. Herpes simplex (Mouth or Genitalia) o Acne is non-infectious food handling duties need not be excused. O Grouped itchy/burning vesicles on an erythematous O base Diet may not be a major factor in acne. o No permanent cure - goal is to dry vesicles fast as Seborrheic Dermatitis possible for symptomatic relief O Centrofacial erythema with a fine greasy scale, over a Cold saline or warm teabag compresses(tannic acid - eyebrows, eyelids, nasolabial folds, behind ears and excellent drying agent!). - midline anterior chest. o Acyclovir 200 mg five times daily for 5-7 days for O Worse in winter, airconditioned environment primary herpetic infection. Most cases of recurrent o Frequently confused with systemic lupus HSV do not need oral acyclovir. Save it for the erythematosus(SLE). patients who really need it! o Avoid excessive soap, appty weak topical steroid o 57o Acyclovir cream is only palliative. creams.(e.g. l7o hydrocortisone) b.i.d. till clearance. O Analgesics for pain relief Use sparingly for maintenance. Impetigo Sunbuln O Itchy, honey colored, crusted, erythematous plaques, O Sunscreen with Skin Protection Factor (SPF) 15 or most frequently seen on head, neck, extremities, more. often around,the nose and mouth. o Topical corticosteroid cream at oight is helpful O Warm saline soaks toremove crusts o Severesunburn use NIAID and cold saline soaks. o 'Boil') , 5-1 day course of antibiotics (see Eczema f o If over beard area, avoid shaving, resume with a new o Red, itchy, scaly and may be actively oozing if acute. blade. Thickened, pigmented, itchy, scaly if chronic. o Patient is a walking fomite (see 'Boil'). Commoner among atopics (history of asthma, Herpes zoster allergic rhinitis). o Grouped itchy/burning vesicles on an erythematous o Contact dermatitis can be secondary to irritants base, in a dermatomal distribution (esp., trunk) (paint, thinner, strong detergents) or allergens (oil. o Managemant is on same lines as herpes simplex, lubricants). except that the acyclovir dose is 800mg five times o Some axioms: daily. - If eczema is wet ... wet it (nomurl saline soaks for Warts l0 minutes TDS). o Warts, especially plantar warts, are ubiquitous among - If eczema is dry ... dry it (creams/ ointments) healthy sailors. o Topical steroids locally BD. o Goal of treatment is to allow the patient to continue o Avoid any precipitating irritant or Allergen normal activities with minimum discomfort, while the Dandruff body's immune system is stimulated to overcome o Dandruff or pityriasis capitis can flare under stress of them. deployments. ) 40Vo salicylic acid plaster applied under occlusion o Zinc pyrithione-based shampoo with/without a (after abrading with a 'zero' grade paper) emery on corticosteroid lotion (applied Dightly into the scalp alternate days till wart regression is useful. Avoid roots) hastensremission abrasion to the point of bleeding Miliaria (prickly heat) o Due to occluded sweat pores in a patient working in TABLE4 hot, moist environment. o Rest from the offending environment. Managementof acneand conmon sczemas o Frequent cold showers I Less occlusive, cotton clothing Acne Vulgaris o Calamine lotion is soothing o Acne may be age-relatedbut hot, greasyenvirons of

Jour.Marinc Medical Society,2ffi6,Vo|.8, No.2 I I5 I

TABLE 5 Managementof scabies,urticaria and pseudofolliculitisbarbae

Scabies Urticaria/A ngioedema o ltchy (esp at night), red papules (often crusted). o Evanescentwheals involvins the skin or subcutaneous concentratedover body folds - web spaces,inner wrists, tissue(angioedema). outer elbows, axillae, nipples, umbilicus, buttocks and o Aetiology - 4 I's - Infections,Inhalants, Ingestants and genitals (prepuce, penile shaft, scrotum). Secondary Injections (drugs) eczematisation/impetiginisatitn is common. o Treatment- Treat the underlying cause if it is apparent. o Alone, Tablet Ivermectin 12 mg, single dose is effective o Acute episode- Parenteralantihistamine and On board ship, it enables sinultaneous oral dosing of hydrocortisone100-200 mg, both 8-12 hourly. If patients as well as contacts, breaking the chain of hypotensionor airway symptoms develop, treat as transmission (with topical therapy, it is impossible to anaphylaxis. treat all the mess inhabitants in one go, due to ship's o Antihistamines- Warn the patient of the'sedativeeffects. watches). A combination of topical therapy and Tab Non- sedatingantihistamines only for cooks, engine Ivermectin 12 mg is optimal for symptomatic patients. room personnel,look-outs! o Effective topical'medications are 57o permethrin cream o Tab Ranitidine can be added for additional antihistamine and lqo gammd benzene hexachloride lotion, used as properti es. follows: o Calamine lotion is soothing - Apply the medication to dry skin from the jaw level o Topical steroids are of no benefit down to the toes. Pay particular attention to all body o Systemic steroids are rarely required folds. Do not skip any areas. Pseudofolliculitis Barbae - lf patient washes his hands, reapply locally. O Manifests as keratotic follicular papules in bearded areas - Leave the cream on overnight. due to close shaving, which results in sharp, ingrowing - While the medication is on the body, launder all hairs. It is far commoner than imagined. clothing, bedding, towels, blankets that have been used o The problem has a simple solution - allow your beard to in the past 2 weeks. Shipboard laundering is sufficient grow out. to kill the mites. O Twin/triple blade razors are inappropriate for the patient - One treatment will usually suffice. with PFB. O Treat close contacts (mess-mates). o No shaving for 2-3 days. , O From next day, topical corticosteroid o Shave with hot water after well. cream from day lfting the beard soak 5-7 days to overcome eczematisation. o Use a well lubricated shavirig foam. o Oral antihistamine for pruritus. O Shave "with the grain" of the hair pattern. o In case of secondary bacterial infection, treat first with o If unableto tolerategentle shaving methodsabove, advise anti-staphylococcal drug. use of a chemical hair removal cream (it leaves a less o Genital (nodular) scabies is likely to continue to itch for pointed hair). several weeks post-treatment.Systemic or intralesional corticosteroids may be indicated - such cases are best referred. and methodsof treatmentthan to attemptthe useof Quadriderm@cream is not recommendedfor many. Corticosteroidcreams should be used with frequent use. Its combinationof corticosteroid, extremecare in patients with (suspectedor overt) antifungal and antibacterialagents requires many bacterial,viral andfungal infections.To avoid long- stabilizersand preservativeswhich can potentially term adverseeffects, they should be usedand for producea contact allergy. Neomycin-based only 2-3 weeksat a time [6,7,8].Weak corticosteroids preparationscan also cause contact dermatitis [9, I 0] . such as l7o hydrocortisoneare preferredover the Salicylic acid containing preparationsare to be face, folds, genitals. Medium potency avoidedover the face, genito-cruralregion and corticosteroidssuch as mometasone, fluticasone are folds.Topical benzoyl peroxide and gammabenzene advantageousfor chronic dermatosesas they have hexachloridecan irritateif appliedon wet skin. fewer adverse effects. Strong potency corticosteroids such as clobetasole and CONCLUSION betamethasoneshould be reserved for thick Skin diseasesare of great importancein the lichenified lesions,where may be appliedfor a few shipboardsetting. Although thereare few fatalities daysunder occlusion for maximum effect. from thesediseases they result in a considerable

1t6 Jour Marine Medical Society,2006,Vol. 8, No.2 I

loss of effective manpower.Knowledge of 2nd rev. Washington,DC: GPO; 1998. dermatologicailments and their therapyis therefore 5. SharmaYK, sawhneyMPS, Singh K, Grewal RS. crucialto the aim of providingfirst-rate medical care Dermatological diagnosis. In: Handbook of dermatologyand STD 200i. in tle ship'ssickbay. 6. Allen AM, Thplin D, Lowy JA, TWiggL. Skin allergy. RETTRENCESi Milit Med 1972; 137 : 295-301. l. Lane CG. Medical progress,military dermatology.N 7. Blank H, Taplin D, Zaias N. Corticosteroidsin Engl J Meil 1998;227 :293-9. dermatology.Arch Dermatol 1969; 99 : 13542. 2. Becker LE. JamesWD. Historical overview and 8. Pillsbury DM, SulzbergerMB, Livingood CS. Manual principles of diagnosis.In: Military dermatology.In: of Dermatology.Philadelphia, Pa: WB Saunders Edwards C, Lawrie C. 4thed. New York: Arnold Company;1942. Publishers,2002; 553-7. 9. GuenstBJ. Commoncutaneous reactions. J Pediatr (2) 3. MacKennaRMB. Specialcontributions on military Health Care 1999;13 : 68-71. dermatology.British Med J 1999;3 : l5E-61. 10.AbramsonC. Contactdermatitis. Clin Dermatol 1983; (1): 4. US Departmentof Defense.Bowen TE, Bellamy RF, 1 14-24. eds. The EmergencyWar Surgery NATO Handbook.

Jour Marirw Medical Society, 2N6, Vol. 8, No.2 117 MULTISLICECT IMAGING OF SINONASALINFLAMMATORY DISEASESIN THE ERA OF FESS

SurgCdr PradiptaC Hande',Surg Capt J D'Souza',Surg Capt E James-

Key Words : CT Imaging, Sinus Inflammation

INTRODUCTION sinusitiswith extensionof diseaseinto the adjacent Inflammatorydiseases is a commonand anatomicalareas with pansinusitis.Intracranial Qinonasal L)recurrent ailment in our patient population extensionwas seen in 2 patientswho had fungal especiallyin the aviators and divers who are also infection. prone to seriousoutcomes as of sinusbarotrauma. CT patternswere classified as per the anatomical Multidetector CT (MDCT) is definitely the distributionand involvement of thevarious sinuses imagingmodality of choiceof paranasalsinus (PNS) and the blockage the drainage pathways i.e. and diseasesin the era of nasalendoscopy. osteomeatalunits. The types were as under: Osteomeatalunit : 38% MATERIALSAND METHODS SinonasalPolyposis : 307o Three hundred and thirty patientsincluding aviatorsand divers were referredfrom ENT OPD Infundibular:l87o with clinicaldiagnosis of recurrent/ chronicsinusitis Sporadic:97o for PNSCT imaging,whetever indicated. t"n"""",n." idalrecel :77n CORONAL- CONTIGUOUS SECTIONS with thin DISCUSSION L5 2.0 mm sections,spiral protocol perpendicular to the hard palate,prone position on Multidetector Symptomsthat include airway compromlse CT (Sensation4)performed-orbisinus protocols. IV discomfort,along with the useof medicationswith contrastinjection given as indicated. unacceptableside eff'ects,and have the potential for in-flight incapacitation,and prolongedperiods Bone/Soft tissue windowswith 3D Multiplanar of groundingfor the aviators.It is of greatvalue in Reformatsdone. 1. aviators who often complain of "night cold" post Systematicapproach to reporting with detailed flying to evaluatethe statusofthe paranasalsinuses descriptionof anatomy,variants, relationship with that can predisposethem to sinus barotrauma. important vital structuresas cranial nervesand The diverscan have moderate to severeepisodes vessels. of vertigo with acutepain. This may resultfrom ear RESULTSAND OBSERVATIONS and sinus barotraumasbeing vulnerable to rapid Of 330 patientsdistribution service wise was: pressurechanges during a dive. Army-58, Navy-147 and Air Force-70. The others High resolution CT PNS gives images with were entitled non servicepatients. The Age Range excellentdelineation of anatomyand thepatterns of was from 09-60 years. Commonestpresenting sinonasalinflammatory diseases. It is the modality complaintswere those of chronic sinusitisas of choice in evaluatingthe characterof bony headache,with nasal congestionand chronic frameworkof the nasalvault andPNS. rhinorrhoea.About l2%opatients had florid infective 3D reformatsand multiplanar imageshelp as a

'Department of Radiodiagnosis, INHS Asvini, Mumbai tr8 Jour Marine Medical Society, 2006, Vol. 8, No. 2 referenceand guiding "road map" for nasal CONCLUSION endoscopyand planning for FESS. Objectivecriteria for assessmentof patternsof Today in the era of FESS which aims to restore inflammatorydiseases in patientswith recurrent/ flow ofsinus secretionsthrough the nativedrainage chronic sinusitiscan be studied.CT images.the portalsin casesof recurrentsinusitis it is essential detailedanatomy of the region and providesa to evaluatethe osteomeatal unit (OMU). It alsooffers preoperativeroad map for the surgeon for nasal theadvantage of a "simulator"approach for theENT endoscopyand planning ofFESS. scrrnn g surgeonhelping in reducing complications. The role of CT is invaluabletoday for the CT evaluationis essentialalso for postoperative diagnosis, o hnrh managementand follow up in sinonasal and follow up imaging post-treatment.Proper and inflammatorydiseases in theera of nasalendoscoprc ous meticulousplanning preoperativelycan greatly surgery. reducecomplications and leadto betterresults after rcarsas FESS. REI.'ERENCES L Kennedy DW. Zinreich SJ, Rosenbaum AE, et al . Functionalendoscopic surgery: theory and diagnostic evaluation.An.h otolurv-ngr;/1985: lll : 576-82. dug by 2. Zinreich S, KennedyDW, Rosenbaurn,{,/ d/. paranasal sinuses: CT imaging requirementsfor endoscopic area surgery.Rndiologt, I987: 163 :769-'15. 3. ShankarL. Evans K, Hawke M, er al. An atlas of imaging of paranasalsinuses. London: Martin Dunitz Fig.Ia: Fig.lb: 1994 41-'72. 4. tJS Navy Aeromedicalreference and Waiver Guide. 5. HudginsP Complicationsof endoscopicsinus sur_eerv: lofc of lhe radiofogistin prcvention.Raditil Clin N,rrttt rrossthc Arr 199.i:3l : li, lrge I 6 Zinreich SJ. AlbiiyrarnS. BensonML, t,r a/. Thc osteomeatalcomplex and functional endoscopic surgery.In : Som PM and Curtin HD eds. Head ancl Neck lrnaging.St Louis. Mosby 4tr'ed. 2003; I49-73. Fig.2a: Fig. 2b :

failures

;.Gels, rblefor y folds ruldbe r drugs

8.No.2 JounMarine Medical Society,2006,Vot.8, No. 2 II9 INTRA OCULARTENSION RECORDING- IS LATESTTHE BEST? Obser' Group

Surg Cdr Thrun Choudhary' *"* Hypotr Ocular ABSTRACT Normo Ocular This paper proposes to present the comparison of Intra Ocular Tcnsion recordings(IOT) in ocular hypotensives, Hypert ocular normotensives and ocular hypertensives using Non Contact Tonometer (NCT), Schidtz Tonometer (ST) and Applanation Tonometer (AT).

178 eyes in the ocular hypotensive group gave on IOT of 6.2mm Hg with ST, 7.6rnm Hg with AT and 6.96mm Hg Itt ocular normotensive eyes showed an IOT of 13.9mm Hg with NCT.f000 ST, l4.2mm Hg with AT and l4.7mm Hg deviat with NCT . 439 ocular hypertensive eyes gave a IOT reading of 23.7mm IIg with ST, 28.lmm Hg with AT and 3l.78mm Hg with NCT. all grt than Analysis of the above data revealed that the NCT though fast, no touch and convenient, has a tendency to hypot exaggerate the disability i.e. show lower IOT in ocular hypotensives as compared to AT and higher IOT as compared to AT in ocular hypertensives . meth( differ The best way in which this new technology can be used will be discussed and the following recommendations j ustified. thatb groul (a) NCT not be used as the sole IOT recording device for diagnosing glaucoma and achieving target pressure.

(b) NCT be used extensively in all our eye centres as a screening device for glaucoma. CON,

Key Words : Measurement, Intra ocular lesion N( moda exagl in oc INTRODUCTION how doesthe instrumentstand in comparisonto ocula incethe time when glaucomawas recognized othermethod of IOT measurement? Q LJas the silent stealerof sight, Intra Ocular Ten- TI Methology sion (IOT) recording has been an integral part of IOT any ophthalmicpractice. Even thoughit is now rec- This projectaims to find out therelative efficacy ognized that IOT is only one of the criteria of of IOT measurementusing schi6tz tonometer (ST), consequencein glaucoma,its staysundiminished. Goldman'sApplanation tonometer (AT) andto Non Contact Tonometer(Topcon CT - 80). The study The effect technologyhas had on the diagnosis commencedin Dec 2005and data collected till Oct and treatmentof glaucoma is unparalleled.With 2006has been analyzed and is beingpresented here. automatedperimetry coming, Lister's perimeter and evenGoldman's perimeter has become a memoryin The subjectsafter obtaining consentare being the distant past. With Scanning Laser divided into threegroups according to the readings Ophthalmoscopy(SLO) ald Optic Nerve Head obtainedwith Goldman'sApplanation Tonometer: Analyzer (ONHA), y'phthalmoscopy for Ocular hypotensiveswith pressureless than are glaucomatousdisc changeshas been relegatedto equal to l0 .nmHg, ocular normotensiveswith the background. pressureof l0-21 mmHg andocular hypertensives with IOT greaterthan 2l mmHg._ So also, for measurementof IOT, Non Contact Tonometer(NCT) orAir pulse tonometerhas been In a doubleblinded prospective study, the IOT adoptedas the routine tool for measuringIOT. But recordingby the threemethods in the threegroups werecompared.

'Classified Specialist Opthalmology - INHS Kalyani.

Jour. r20 Jour Morine Medical Society,2a06, Vol.8, No.2 I

T? Observations glaucomapatients and ocular hypertensives. Patientswith IOTof L7-21mm Hg withAI may Group No. of IOT ST IOT AT IOT NCT Eyes (mmHg) (mmHg) (mmHg) be shown to be having IOT of 2l-25 mmHg with NCT, this labeling them as having raisedIOT. In Ocular such caseswith borderline high IOT, the readings Hypotensives 178 6.2 7.6 6.96 must be reconfirmed, preferably with AL Also other Ocular pillars in the diagnosisof glaucomalike Visual Fields Normotensives l 000 l 3.9 t4.2 | 4.7 Ocular and Disc Changes should be assessedbefore ensives, Hypertensives 439 z5. t 28.l 3t.78 startingsuch patients on glaucomatreatment. er (ST) To conclude, NCT is an excellent tool for IOT measurementsince it offers the patientadded comfort mm Hg It was observedthat NCT recordingsshowed a and no chanceof trinsmission of any infection in mm Hg deviation away from the mean for IOT recordingsin {T and addition to saving time for the examiner in a busy all groups i.e. the IOT recording by NCT was lower Eye Centre.In additionthe userfriendliness of this than those of the other two methods in ocular sncyto method allows it to be operatedby the eye hypotensive group and higher than the other two IOT as technicianswithout any chanceof error. However, methods in ocular hypertensivegroup. The only in doubtful casesof borderlineIOT, this equipment difference which was statisticallysignificant was dations is of no use in labeling the person as normal or a that betweenNCT and ST in the ocular hypertensive glaucomapatient for which the gold standardof AT groups. essure. standstall and unchallenged. CONCLUSION It is our strong recommendationthat Target NCT in comparison to the other two common pressureachievement and first time diagnosis of modalities of IOT measurementhas a tendency to glaucoma should not be based solely on NCT exaggeratethe condition i.e. give high IOT readings readings.NCT shouldle usedalways as a screening in ocular hypertensives and low IOT readings in testand for long termfollow up of glaucomapatients ocular hypotensivesvis-i-vis ST and AT. on optical medical therapy or those who have glaucoma This needsto be kept in mind while analyzing undergone surgery and achieved target IOT recordings obtained from NCT mainly in IOT. fficacy :r(ST), to Non l study tillOct :dhere. : being adings rmeter: an are s with lnsives re IOT groups

Jour.Marine 8.No.2 Medical Society,20A6, Vol.8, No.2 t2t HEMAIOLOGICAL CHANGESIN ALCOHOLDEPENDENCE ( T

S Chaudhury',AAPawar*, D Bhattacharyyar, D Saldanha-- r

Abstract Sr

Although alcohol abuse is known to create a variety of adverse effects on hematopoiesis, lhe associations between ethanol consumption and hematological abnormalities have not been fully established. In 100 consecutive male inpatients with alcohol dependence and an equal number of age, sex, occupation and regional A background matched controls; the level of hemoglobin and thrombocytes were statistically significantly less, A while the values of serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvic transaminase dr (SGPT),and reticulocytc and mean corpuscular volume (MCV) were statistically significantly raised among m alcoholics on admission as compared to controls. In the absence of reliable data on alcohol consumption, these dr objective laboratory tests can be used to support the clinical diagnosis of alcohol dependence. X Key Words : Alcohol dependence, laboratory tests

INTRODUCTION larly lymphopeniacould predisposethe alcohol n abuserto infections.Thrombocytopenia from bone I lcohol has pervasiveconsequences for the hu r larun body.The medical consequencesof alco- marrow suppressionand splenicplatelet sequestra- hol representsome of the most important public tion in combinationwith decreasedhepatic It health problems confronting society.They are productionof clotting factors, all contribute to r?. among the most common causesof hospital visits gastro-intestinalbleeding, easy bruising, and other C and the fburth leading causeof death among the coagulopathies.Alcoholic liver diseasemay cause ril agegroup of25-65 yearsin urban areas.Substance alteredRBC membranelipids manifesting as Sr abusein general and related health problems add macrocytes,target cells, burr cells,and schistocytes )n, $l 14 billion eachyear to the cost of healthcarein leadingto hemolyticanaemia and acanthocytosis. r' fe the US. Additional costs include lost employment Malnourishedalcoholics often have ringed tc opportunitiesand crime that occur becauseof alco- sideroblastspossibly as a resultof inhibitionof heme T hol. Alcohol can have a profound effect on the synthesis.Also, depressedserum and RBC phos- c( body's hematologicalsystem resulting in a variety phatelevels may leadto spherocytosis,decreased g of anemias,leukopenias, and coagulopathies.Over- RBC membranefluidity, decreasedATP production, D k all, a picture ofpancytopenia can occur becauseof andacute hemolysis []. Thereis paucityof Indian ir bone marrow toxicity and/or splenic sequestration work in this field and no work has beencarried out from portal hypertensioninduced splenomegaly. In in the SecurityForces. This prompted us to focus lt addition,macrocytic anaemia results from folic acid on few laboratorytests to evaluatethe hematological R and vitamin B l2 deficiencv.abnormal RBC release changesin servicepersonnel with alcoholdepend- d from the bone marrowy'ni ."-U.une defects.Mi- encesyndrome. crocytic anaemiamay result from iron deficiencyand MATERIALANDMETHOD c ongoing upper gastrointestinalblood loss.Normo- t cytic anaemiamay result from a stateof chronic Onehundred consecutive male inpatients admit- 3 disease and./orbone marrow suppression.A de- tedto thepsychiatric centers of two BaseHospitals I t creasedhematocrit may resultsolely from expanded andmeeting the DSM IV criteria [2] for alcoholde- plasmavolume. White cell deficiency and particu- pendencewere included in the study with therr

'Professor and Head, Departmentof Psychiatry,Ranchi Instituteof Neuropsychiatryand AIlied Sciences(RINPAS), Kanke. Ranchi - 834 006. *SeniorAdviser (Psychiatry),INHS Asvini, Colaba,Mumbai. iClassifiedSpecialist (Psychiatry), l5l BH c/ o 99APO. "Professor and Head, Departmentof Psychiatry,AFMC, Pune - 4ll 040.

122 Jour.Marine Medical Society, 2006, Vol.8, No.2 informedconsent. An equalnumber of age,sex and TABLE I regionalbackground matched subjects without any Demographiccharacteristics of alcohol dependent patients(N=l00) and normal controls (n=100) physicalor psychiatricillnesses formed the control group. Characteristic Alcoholics Controls Comparison Exclusioncriteria for patientsand controlswere Age distribution as under: (in years) l. Known casesof cardiorespiratorydisease, 2t -25 I I hypertensionand diabetes. 26-30 25 25 3l-35 l8 t9 2. Clinical evidencecirrhosis, hepatocellular failure 36-40 22 24 NS and portal hypertension. 4l -45 t4 l3 3. Dehydrationand obvious malnutrition. 46-50 l8 l6 5l-55 2 4. Clinical, radiological and echocardiographic Service(in years) evidenceof cardiomegaly. 6-r0 l5 l6 5. Use of phenothiazines, antidiabetics, I l-15 JI 32 antihypertensives,antitubercular drugs, t6-20 l9 t9 -25 antibiotics,and anticonvulsantsduring past 2t 22 2l 26-30 l3 l2 one month. Rank Each patient and control subjectwas examined Officers independentlyby two psychiatriststo confirm the JCOs ll 9 NS diagnosisand the absenceof exclusioncriteria, and Otherranks 39 4l was included in the study only after the concur- Maritalstatus Married 93 92 renceof both.Aphysician carried out a symptomatic 'l Unmarried 8 analysis pertinent to the cardio-vascularsystem. Educaiion I Detailed history about the alcohol habit was ob- Uptoclass 5 u 8 tained from the patient on a specially prepared Class6 to l0 67 69 proforma.Additional information was obtainedfrom Classl0 & above 22 z) family members(If available),colleagues and his unit. Religion Within 24 hours of admissionblood for laboratory Hindu 19 74 testswas collected in an overnight fasting condi- sikh l4 l8 NS Christian 5 z tion. The following laboratorytests were performed: Muslim 2 I serumhemoglobin, bilirubin, serumproteins, serum Domicile albumin,SGOT, SGP! MCV. The control subjects Rural 9l 89 also underwentall the tests given to the patients. Urban 9 II The data was tabulated.Statistical analysis were Bloodgroups 't' carriedout using the students test and chisquare A 25 3l test with Yates correction as appropriate. B J-t 35 o 36 2'l RESULTS AB 6 Mean age of the patients and control subjects (837o)of alcoholdependent subjects was afterjoin- was38.05 years and 38.57 years respectively. Range ing the security forces. The majority of subjects of age was 25-54 yearsfor both groups.Socio-de- (7\Vo)hadbegun voluntarily, while 22Voclaimedto mographic characteristicsand blood group of have done so due to peer pressure.The average patientsand controls are shown in Table l. There daily intakeof alcohol as statedby the patientswas were no significant differences between the two 7l.36 GMS. The meanduration of drinking was 14.7 groups on any of these variables and also their years (Range 5-28 years). The frequency of con- blood group. Onset of alcohol use in the majority sumption was: daily in 48Vopatients, 3-5 times a

Jour MarineMedical Society,2006, Vol. 8, No. 2 I2-l week in 4lVo patients,while llTo patientsgave a the blood cell precursors;and the maturered blood binge patternof drinking. The majority of alcohol cells(RBC's), white bloodcells (WBC's), andplate- dependentpatients (72Vo) consumedalcohol alone lets.Alcoholls indirecteffects include nutritional while2SVoclaimed to drink only in company. deficienciesthat impair the productionand function Alcohol dependentpatients had significant of variousblood cells.These direct and indirect ef- thrombocytopeniaand reticulocytosis.There were fects of alcohol can result in seriousmedical no differencesin the total anddifferential leucocyte problemsfor the drinker.For example,anaemia re- counts between alcohol dependentpatients and sulting from diminishedRBC productionand control subjects.Other laboratory tests results of impairedRBC metabolismand function can cause the alcoholdependent patients and control subjects fatigue, dyspnea,lightheadedness, and even re- are given in Table 2. The findings of the present ducedmental capacity and abnormalheartbeats. A study along with the findings from earlier studies decreasein the number and function of WBC's in- aregiven in Table3. creasesthe drinker's risk of seriousinfectioni and impairedplatelet production and function interfere DISCUSSION with blood clotting,leading to symptomsranging Peoplewho abusealcohol are at risk for numer- from a simple nosebleedto bleeding in the brain ousalcohol-related medical complications, including (i.e.,hemonhagic stroke). Finally, alcohol-induced those affecting the blood (i.e., the blood cells as abnormalitiesin theplasma proteins that are required well as proteins presentin the blood plasma)and for blood clotting can leadto the formationof blood the bone marrow.Alcohol's adverseeffects on the clots(i.e., thrombosis). hematopoietic,system are both direct and indirect. Alcoholis themost commonly used drug whose The directconsequences ofexcessive alcohol con- consequencesinclude the suppression of bloodcell sumptioninclude toxic effectson the bonemarrow; production,or hematopoiesis.Because its toxic ef- TABLE2 fects are dosedependerf however.significantly Laboratory test results of alcohol dependent impairedhematopoiesis tlsually occurs only in peo- patients (n=100) and normal control subjects plewith severealcoholism, who alsomay sufferfrom (n=100) nutritionaldeficiencies of folic acid and other vita- mins that play a role in blood cell development. Test Alcoholics Controls Comparisons excessivealcohol ingestionreduces the Mean (SD) Mean (SD) Chronic numberof blood cell precursorsin thebone marrow ESR tt.44 (6.02) 9.r8 (5.46) P < 0.006 and causescharacteristic structural abnormalities Hb t2.22(r.77) 13.65(0.34) P < 0.000 in thesecells, resulting in fewer-than-normalor non- MCV 97.62 (21.3) 89.r 3 (6.48) P < 0.01 functionalmature blood cells. As a result,alcoholics may suffer from moderateanaemia, characterized by NS = Not significant

TABLE 3 Data from studies pertaining to anaemia in alcohol dependence

Study No. of Anaemia Reticulo MCV,I Patients Va cytosis 70

Heidemann & Nerke, [9] 120 64 Gheno et al [l0] 220 + + Savage & Lindenbaum Il] t2l r00 40 73 Pfefferbaum et al [6] 58 + Latvala et al [12] 57 5l + Chaudhury et al, 2006 100 + + + (Present study)

Modified from Ballard (1997)

124 Jour Marine Medical Society,2006,VoL 8, No.2 T

enlarged,structurally abnormal RBC's; mildly re- The MCV is elevatedin approximately50 to 60 ducednumbers of WBC's, especiallyof neutrophils; percentof peoplewho chronicallyingest excessive and moderately to severely reduced numbers of alcoholquantities [3]. With theadvent of automated platelets.Although this generalizedreduction rn instrumentsthat determine the MCV during routine blood cell numbers(i.e., pancytopenia) usually is bloodcounts, physicians and other health care pro- not progressiveor fatal and is reversiblewith absti- vidersfrequently detect elevated MCV's in patients nence,complex aberrationsof hematopoiesiscan who arewell nourishedand who haveno obvious developover time that may causedeath. Many bone disordersto explainthis finding. In thesepatients, a marrow abnormalitiesoccurring in severealcohol- moderatelyincreased MCV may be a clue to unsus- ics affect the RBC precursor cells. These pectedalcoholism. Analysis of blood smearscan abnormalitiesmost prominentlyinclude precursors supportthis diagnosis:In patientswith an alcohol- containingfluid-filled cavities (i.e., vacuoles) or char- related increasein MCV the enlargedRBC's are acteristiciron deposits. roundand of uniformsize. Conversely, in patients In additionto interferingwith the properabsorp- with certaintypes of anaemiathat resultin an in- of tion of iron into the hemoglobin moleculesof red creasedMCV theRBC's typicallyare oval and returnsto bloodcells (RBC's), alcohol use can leadto either variablesize. Because the MCV usually irondeficiency or excessivelyhigh levelsof iron in normalwithin 2 to 4 monthsof abstinence,the in- the body. Becauseiron is essentialto RBC func- creasein RBC sizeapparently is a directeffect of tioning,iron deficiency,which is commonlycaused alcoholon RBC production[4-6]. However. the un- by excessiveblood loss,can resultin anaemia.In derlying mechanismis unclear.Three recent many alcoholicpatients, blood lossand subsequent epidemiologicstudies consistently showed that iron deficiencyare caused by gastrointestinaibleed- MCV waselevated b1'alcohol drinking more mark- ing. Iron deficiencyin alcoholicsoften is difficult to edly among individualswith geneticallyinactive (ALDH 2) (encodedby diagnose,however, because it may be maskedby aldehydedehydrogen4se-2 *t with symptomsof othernutritional deficiencies (e.g., folic ALDH2*2 mutant/lele) than those active genotype), acid deficiency)or by coexistingliver diseaseand ALDH2 (encodedby ALDH2* ll2" I sug- otheralcohol-related inflammatory conditions. For gestingthat the elevatedMCV was etiologically par- an accuratediagnosis, the physicianmust therefore linkedto acetaldehydeexposure [7]. In a study years excludefolic acid deficiency and evaluatethe pa- ticipantswere 159men who wereaged 40 to 69 popu- tient's iron storesin the bone marrow.Conversely, and randomlyselected from a Japaneserural alcohol abusecan increaseiron levels in the body. lation,the relationship between alcohol drinking and For example,iron absorptionfrom the food in the serumfolate concentration was significantlydiffer- gastrointestinaltract may be elevatedin alcoholics. ent betweenALDH2 genotypes,indicating that the Iron levelsalso can rise from excessiveingestion of reductionof serumfolate by alcoholdrinking was iron-containing alcoholic beverages,such as red moremarked in men with ALDH2*ll2*2 thanthose wine. The increasediron levels can cause with ALDH2* l/2* L The relationshipbetween alco- hemochromatosis. hol drinking and elevatedMCV was significantly strongerin menwith ALDH2*ll2*2 thanthose with Alcohol-relatedabnormalities in RBC production N,DH2*llz* I evenafter adjustmentfor serumfolate manifest themselvesnot only in the bone marrow andvitamin B l2 concentrations.These findings in- but alsothrough the presenceof defective RBC's in dicatethat acetaldehydeplays a significantrole in theblood. For example,grossly enlarged RBC's can the developmentofdecreased serum folate concen- occurin the blood-acondition called macrocytosis - trationand elevated MCV by alcoholdrinking[7]. as well as oddly shapedRBC's that are subjectto prematureor accelerateddestruction (i.e., hemolysis) Thrombocytopeniais a frequentcomplication of becauseof their structuralabnormalities. As a re- alcoholism,affecting 3 to 43 percentof nonacutely sult, alcoholicsfrequently are diagnosedwith ill, well-nourishedalcoholics and 14to 8 I percentof anaemia. acutelyill, hospitalizedalcoholics. Thus, apart from acquiredimmune deficiency syndrome (AIDS). al-

JounMarine Medical Society, 2006, Vol. 8, No.2 1:J coholismprobably is the leadingcause of thrombo- maintainnormal platelet levels. In additionto differ- cytopenia.Except for the most severecases, however, encesin thequantity of alcoholconsumed, inherited the patientsgenerally do not exhibit manifestations or acquiredvariations in an individualdrinker's bio- of excessivebleeding. Moreover, alcohol-related chemistry may accountfor thesedifferences in thrombocytopeniagenerally is transient,and plate- suscepribiliry. let countsusually return to normal within I weekof We concludefrom study that patientswith alco- abstinence.Failure of the plateletcounts to rise af- hol dependencehave significantly lower levels of ter 5-7 days of abstinenceusually indicatesthe hemoglobinand thrombocytesand significantly presenceof anotherunderlying disorderaffecting higherlevels of reticulocytesand MCV ascompared the platelets.Therefore, patients generally require to healthycontrols. no therapeuticintervention other than that needed to easealcohol withdrawal.Only in patientswhose REFERENCES thrombocytopeniais severe and associatedwith l. SchenkerS, Bay MK. Medial problems associatedwith excessivebleeding are platelet transfusionsindi- alcoholism. Adv Intern Med 1988. 43 : 27-78. cated. In many patients with thrombocytopenia, 2. American Psychiatric Association. Diagnostic and (DSM reboundingplatelet numbers even exceednormal Statistical manual of Mental Disorders 4th ed. IV). WashingtonDC: APA; 1982. values.This rebound thrombocytosisafter cessa- 3. Homann C, Hasselbalch HC. Hematological tion of alcohol consumptionalso occurs in the abnormalitiesin alcoholism. Ugeskr Laeger. 1992' 154 majority of patientswhose plateletcounts are nor- (32) :2184-7. mal at the time of hospitalization.In thesepatients, 4. Ballard HS. Alcohol, bone marrow and blood. Alcohol the extentofthe excessin circulatingplatelets usu- Health and ResearchWorld 1993: 17 : 310-5. ally is higher than in patients presentingwith 5. Ballard HS. The haematologicalcomplications of thrombocytopenia. alcoholism. Alcohol health and research world. 1997: 2l :42-52. The exactmechanisms alcohol-related underlying 6. Pfferbaum A, Rosenbloom MJ, Serventi KL, Sullivan thrombocytopeniaremain unknown. Some research- EV. Brain volumes,RSlstatus, and hepatic function ers have suggestedthat alcohol intoxication itself, in alcoholicsafter I and I weeks of sobriety: Predictors ratherthan alcohol-relatednutritional deficiencies, of outcome.Am J Psyrhiatry 2O04: 16l : l190-6. causesthe decreasein platelet numbers.This view 7. Yokoyama T, Saito K, Lwin H, Yoshiike N, Yamamoto A, Matsushita Y, Date C, Tanaka H. Epidemiological is supported by findings that thrombocytopenia evidence that acetaldehydeplays a significant role in developedin healthy subjectswho receiveda diet the developmenl of decreased serum folate containingadequate protein and vitamin levels(in- concentrationand elevatedmean corpuscularvolume cluding largedoses of folic acid) andconsumed the in alcohol drinkers. Alcoholisnt: Clin Exo Rcs 2005: 29 (4\:622-30. equivalentof1.5 pints (i.e.,745 milliliters) of 86-proof whiskeyfor at least10 days The subjects'plate- 8. Lindenbaum J. Hematological complications of alcohol [8]. abuse.Seminars in Liver disease1987; 7 (3) : 169-81. let levels returned to normal when alcohol 9. Heidemann E, Nerke WHD. Alkoholtoxische consumptionwas discontinued.Similarly, platelet veranderungender hematopoiese:eine prospective countscan be reducedin well-nourishedalcohollcs studie bei chronischen alcoholikern. Klitt Wtx'ltensthr who do not suffer from folic acid deficiency.The l98f;59 l3O3-12. availabledata also suggestthat alcohol can inter- 10. Gheno (i MagnaboscoV. Mazzei G. Macrocytosis and fere with a late stageof plateletproduction as well anaemiain chronic alcoholism. Correlation with the results of hepatic needle biopsy. Minerva Med 1981 as shortenthe life span platelets.Indi- , of existing 72 (20\: 130l-6. vidual drinkers appearto differ in their susceptibility I l. SavageDS, AndlindenbaumJ. Anaemia in alcoholics. to alcohol-inducedthrombocytopenia. Thus, clini- Medicine 1986: 65 : 322-38. cians have noted that some people who consume 12. Latvala J, Parkkila S, Niemela O. Excessalcohol alcoholin excessrepeatedly develop thrombocyto- consumption is common in patients with cytopenia: penia (often severely), whereasother drinkers studies in blood and bone marrow cells. Alcoltol Clin Exp Res 2OO4:'28 (4) : 619-24.

126 Jour.Marine Medical Society,2006, Vol.8, No. 2 CaseReport DECOMPRESSIONSICKNESS DURING SATURATION DIVING : A CASE REPORT

SurgLt Cdr Vivek Verma' ciations In 100 regional ABSTRACT ,tly less, yr from Type DCS in into aminase A 3l old Saturation diver suffered I a Bounce dive converted a Saturation dive at a depth of 52 m during an open sea dive. The diver was compressed to a depth of 84M and was given Therapeutic I among mixture containing Oxygen and Helium (20:80) . The diver was thereafter decompressed using modified )n, these decompression schedule, The diver was asymptomatic on surfacing and a post dive clinical examination, Chest X-ray, ECG and PFT was WNL.

Key Words: Excursion Depth, Bounce Dive, Therapeutic Mixture

alcohol INTRODUCTION Diver who was compressedalong with a buddy diver, to a ombone depth of 42 m inside a SubmersibleDecompression Chamber ,The conceptof SaturationDiving was proposed )questra- (SDC). The dive was a bouncedive which was later converted hepatic I and proved by Captain George Bond and to a Saturation Dive. On the first day he locked out twice fibuteto JacquesCousteau who carriedout a seriesof Satu- and worked betweendepths 42-60 M. His total dive time ration exposuresin humans named Sealaband was 0l Hr and 20 min. On completion of the dive, he was rndother transferredto the Deck;DecompressionChamber (DDC), Conshelfrespecitively I With laycause I ]. the adventof Satu- where two pairs of divgfs were already presentat a depth of )snngas rationDiving camethe problemsof Decompressi,on 42 m.Thereafterthe Living Depth of the chamber was ristocytes Sicknessrelated to Saturationdiving (DCS)and High increasedto 52 m and divers were saturated at this depth. pressureNeurological Syndrome (HPNS). The mani- On 2"d day two remaining pairs of divers carried out diving locytosrs. which was uneventful.On the 3" day, the l" pair of divers festationsvary from minor e ringed constitutionalsymptoms was again shifted to the SDC and taken to an Excursion n ofheme to fatal neurogical and respiratorycomplications. Depth of 74 m. The depth was then decreasedto 52 m and BC phos- The treatmentof DCS during SaturationDiving is the diver locked out for inspection of a submergedwreck.. complicatedbecause of the specificcomposition of He made two trips to the SDC carrying heavy articles. lecreased When he returned to the SDC for the third time, just Olm 'oduction, gas mixtures dependingupon pro- depth and the below the SDC, he felt extreme weaknessand was unable to of Indian longed DecompressionSchedules. The exact keep himself afloat. He signaled to the standby diver in the aniedout incidenceof DecompressionSickness in IndianNa- SDC, who immediately locked out and helped the diver to val Divers during Saturationdives is not known but get inside the SDC. Inside the SDC the diver reportedextreme i to focus weaknessand pain in both his kneejoints. The pain was it is rare as the DecompressionTables used are of atological dull aching to start with and was increasing in intensity. I depend- Royal Navy which are very conservative.The inci- There was no difficulty in breathing or any other dence of DCS while using US Navy Dive Tables Cardiovascularor Neurological symptoms.The diver was variesfrom l7o - 57o [2]. In spite of ideal climatic diagnosed to have Typel DCS and was immediately compressedto 74m and was put on a TherapeuticMix of conditions and strict adherenceto Decompression Oxygen and Helium (20:80). After l5 min at 74 M the rtsadmit tables,we had a diver who sufferedfrom Decom- condition of the diver did not improve. His depth was Hospitals pression Sicknessduring an open sea dive while further increasedto 84m and the Therapeutic Mix was continued. After l0 min at 84 m, the diver reported relief coholde- under Saturationwithout any apparentcause. in the pain. The depth was maintained at 84 m and the viththeir CASEREPORT diver was given 03 cycles of TherapeuticMix of 20 min each with 05 min breaks between each cycle breathing The affecteddiver was a 3l vr old exoeriencedSaturation S), Kanke. 15l BH c/ 'Medical Officer, Diving School, Kochi. bl.8. No.2 Jour Marine Medical Society, 2006. Vol.8, No.2 127

L DTYEPROFILE hrs if depth< -50Mand 06 hrs if depth> 50 M. These oralfl limits canbe increasedto 06 hrsand 08 hrs in case lr themi ofemergency. ous T The irrcidenceof DCS in SaturationDiving var- comr ies dependingupon the Dive Tables(Royal Navy, lium. Fo US Navy,etc.). The incidenceis morewith bounce 9. condi HJ divingas compared to SaturationDiving [3]. The oultt incidenceof DCS is lesswhen these limits aread- physl( a heredto strictly.The most common cause of DCS is troller unsafediving practices.The casesof DCS which ! PPO. occur without any apparentcause like accidental anall' I}AYSltlllt2Stttrrlllls6r lossof depth,breach of ExcursionSat-ety Limits etc. andac Fig. I : Dive profile of affected diver can be becauseof variousfactors like Individual calan susceptibility,Lack of physicalfitness, Hypother- shoul chamber atmosphere.After a halt of 02 hrs at tbig depth mia, Physicalexertion, Patent Foramen ovale, durinl in his the diver reported 909o relief symptoms. IncreasedPartial Pressure qf CarbonDioxide (PPCO,) calex Decompressionwas then startedon Modified Decompre' ion Schedule(Table 2). The diver was asymptomaticwhun he / DecreasedPartial Pressure of Oxygen(PPO,) [4-6]. emph surfaced on the 7h day. The post dive clinical examination. DCS in these casescan occur during Excursion. Neurt Chest X-ray, ECG and PFT was WNL. The divc profile of Decompression,'UncontrolledAscent from depth anda the diver is depicted in Fig. l. or on Surfacing.The mostcommon form of presen- cases DISCUSSION tationof DCS in Saturationdiver is Lower Limb Pain. MRI The managementconsist oi 4 R's namelyRecog- T)'pe Diving to depth deeperthan 50m is carried out nise,Respond with Oxygen,Relay to emergency calD usingBounce Dive or SaturationDive asair diving Medicalservice / Marine MedicineSpecialist and cham is not efficient.In Bouncedive the divers are di- Recompressiontherapy. The treatmentof DCS at withir rectlycompressed in a SDC usingNitrox or Heliox presentis carriedout asper UK Navy Diving Manual shoul without Saturation,and lowered to thediving depth. (Supplement)[7]. When DCS is diagnosedduring incide In SaturationDive, once the divers reachthe Stor- an Excursion,the depthof thediver shouldbe im- pressr age/ Living depth,they arekept there for a minimum mediatelyincreased using Helium @ a rateof l5m/ 04da periodof 12-24hrs to achievesaturation of the tis- min by 20m in caseof Type I and 30m in caseof degre sues. Once saturated,the divers can carry out Type2 DCS but shouldnot be normallyincreased can0 Unlimited DurationExcursions to depthsboth shal- morethan the depth of Excursion[8]. Thediver can surfar lower ancideeper than the living depth. The be givenup to 06 sessionsof Therapeuticmix hav- can'ie excursiondepths for a particular living depth are ing PPO,between 1.5-2.5 ATA. Oncethe diver has gests laid down in ExcursionTables. The excursionlimits been stabilised,he should be kept at the depth of inonl pertainingto this dive are depictedin Table l. relief for atleasttwo hoursand then decompressed andI Thereare no limits as to how long a diver can usingmodified Decompression Schedule (Table 2). carry out excursionand it dependson the physical No initialupward excursion should be carriedout. andmental capability of thpdiver. However, the nor- Hydrationshould be maintainedwith plentyof mal duration of lockout/durins an excursionis 04 TABLE2 TABLEI Modified decompression schedule Unlimitedduration excursion limits Depth Rate of decompression Min depth Max depth Distance X m-100m l.5m/Hr 42M 62M 20M 100m-10 m I m/Hr 't4M 52M 22M l0 m-0m 0. 5m/hr

Vol. No. 2 128 Jour Marine Medical Societv,2a06, 8, Jour I N{.These oral fluid [9]. When the affecteddiver is in theSDC, REFERENCES lrs ln case the managementbecomes more difficult dueto vari- l JamesT, Francis R. Mitchell J. Pathophysiology o1' ous additional factors like difficulty in DCS. In: Bennet PB, Elliot DH, eds. The physiology and medicine of diving. 4'h edition. London: WB ivingvar- communicationdue to Donald Duck effect of He- SaunderslI 993:433-53. yal Navy, lium, limited food and water supply.The climatic US Navy Diving Manual, Vol th bounce 5, Revision4. Diving conditionslike temperatureand humidity arediffi- Medicine and RecompressionChamber Operations. The 3 [3]. cult to manage.Temperature is maintainedby BR 2806 (Supplement) Procedure for Deep and itsare ad- physicallypouring cold waterand humidity is con- SaturationDiving. Revised 1987 edition. of DCSis trolled using silica crystalsand CO, scrubber.The Cook SF, Environmental factors affecting CSwhich PPO, and PPCO2are monitored using the portable decompressionsickness. Part lll. Role of exercise. rccidental analysersand maintainedby using CO, scrubber temperature,drugs and water balance in decompression -imitsetc. sickness.In Fulton JF, ed. Decompressionsickness. andaddition of Oxygen.As itentails a lot of physi- Philadclphia:WB Saunders:l95l:223-41 . ndividual cal and psychological stresson the diver,the diver Cross SJ, Evans SA, Thomson LF, et al. Safety of :Iypother- should be comforted and reassuredperiodically subaquadiving with patent foramen ovale. BR Med J en ovale, during the treatment.On surfacinga thoroughclini- 1992.304 481-482. e(PPCO,) cal examinationshould be carried out with special Dunford R. Hayward J. Venous gas bubbles production ,o,) [4-6]. emphasison the Respiratory,Cardiovascular and following cold stress during a no decompressiondive. ixcursion, Neurologicalsystem. A postdive chestX-ray, ECG Undcrsea Bionrcd Re.r l98l :8:41-49. om depth and a PFT should invariably be carried out in all Para 0678, Fig 6-2 UK Navy Diving Manual (Supplement).Emergency procedures. of presen- casesof DCS during SaturationDiving [0]. ACT / 8. Van Liew HD, Ray Chaudhri S. Stabilisedbubbles in the -imbPain. MRI scanof Head lungs required and may be rn body pressure-radiusrelaiionship and the limits to ly Recog- Type2 DCS caseslike Respiratoryand Neurologr- stabilization.J Appl Pltvsiol 199'1,82:2O45-53. mergency cal DCS [0,] l]. The diver hasto be kept nearthe o BoussugesA. Haemoconcentrationin Neurological :ialistand chamberfor at least04 hrs and a further 24-48hrs DCS. lnr J SportsMed 19961'l7 (5):351-55. rf DCS at within 30 min of travelingtime to thechamber [3]. He IO Koch GH. Weisbrod GL, Lepawsky M, et al. Chest rgManual shouldnot dive for a periodof 3-7 daysfollowing an radiograph can assist in diagnosis of Pulmonary (Suppl) ,edduring incidentof Typel DCS Flying in aircraftswith Barotrauma.Uttdersea Bioned Res l99l:18 [3,12]. :100 rld beim- pressure< 1ATAshould be avoidedfor at least02 - teofl5mi ll Moon RE. Massey EN, Debatin JF, et al. Radiographic 04 days,though it may be modified accordingto the lmaging in Neurological Decompressiot"illness. in caseof degreeof severity [3]. Recunence of symptoms UnderseaBioned Res l9 (Suppl): 42.8.Article 0677. increased can occur at any time during the treatmentor on Chapter 6 rdiver can surfacing,and shouldbe treatedpromptly. A survey t2 Verma V, Mishra K, Bajaj R. et al. Decompression :mixhav- carriedout by the Diver's Alert Network (DAN) sug- Sicknessthree unexpectedcases. lour Marine Medical Sorielv 20O5:7 : 2. diverhas geststhat completeresolution of symptomsoccurs l-) Robyn Walker Decompression Sickness : Treatment. : depthof i n only 56Vo cases, | 8Vohad neurologi cal complai nts In Edmond C and Lowry C. Diving and Subaquatic mpressed and lTVocontinue to experiencepain [4]. Medicine 4'r'edition (Table2). 'ried 14. Thalmann ED, Dunkan R, Dovenbarge J. DCI what is out. it & what is the treatment. DAN Report 1994. plentyof

t\.8, No.2 Jour.Marine Medical Society,2006, Vol.8, No.2 129 LESSONSFOR MENTAL HEALTH FROM 26 JIJLYDELUGE : MUMBAI

Surg CdrAIAhmed'

ABSTRACT Increasingly, trauma and disasters are part of everyday lifc. The psychological nceds of the victims and their ll help-providers in the aftermath of disasters are just bcginning to be understood. A host of psychological and behavioral responses are seen in adults following trauma and disaster like angcr, disbelief, sadness, anxiety' fear, irritability, arousal, numbing, sleep disturbance, and increases in alcohol, caffeine, and tobacco use, Post- Fig traumatic Stress Disorder (PTSD). Acute Stress Disorder

This paper by way of two case reports highlights thc likely presentation and the strategy to address the psychological concomitants of disaster amongst the victirns. It would include tcchniques for management of stress

Kcy Words: Disaster, PTSD, Critical Incident Stress Dcbriefing (CISD)

INTRODUCTION concentration.Mood swings.Troubling dreams,sadness and clcprcssionof 3 daysduration follorving being caught up in a traumaand disasters are part of eve Jncreasingly,a -' car in thc deluge. Iryday life [ ]. "The devastatingeffects of natural disasterscan have tremendouspsychological im- CASE- B pactson thoseaffected," said Anthony T. Ng, M.D., 6l year old female brought in mid- August with history of chairof theAPA Committeeon thePsychiatric Di- being Numb/Emotionallyshut down, irritable, easily i frustratedinsecure of insidiousonset and progressively i Fir mensionsof Disaster."Affected indiviciualsmay worsening.She had repetitiveintrusive memories of the t have various stressreactions that presentpsycho- trauma, avoided going on the road where she was caught up t logical,as well asphysical symptoms. Psychiatrists in the floods and exhibitedstartle response. She was being can play an importantrole in assistingindividuals fearful, refusing to go near the bcach and was unable to recall the datc of the floods or where shc was caught up. and communitiesto recover.They bring a unique There was loss of interest in any activities and she was setof skills andexperiences that can be invaluable having fitlul sleep.She expresseduncertainty about future. in minimizingmorbidity and facilitatingrecovery. This paperdiscusses psychological, physiological DISCUSSION and behavioralresponses encountered in the after- Critical Incident StressDebriefing (CISD) mathof the26 Jul 2005downpour disaster in Mumbai Goals were to reduce the impact of the crisis/ and the ways a psychiatristcan contributeby Com- traumaticevent, provide an opportunityfor cathar- munity participationin addition to the role as a sis, opportunity to verbalizetrauma. accelerate clinicianin disastersituations. normalrecovery process, provide group support and CASES peersupport and opportunityfbr follow-up. (CISD)is CASE.A TheCritical Incident Stress Debriefing a 7 stepprocess: l. Introduction,2. Fact,3. Thought, 42 year old lady under OPD psychiatric care for Mixed for past I year presentedon 29 4. Reaction,5.Symptom.6. Teaching, T. Re-entry anxiety depressivedisorder t Jul 2005 to casualty with worsening of her condition. She l. Introduction-To introducethe doctorand his t presentedwith physical symptoms of pounding heart, experience,explain process,establish sweating, flushing, shortnessof breath/hyperventilationand I chest pains. She reported Horror, Confusion, Poor expectations,ground rules.

'Classified Specialist(Psy), Instituteof Naval Medicine. INHS Asvini, RC Church Colaba. Mumbai- 400 005

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2. Fact - To describe traumatic event from each o Physicalexercise, e.g.: walking, jogging, participant'sperspective on a cognitive level swimming,sports, etc. 3. Thought- To allow participantsto describe o Sex& sexualorgasm cognitive reactionsand to transition to o Catharsis,e.g. yelling into a pillow or inside emotionalreactions thecar, in the foresUwoods,throwing stones 4. Reaction-To identity the most traumatic aspect into the river, etc. of the event for the participants and identify emotionalreactions. Pharmacotherapy not 5. Symptom- To identify personalsymptoms of Use ofdrugs should be delayedunnecessar- ily. B neededto be prescribedmedication at distressand transitionback to cognitive level. Case the outset.The drug of choice areTricyclic antide- 6. Teaching-To educateas to normal reactions pressants(TCAs) e.g.Imipramine, Amitryptilline. and adaptive coping mechanisms,i.e. stress AlternativelySSRIs may be useddepending on the managementand provide cognitive anchor sideeffect profile. 7. Re-entry- To clarify ambiguities,prepare for In disastersituations, the vastmajority of people termination,to facilitate psychologicalclosure", will experiencetransient psychological and i.e. reconstruction. behavioralsymptoms that representnormal re- Managementof Stress sponsesto an abnormalevent. In disastersettings, then, care is given to avoid the use of diagnostic 4 major techniques: labels prematurely.As in case A the diagnosis of l. Techniques to avoid or reduce exposure to PTSD was not offered and she respondedto the StTESS stepsof CISD without any needfor revision/ addi- 2. Techniques to re-appraise or re-interpret tion of medication.In the acute phase,the stressors. psychiatristprimarily educatesand facilitates the 3. Techniques to reduce stress arousal natural recovery processrather than treating pathology. In the acute aftermath of a disaster or 4. Techniquesto ventilate the stressarousal trauma, the psychiatrist must be alert to organic (a)Techniquesto avoid or reduceexposure to mentaldisorders secondary to headinjury, toxic ex- stress posure,illness, and dehydration.Persistence of o Problemsolving symptomsover time, accompaniedby a high level o Timemanagement of severityand impaired function, can leadto a wide variety of psychiatricdiagnoses. Post-traumatic o Nutritionaltechniques StressDisorder (PTSD) is, perhaps,the best-known o Avoiding known stressors psychiatricdiagnosis that is associatedwith trauma (b)Techniquesto re-appraiseor re-interpret response.It is characterizedby exposureto a seri- STTESSOTS ous event in which threat to life or physical injury o Cognitivereframing (to self or others) is accompaniedby intense feel- ings such as terror, helplessness,or fear and o Psychotherapy [2] needsspecific management. (c)Techniquesto reduce stressarousal Other psychiatricdiagnoses are also seenin the o Propersleep pattems, i.e.: sleepduring the aftermathof significant trauma.These include ad- night and awake& active during the day. justment disorders,substance use disorders o Relaxation response training, e.g.: (including increasedtobacco use), major depression, meditation, imagery,biofeedback, etc. complicatedbereavement, and generalizedanxiety o Prescriptionof anxiolytic medications disorders.Importantly, injured survivors may have psychologicalfactors affecting their physical con- (d)Techniquesto ventilate the stressarousal dition [3-7].Psychiatrists and physicians should also

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be alert to the occurrenceof family violencein dis- Holloway HC, Ursano RJ. The Vietnam veteran: aster situations that bring significant stressorsto memory, social context, and metaphot. P.rvchiatry 1984: 41(2): 103-8. families[8]. Shore JH, Tatum EL, Vollmer WM. Psychiatric Threat to life has been shown to be associated reactionsto disaster:the Mount St. Helens experience. with perhapsthe highestrisk of psychiatricmorbid- Ameriran Journal of Psychiatry 1986: 143(5) : 90-5. ity [9,10]. Those persons who actually sustain 5 injuriesare at greaterrisk of developingpsychiatric 4. Shore JH, Vollmer WM, Tatum EL. Community patterns of posttraumatic stress disorders. Journal ol' sequelaethan those not injured. Exposure to the Nervous and Mental Disease 1989; 177(ll) : 681-5. dead and mutilated increases the potential for ad- 5. Kulka RA, SchlengerWE, Fairbank JA, et ai. Trauma versepsychiatric events I I I, l2]. and the Vietnam war generation: Report of findings The psychiatristalso needsto step out into the from the National Vietnam Veterans Readjustment Study. New York, NY USA: Brunner/Mazel, Inc. 1990. community and aid in Community Interventionsas follows: Consultationto community leaders 6. Smith EM. North CS. McCool RE. r,r a/. Acute postdisasterpsychiatric disorders: Identification of r Public educationand outreach persons at risk. Aneriran Journal of Psv(hiatrv 19901 l4'l(D : 202-6. o Interventionswith "At-Risk" Populations Goenjian A. A mental health relief program in Armenia o Longer-term Interventions- to perform outreach after the 1988 earthquake: Implementation and in thecommunity to increasethe likelihoodthat clinical observations.Eriti.rrr Jounwl of Psvchiutry those who are suffering psychiatric sequelae 19931163 :230-9. from the disasterseek appropriateassistance 8. Pynoos RS, Nader K. Issues in the treatment of posttraumaticstress in children and adolescents.in CONCLUSION International Handbook of Traumatic Stress Syndromes. Edited by Wilson JP, Raphael B. New York. There is an intimate relationshipbetween disas- Plenum Press, 1993. ter situationsand mental health.Psychiatrists have 9. Ursano RJ, Fullerton CS, Kao TC, et al. Longitudinal many important skills that can assistcommunities assessment of posttraumatic stress disorder and and individuals in the wake of catastrophe.Apart depressionafter exposure to traumatic death.Journal of Nervous and.Mental Disease 1995t 183 (l) : 36-42. from serving asaclinician, standardpsychiaffic prac- l0 Ursano RJ, McCarroll JE. The nature of a traumatic tice can be modified when a psychiatristleaves the stressor: Handling dead bodies. Journal o.f Nerwtus office. In disasterpsychiatry, outreach is key to more and Mental Disease 1990; 178 (6) : 396-8. effectively meetthe demandsof communitiesover- McCarroll JE, Fullerton CS, Ursano RJ, et al . whelmed by disasters.Involvement in disaster Posttraumatic stress symptoms following forensic planningis an excellentway for psychiatriststo help dental identification: Mt. Carmel. Waco. Texas. Anreriran Journal of Psychiatry 1996: 153 (6) : their communitiesprepare for the unthinkable. '778-82.

REFERENCFS 12. Fullerton CS, Ursano RJ, Kao T-C, et al. Disaster- related bereavement:Acute symptoms and subsequent l. Ursano RJ, Fullerton CS, Norwood AE. Psychiatric depression. Aviation, Space, and Environmerttal dimensions of disaster: patient care, community Medk'ine 1999:'70 (9) : 902-9. consultation, and preventive medicine. Harvard Review of Psychiatry 1995; 3(a) : 196-209.

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MANAGEMENTOF PARTIALANODONTIA _ A PROSTHODONTIC APPROACH

Surg Cdr (D)Arthana Khanna.

ABSTRACT

Partial Anodontia is not a clinical rarity. Multiple missing teeth pose a lot of functional and psychological problems. The management of a problem consists of proper diagnosis and deep insight into its etiology and treatment planning. Dental treatment is particularly important since oral and dental health are critical for normal mastication, diet, speech, facial appearance and esthetics. Completion of dental treatment often has a positive effect on the psychosocial well being of the patient.

Ovcrdenture therapy envisages essentially a preventive prosthodontic concept since it attempts to conserve the few remaining natural teeth. Overdentures hclp to partly ov€rcome many of the problems posed by conventional complete dentures like progressive bone loss, poor stability and retention, loss of periodontal proprioception and low masticatory efficiency.

This article is derived from hands on experience of two clinical cases taken up for rehabilitation and attempts to encapsulate the concepts in conservative and prosthetic dentistry with emphasis on clinical and laboratory procedures manned through abutment preparation, prcparation of copings and stages in fabrication of overdentures,

Key Words : Missing teeth, Aesthetics correction

INTRODUCTION the secondrelates to the continuing presenceof anodontiaor missing teeth pose many periodontalsensory mechanisms that guide and Dttiot I problemsto the affectedindividual viz esthetics, monitorgnathodynamic functions [3]. speechand function relatedto masticatoryefficiency. Overdentureshelp to overcome many of the The failure to developtooth buds can be the result problemsposed by complete dentures,like of many factors,which include trauma,nutritional progressivebone loss, poor stability and retention, deficiency,endocrine disturbances, rubella, syphilis, lossof periodontalproprioception, low masticatory scarletfever, radiation therapy and heredity.Over efficiency etc. [4]. Two casesare discussedin this 120 syndromeshave been found to be associated article, which were successfullymanaged with with congenitallymissing teeth. overdentures.The first case pertains to the Overdentureshave emergedto be the prime managementof ectodermaldysplasia syndrome (X- choicefor rehabilitationofcases ofpartial anodontia. linked hypohidrotic ectodermaldysplasia), which An overdentureis a removable prosthesis,either affectsI to 7 individualsper 10,0000.The casewas completeor partial,whose denture base covers one comprehensivelyrehabilitated with overdentures. or more natural teeth, or tooth roots []. Various The second case was diagnosedwith partial terms have been used to describe this treatment anodontia,including severeattrition of dentition, modality, such as overlay dentures,telescoped during a routine screeningas part of annualdental dentures, tooth supported dentures, hybrid examination.The case was rehabilitatedwith prosthesisand superimposingdentures etc. There telescopic overdentures,where the selected are two physiologic tenetsrelated to this therapy: abutmentteeth after being subjectedto endodontic the first concerns the continued preservationof therapywere coveredby castcopings. The support alveolarbone around the retainedteeth [2]. While and frictional retention for the prosthesiswas 'Graded Specialist(Prosthodontics), Dental Centre, INHS Kalyani, Visakhapatnam,Pin: 530014

Jour Marine Medical Society, 2006, Vol.8, No.2 r33 providedby secondarycast copingsfitting over primarycopings and were incorporated as an integral part of the denture.

CASE I 7 Case History , A 15 yrs dld female patient who was awareof her missing teeth which were harnperingher speechand looks causing f' inability to chew and speakproperly reported!o the Dental OPD with a chief complaintof missingdentition. Dental history revealedthat rehabilitation in the form of acrylic removablepartial dentureswas done earlier but the patient did not find the prosthesiscomfortable. Clinical history revealedthat the patientwas a caseof ectodermaldysplasia with partial anodontia.Though she did not exhibit the classicfeatures of eclodermaldysplasia i.e. saddlenose, frontal bossing,etc., the pdtient did have some features suggestiveof ED i.e. dry thin skin and fine sparsehair (Fig Fig.2: PreoperativeLateral profile (Case l). I & 2). However,there was Do palmer or plantarkeratosrs. Extraoralexamination rcvealed that the patienthad a depressednasal bridge, and wrinkling of skin aroundthe mouth. TMJ and mandibular movem€ntswere normal. Intraoral examinationrevealed that the patient had a total of only 12 teeth (Fig 3). There were 4 anteriorteeth in the maxilla, 6 anteiior teeth and 2 permanentmolars were presentin the mandible.Radiographic examination revealed that there were no impactedteeth or any osseousor skeletal abnormality.No other soft tissue abnormalitieswere detected.

Treatment Procedure The primaryimpression of the upperand lowerjaws was Fig.3: Intraoralview. made in alginate impressionmaterial and poured in stone plaster.Maxillary special tray was fabricatedfor definitive Thereafter the casts were surveyed and undercuts were impression.The edentr,rlouspart was recordedin Zinc oxide blocked on teeth as well as tissues. Record bases were jaw eugenolimpression material aod the dentulouspart was fabricated and relations were recorded. The selected recordedin alginate. Both the trays were removed teeth were set in wax, though it was a difficult task to simultaneouslyto obtain a dual maxillary impression. arrange the teeth since they had to be reduced to the thickness of the veneers to achieve optimum aesthetics and function. During the try in, aeshetics, occlusion and phonetics was evaluated. The dentures were processed in the heat cure acrylic resin in the usual manner. The prosthesis was linished and polished (Fig. a). The dentures were thereafter inserted in the patient's mouth to check the occlusion and extensions. Recall appointments were scheduled for 24 hrs, one week, two weeks and any minor adjustments were made, up to the patient's satisfaction. The maxillary and mandibular overdentures had adequate retention and there was marked improvement in the facial appearance of the young girl (Figs. 5 & 6).

CASE 2

CaseHistory The patientwas a servingsailor, 45 yrs old, who reported to the DentalOPD for annualdental examination and was found to be unfit due to inadequate dental points. The patient Fig. I : heoperativefrontal profrle (Case l). had symmetric straight profile and competent lips (Fig. 7).

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rnd their f Eicaland anxiety, lse,Post- Fig. 4 : Intagliosurface of dentures.

Fig.7 : Preoperativefrontal profile (Case2). lressthe ementof

.dnessand tht up in a

Fig.8: Secondarycopings in situ history of examination was performed and there were no impacted Le.easily '{ teeth. No osseousdefects were detectedand the canines had ;ressively Fig.5: Postoperativefrontal profile (Case l). about 7 mm of residual bone support. ies of the caughtup Treatment Procedure wasbeing ,l The abutments were prepared to a height of 3mm unableto occlusogingivally.Taper of about 7-8" was given and apical aughtup. chamfer was made at the dentogingival junction. I she was Antirotational element was prepared in the canal. Post and )ut future. Core patterns were fabricated and cast in NiCr alloys. Primary copings were cemented with Glassionomer cement. Impression was made in rubber base impression material (with primary copings in situ). Wax patterns were fabricated and secondarycopings were cast in NiCr alloy. The copings e crisis/ were tried on the patient's abutment teeth and were fixed "cathar- with copalite varnish (Fig. 8). Impression was made with regular body oelerate silicone impression material. Dentures were fabricated in the conventional manner with high impact portand resin (Lucitone). Fit, extension, occlusion of the ). overdentures was checked. The secondary copings were Fig 6: Postoperative Lateral profile (Case 1). embedded in the denture base with self curing resin flowing )ISD)is of consistency. Vents were made on the denture in the area of 'hought, There were no signs of abnormality of hair, eye and tear abutment teeth. Excess material (resin) visible at the vents secretions. TMJ and mandibular movements were normal. -entry was removed and the dentures were finished and polished Intraoral examination revealed that the patient had a total (Fig.9). Post insertionprotocol was explained to the parient. of only 16 teeth. Dental history revealed that the patient andhis I The patient was satisfied with apperanceand results of the did not undergo any extractions in the past. There was tablish treatment (Fig. l0). mobility of all the teeth except maxillary and mandibular ,1 canines. DISCUSSION There was also evidence of generalized attrition. However The salient the canines had a good periodontal status with no mobility considerationin deciding the and no gingival recession. A complete-radiographic treatmentobjective in our first case (ectodermal

8,No.2 Jour Marinc Medical Society, 2006, Vol.8, No.2 135 LESSC

Surg Cdr,

ABSTRAC'

Increasingl help-provir behavioral I'car, irritai traumatic I Fi-c.l0 : Postopelativetiontal profile (Case.2). This papcr psychologir Fig.9: lntagliosurface ofdentures. flrroricte strcss massagewith toothbrush,use of the dysplasia)was that the patient'sresidual dentition toothpasteand mouthwash,r'emoval cl - .' at Kcy Words was not to be modified at this stage.We wantedto nightand recall visits which are also very i:..portant. fabricatea prosthesiswhich was cost effectiveand SUMMAITY could also be easily acceptedby the patientbefore INTRODU executionof the extensivetreatment. In the second Overdenture constitutes a preventive prosthodonticconcept and this modalityshould be ]ncreasinl caseour treatmentobjectives were to conservethe Iryday lifr healthy dentition,enhancement of retentionand consideredvirtually tbr everypatient with multiple disastersci stabilityof thedenture and also the improvement in r.nissingteeth and tor whom full mouthextractions pactson th( speechand mastication of the patient. havebeen planned. The overdentureshave plenty chairof the of advarrtagesi.e. preservationof residuallidge. Retentionof teeth is meansof alveolarridge mensions( pfeservatiorlclf ploprioceptive impulses, enhanced preservation.Residual Ridge Resorption (RRR) afier have varior retention,stability and most importantlygives a tooth loss was chronic, progressive,cumulative, logical,as r psychologicalboost to the patient. irreversible,and perhaps inevitable Retentionof can play an [5]. the root meansmore thanjust preservingthe l'oot and comml IiEI'I'ITENCES (physicalretention). In essence,this action setof skills I . Miller PA. Cornpletedentures supported by natural presefvesan integral componentof the sensory .l Proslltct Dant 1958l.8 : 924. in minimizi tcetlt. feedbacksystem that programsthe masticatory This paper 2. Prince lll. Conservationof supporting mechunisnr../ systemthroughout the patient'slife. Periodontal Prq.\tlt(tDatrt 1965 l5 : 327. and behavi< receptorinput is also protectivesince it monitors 3. YalisoveIL. Crown and sleevt'- coping rctainctsfor math of the I theteeth against overloading [6]. Caninesare richly renrovablepaltial prosthesis.J Prrtstlttt Dartl l,966. and the way l6 : 1069. innervated,most sensitiveand are preferredas munity par .1. abutmentsas was seenin our secondcase. Reitz PV.Weincr MG. Levin B. An oveldentulesurvcy: clinicianin Preliminary report. ./ Prosthct Dattr l9'l'7. 3'7 : However,the disadvantagesof overdenture 246-58. CASES therapycannot be ignoredi.e. periodontal breakdown 5. Atwood DA. Reductionof r-esidualtidges: A tna.jororal reducedinterocclusal diseascentity. J Prtt.slltatDertt l9lll- 26 : 266. CASE-A of teeth.carries susceptibility, distance.Further, most of the disadvantagescan be 6. Pacel FJ. Bowman DC. Occlusal force discriminatittn 42 year old I bv denturenatisnts. J ProsthetDent 1975. 33: 602-9. anxiety depres preventedby diligentlyfollowing the post insertion Jul 2005 to c: protocol by the patient i.e. gentle cleaning and presentedwi sweating, flusl chest pains.

"ClassifiedSpr t30 I -1(t .lour Marinc Medical Soc'ietv.2006. Vol.8. No.2 DECEMBER2006 Registeredwith Registrar of news paper fbr lndia Reg. No. 69828199