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Agar firdaus bar roo-e zameenast, Hameenast-o hameenast-o hameenast” If there is heaven on earth, it’s here, it’s here, it’s here!

It is here in Kashmir, the distant North, where exists a paradise called“Gurez”. Away from the hustles and noises of modern-day life, peace exists amidst the mesmerizing sounds of gurgling cold waters, gushing springs, and divine music of rustling leaves. There is some kind of serenity and freshness in the very air we breathe here. By virtue of being a doctor by profession, soon I started interacting with the valley. Activities like ‘Doctor on foot’ and lately Tele-medicine and Tele-consultation. Then came winters, the first one for me in the valley. Seeing snowfall for the first time I was amazed by the beauty of nature. The pristine streams running through the gorges and snow- clad mountains provided me with immense opportunities of photography and adventure activities.

These winters were not just going to pass by like a lullaby, soon I started to realize the continuous snowfall and precipitation has led to cutting off of the routes and the temperatures dipped sub-zero. Although I as an RMO had already prepared the winter cut-off posts of unit with advanced winter stockings of medicines and diligently posted Nursing Assistants at these locations, yet these severe weather conditions were always a cause of worry me for any looming casualty. On 10 Feb 2021, I got a call from a Nursing Assistant at one of the highest post of our unit. It was not a regular reporting call. Panicking my Nursing Assistant explained about a Sepoy at his post. This individual reported to MI Room with complains of fingers of both of his hands turning white having tingling sensations. The communication line for tele medicine was also broken, so on ground it was just the Nursing Assistant to treat and manage the patient with help of RMO on telephone line.

By next morning, the Wi-Fi was functional and I could speak with the Nursing Assistant over a video call. I carefully took the history and observed the patient for a while,the most probable diagnosis of chill blains or frost bite was not evident from what I could make out of the video call. Therefore I asked the Nursing Assistant to send some good quality photos of the same and continue the first aid. Upon receiving the photographs, an afternoon surgery lecture at AFMC flashed through my memory labyrinths. Could this be a case of Raynaud’s Disease?

Raynaud's is characterized by intermittent attacks of blanching or cyanosis of the digits,which is usually precipitated by exposure to cold temperatures and/or emotional upset. It primarily affects the fingers,usually distal to the knuckles and less commonly the toes, these attacks may last from minutes to hours and are relatively benign in most patients.

The affected digits often feel cold and numb and there is a typical triphasic series of skin color change,which proceeds from pallor (white)to cyanosis (blue) to reactive hyperemia (red). Raynaud's is diagnosed primarily by a history of these classic symptoms and finding of a history of exposure to environmental stress. No single office or laboratory test confirms the diagnosis. The history provided and now the photographs have made the diagnosis confirmed. I passed the instructions to Nursing Assistant and then discussed the case with Medical Specialist who suggested to evacuate the patient. Now because of the bad weather and winter cut-off post, the casualty evacuation couldn’t happen for next 4-5 days, a bit anxious I relied upon the inputs from my Nursing Assistant and continued the first aid and management of the same. Once the weather was clear and the patient was evacuated to hospital his symptoms had already improved and the diagnosis of something which we never see often was confirmed by the specialist. Thus, adding to the list of many mysteries of Gurez, I was able to discover with a hope of unraveling many more in coming days.

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