Sri Lanka

Combat-Related Geography, Terrain, and Weather

The conflict zone comprised heterogeneous vegetation types: semiarid flat land with tropical thorn forests, dry evergreen jungles, and bush-type vegetation. Occasionally, heavy fighting erupted in coastal areas where there was minimal cover, which took a heavy toll on both sides due to concentrated artillery fire. In the urban and suburban terrains where close-range fighting occurred, injuries sustained were predominantly due to small arms fire. In the last phase of war, a unique strategy used by the LTTE cadre was to build 10-meter-high earth bunds-cum-ditches; the bunds were saturated with improvised antipersonnel mines (iAPMs) causing multiple deaths and limb losses ( Fig. 29.2 ).

Furthermore, the areas concerned were afflicted with seasonal North-Eastern monsoon rain from December to February. Therefore, the terrain became water-logged, thus making casualty evacuation extremely challenging. This in turn led to delay in admissions to role 3 military base hospitals (MBHs). At other times, the scorching sun caused heatstroke to the combatants, particularly during the mass withdrawal of the 3rd Eelam war.

War Tactics and Weapons

During the 26 years of protracted war in Sri Lanka, there were four main phases, with intervening periods of lesser activity and intensity, especially during ceasefire. During the active phases, forces engaged in conventional war with a defined front line. They used high-velocity rifles (AK-47 and T-56), rocket-propelled grenades, 60-, 81-, and 120-mm mortars, and heavy artillery including 122-, 130-, and 152-mm howitzers. “No man’s land” was seeded with iAPMs with the aim of maiming rather than killing soldiers. Unique to tiger guerrillas were improvised devises connecting multiple blast components together to inflict severe injuries on a number of victims at a given time. In addition, claymore mines were used; these fire steel balls in a 60-degree arc, inflicting heavy damage to dismounted troops.

APMs inflicted heavy tolls on infantry troops, which resulted in a large number of amputations and there are around 6000 post-war amputees in the Sri Lankan Army. Most of these APMs were locally manufactured and referred as “Jony mines” and intended to be triggered by the victim stepping on it. The shock from the explosion drives dirt, clothing, metal, and plastic fragments into the soft tissues with the ballistic effect causing blood vessels to thrombose extensively beyond the visible injury zone. This in turn leads to ischemic and contaminated musculofascial layers at a high risk of infection and sepsis. Most of these victims ended up with below-knee amputations and post-conflict rehabilitation of these amputees is a challenging task in a resource-poor setting. Furthermore, the indiscriminate nature of these mines caused civilian and animal injuries during the war and post-war period.

In a single-surgeon experience spanning a period of 26 months commencing from June 1st, 1990, there were 191 victims of APM injuries. In this cohort, 153 (80%) were victims of direct injuries to lower limbs (due to stepping on an APM) and 24 (12.6%) had shrapnel injury in multiple body regions by being close to the explosion. Ten (5.2%) had injuries sustained while handling APMs and four victim’s data was not adequate for analysis. Of the 191, 113 (73%) underwent below-knee amputation.

In September 1997, with the clear aim of ending the suffering caused by APMs, the Antipersonnel Mine Ban Convention was adopted by 133 signatories under the auspices of the United Nations.

Demographics

In the last phase of the civil war, an incidence of vascular injuries of 2.2% was reported in 5821 security personnel injured between December 2008 and June 2009. High- velocity rifle bullets (65/128) and natural and preformed explosive fragments (52/128) were responsible for combined arterial and venous injuries in 58 patients, arterial injuries in 53, isolated major venous injuries in 11, and nonaxial vessel injuries in 4. Injury types included 73 transections, 24 lacerations, 13 thromboses, 4 through-and-through injuries, and 1 case of arterial spasm. Reconstruction with interposition vein graft (IPVG) was the commonest mode of repair (80/128) ( Fig. 29.3 ).

Medical

The first line of care was sited in close proximity to the front line for provision of basic casualty care immediately after injury ( Fig. 29.4A ). This primary care included arrest of bleeding, establishment of intravenous access, pain relief, and fracture immobilization. A variety of tourniquet types were used to manage severely mangled extremities, from a piece of twined cloth to improvised military tourniquets consisting of a belt and a buckle.

The second line of care consisted of advance dressing stations (ADS) ( Fig. 29.4B ), main dressing stations (MDS), and field hospitals. ADS facilities were sited equidistant from three forward regimental aid points, around 400 to 5000 m behind the front line. Typical ADS manning included a single medical officer, two nurses, and three nurse assistants who were equipped and trained to handle emergency combat resuscitation, including intubation, chest-drain insertion, arrest of bleeding, and infusion of intravenous fluids. A single MDS facility was sited behind three ADSs, and had capability to stabilize and airlift casualties to definitive care facilities. MDSs were manned by one senior medical officer, four nurses, six nurse assistants, and other supportive care personnel. Staff at the MDS had the capacity to transfuse uncrossmatched group O blood and to perform basic lifesaving surgical procedures such as tracheotomies, emergency amputations, and wound exploration to achieve hemostasis.

The third line of care were MBHs and general hos-pitals capable of delivering definitive surgical care via specialized services that included vascular, orthopedic, oral-maxillofacial, neurosurgical, and intensive care unit facilities. In 2008–09, the MBH in Anuradhapura, situated 180 km away from the conflict zone, was converted to a center for definitive extremity vascular care. General surgeons trained in vascular surgery were deployed to this hospital to minimize the delay in revascularization. The MBH was equipped with two operating theaters ( Fig. 29.4C ), a three-bed intensive care unit, and an 80-bed ward.

Complex vascular injuries that required combined orthopedic and reconstructive services were transferred to Colombo Army Hospital (CAH) and the National Hospital of Sri Lanka (NHSL), situated 199 km from Anuradhapura (equivalent to 5–6 hours of travelling time by road). All injured combatants ultimately ended up in CAH and Ragama Rehabilitation Hospital where they underwent rehabilitation.