MILITARY SURGERY

A civilian surgeon’s perspective in managing missile injuries in Sri Lanka

Dr Gamini Goonetilleke  FRCS

Southern insurrection 1971

While the Southern insurrection in 1971 led to an increase in the number of patients with gunshot injuries admitted to our hospitals, they were injuries caused by shot guns and home- made weapons called “galkatas”. My memories of this conflict dates back to the time I was a third year medical student at the Faculty of Medicine, Colombo. I remember seeing these patients being admitted to the Accident Service of the then General Hospital, Colombo for treatment. There is a lack of documentation about these injuries in the medical journals in Sri Lanka and therefore I am unable to describe anything more. I suppose they did not pose problems for the surgeons and the resources of our civilian hospitals as the numbers were small and distributed throughout the hospitals in the South of the country.

Trap guns

Trap guns are locally made illicit weapons used by the farmers in rural chena cultivations to kill or injure wild animals that enter their cultivations. These guns may on occasions injure fellow farmers who may accidentally activate the trigger mechanism. These are low velocity injuries usually causing injury to the lower limbs but other parts of the body may also be injured. These injuries are contaminated and require early surgery. They were common in the District of Polonnaruwa. Some may end up with amputations. Death is a rare possibility.

North- East conflict

 If the Southern insurrection was bloody and traumatic, the one that followed in 1983 was savage and brutal lasting till mid May 2009. The conflict during the period from 1983 to 2009 May resulted in an unprecedented increase in the number of patients admitted to our hospitals injured by various types of high velocity missiles and explosive devices hitherto not seen in this island nation.

This was brought about by the North-East conflict together with the Southern insurrection in 1989. These injuries contributed to a large number of trauma victims admitted to our hospitals and according to the bulletin of The Ministry of Health, trauma accounts for the highest number of admissions to our hospitals since 1995.

Although the victims of the North- East conflict were armed forces personnel and terrorists of the Liberation Tigers of Tamil Ealam, a significant number of civilians from both sides of the divide were injured or killed. The accurate number of the injured and killed is not known and will never be known. The conflict also resulted in massive destruction, displacement of people and refugees. With the end of the war in May 2009 a large number of civilians had to be cared for in makeshift camps and the health issues in these camps added a further burden on the resources of the Health Department which I will not discuss in this brief article.

Hospitals used for management of casualties

The hospitals used for the treatment of these victims were both civilian and military. These included the Military Hospital in Colombo, the National Hospital of Sri Lanka, The Sri Jayewardenapura General Hospital, General Hospital Anuradhapura, Base Hospital Polonnaruwa, Base Hospital at Palaly, Jaffna and to a lesser extent hospitals at Kalubowila, Ragama and Kandy when the resources of the other hospitals were exhausted. In fact military wards were established at Anuradhapura for casualties from the North and another at Polonnaruwa for the casualties from the East. The Hospitals at Trincomalee, Batticaloa and Ampara were hardly used for security reasons. The Teaching Hospital in Jaffna was not used by the armed forces for obvious reasons, but was used by the LTTE during the time of the Peace Process.

Base Hospital, Palaly,

situated within the high security Jaffna Military Base was the centre for the admission, resuscitation and initial stabilisation of the wounded armed forces casualties from the Northern Front. This Military Base was not accessible by road. Transportation of troops and everything else to this base was by air or sea. Civilian and military medical teams providing care to the casualties at Base Hospital Palaly had to travel by air. This was in Y8 and Y12 Chinese built transport planes initially and later on in British built Avro 748 and the Antonov 32B.  I remember travelling in these planes to Jaffna and back on several occasions.

Flights to Jaffna

The flights operated from Ratmalana airport to Jaffna. It was exciting, dangerous and risky. After a security check we embark the plane with our luggage. The flight was multipurpose: carrying medical teams, armed forces personnel going back for duty after their vacation, stocks of arms, ammunition and other munitions, vegetables and provisions etc. In order to accommodate all these items, many were the occasions where the seats were removed to give extra space. Thus we had to travel sitting on the floor of the plane and sometimes sitting on “barrel bombs”.

Air crashes

Although the flights operated over land, the destruction of some planes by missiles in April 1995 led to diversion of flying over the sea towards India and coming back and landing at the Palaly air strip protected by naval gunboats at sea.

The return trip to Colombo was even more hazardous. This time it was with the military casualties on their way to the hospitals in Colombo together with dead soldiers in polythene bags, referred to as “body bags” by the soldiers. These soldiers had made the supreme sacrifice in the fight to eliminate terrorism from the country and were on their last journey home and had to be treated with respect. The addition of more planes for transport with time eased the burden somewhat although the journey was still hazardous.

Deficient medical manpower

There was a dearth of surgeons in the armed forces at that time and many civilian surgeons volunteered to help in these hospitals, especially the one at Palaly, Jaffna which was the front line hospital for the victims in the Jaffna peninsula. There were no trauma teams and most of the casualties were treated by General Surgeons and sometimes it was left to a single surgeon to tackle a large number of casualties. In fact, we were not prepared to manage military casualties in our hospitals in the early phase of the conflict.

Learning the principles of managing war wounds

Military surgery is a different subject and was neither taught in medical schools nor in postgraduate courses at that time. Therefore, surgeons managing these casualties had to learn on the job and through experience. There were other avenues to learn as well. Reading journal articles on the management of war wounds in various conflicts around the world also enhanced our knowledge. Workshopsin the management of war injuries were conducted by The College of Surgeons together with the Military and The International Committee of the Red Cross in 2001, 2002 and 2003 in Colombo and Anuradhapura. These were well attended. Surgeons with experience in the management of the war wounded from US, Israel etc visited Sri Lanka to impart their knowledge to the local surgeons and gradually we learnt the correct techniques of care. Scholarships were also offered to improve our knowledge and I am proud to be a recipient of one of those scholarships to Israel to learn the correct technique of amputation and rehabilitation of the amputee at the Sackler Faculty of Medicine, Tel Aviv, Israel. One might wonder how the terrorists managed their casualties. They too had their own hospitals, some underground, their medical teams comprised of qualified doctors as well as those fellow terrorists trained to be “doctors’ in jungle hideouts in the Wanni. Some of their injured were also transported across Palk Straits to hospitals in India for treatment.

First aid for the injured

At the beginning, the conflict in the North – East was essentially guerrilla warfare and providing first aid was not an easy task. But when planned military operations were carried out the Army had their first aid teams at the war front. These were designated Advance Dressing Stations (ADS) and their primary function was to provide first aid, especially arrest of bleeding by pressure dressings and fluid replacement. The casualties were then transported to the nearest hospital for emergency care. The first aid too improved with time, thus improving the prognosis for victims. Field hospitals were established in the front line in the latter part of the conflict especially in Ealam war 4. Doctors in these hospitals performed operations such as amputations and insertion of endotracheal tubes to maintain a compromised airway followed by despatch to a hospital for further surgery.

Transport of the injured

The transport of casualties from the field to the hospitals were also disorganised in the early stages. There was no proper system, with casualties being transported in whatever vehicles available. Ambulances were rarely used in the early stages. Transport of casualties from the North to Colombo and Anuradhapura was by air. Once the casualties reach the airports, a fleet of ambulances were ready to transport them to specially designated hospitals depending on the numbers and availability of beds.

Communication about the injured

Communication regarding the casualties as well as their numbers coming into hospital would have helped the surgical teams to be prepared. But most times there was a failure in communication resulting in the sudden arrival of casualties to hospitals resulting in the hospital being flooded with patients thus causing problems to the surgical teams as well as the administration. These problems were overcome after discussion so that the hospital could plan well ahead and await the arrival of casualties.

Triage

The unexpected explosion of bombs and other devices especially in the capital city of Colombo and other locations island wide added to the problems faced by the hospitals. These explosions resulted in mass casualty situations testing the resources of the hospitals up to the hilt. Mass casualty situations can be managed effectively only by the use of the principle of TRIAGE. This is a French term and means to sort out. This too was something new and had to be learnt with experience. Triage entails the selection of casualty according to the severity of the injury and then treating them to give the best care to the most. The two common priorities were those with bleeding and obstructed airway. This too was learnt with experience.

Weapons

The weapons used in the conflict consisted of various types of missiles and explosive devices. While the army used conventional weapons, the terrorists used not only conventional weapons but some seized from the army as well. They also had their armament factories in the jungles producing Improvised Explosive Devices which were lethal. The weapons consisted of high velocity machine guns such as the AK 47, T 56, M 16, long range artillery, rocket propelled grenades, grenades. mortars, land mines, sea mines, multi barrel launchers, booby trapped devices, anti-personnel mines etc. An improvised device called the Barrel Bomb was used by the armed forces. This was manufactured by the Air Force and consisted of half a tar barrel filled with explosives, closed with a fin on one side and a trigger mechanism on the other side. These were not very effective and could not be directed to the required site.

Injuries

The injuries caused by high velocity machine guns were different to low velocity in the sense that they caused extensive damage away from the bullet tract. This was the result of the bullet imparting its energy to the tissues resulting in the tissue vibrating outwards thus resulting in the formation of a cavity with negative pressure which sucks the dirt and bacteria into the cavity resulting in extensive contamination. The moving high velocity bullet also causes a shock wave which can result in structures away from the bullet track being injured. The surgeons should be aware of these mechanisms when treating high velocity bullet wounds and appropriate principles which I will mention later should be used in their management to prevent dangerous complications. 

Explosive devices  

Explosive devices caused injury by various mechanisms and they produced burn injuries, both flame and flash burns. Explosive devices also caused injury by shrapnel present within the device as well as those from the surroundings. These were penetrating injuries and were fatal when a vital organ was penetrated. The blast wave resulted in victims being torn apart and also produced injury to air containing organs. Thus, victims suffered deafness, others had shock lung syndrome resulting in acute difficulty in breathing, with blood-stained froth oozing out of the mouth and nose and needed positive pressure mechanical ventilation in intensive care units. Injury to the abdomen by the blast wave also resulted in acute abdominal injury with no obvious injury to the abdominal wall.

Mines

Mine warfare was also seen for the first time in Sri Lanka in this conflict. In fact, the first land mine that exploded on the 13^th of July 1983 at Tirunelvely in Jaffna resulted in the death of 13 soldiers leading to the so called “Black July” in Sri Lanka. Among the most horrendous injuries I have seen were those of the victims of mines. My first experience of treating mine victims was in July 1985 when I was the Consultant Surgeon at the Base Hospital, Polonnaruwa. An Army jeep carrying 6 soldiers was blown up on the main road at a place called Punani bordering the Batticaloa district. The jeep was blown up into pieces. Three soldiers died on the spot and their mutilated bodies were brought to the hospital mortuary. The other three soldiers sustained multiple injuries and were admitted to my ward for further care. The victims were decapitated, bodies were mangled and mutilated with traumatic amputations sometimes even beyond recognition. Land mines are defined as “any munition placed under or near the ground or other surface area and designed to be detonated by the presence, proximity of contact of a person or vehicle.’’

Antipersonnel mines

Antipersonnel mines are small in size and were specially targeted for the infantry. They had ruinous effects on the human body. They drive dirt, bacteria, clothing, metal and plastic fragments into the tissues causing serious infections. The shock wave from the exploding mine can destroy blood vessels located much higher than the site of the primary wound as a result of which surgeons had to amputate much higher than the level the injury was seen. The commonest method of triggering an antipersonnel mine was by stepping on it. Large numbers of these had an amputation below the knee. There were also those who were injured by handling mines. These victims had injuries to their hands, chest, abdomen and eyes. A significant number had their hands amputated, while injury to the eyes leading to blindness was not uncommon. The antipersonnel mine that was commonly used by the terrorists was called the Jony Mine and was equally effective. It cost only about US $ 2 to manufacture these devices, but the management of a victim would cost over Rs 1 million.

In Sri Lanka an estimated 1- 1.5 million antipersonnel mines had been laid in the North and East. One hundred and fifty sq. km of land was said to be contaminated with Jaffna peninsula being the most affected. The majority of the victims were males. A significant number of women and even children were injured. While combatants were injured during the war, the civilians often returning to their homes were the victims after the war. Programmes on mine awareness and demarcating areas that were likely to be affected combined with mine clearing activities have been useful in reducing the number wounded or killed after the conflict.

Principles of managing missile injuries

The principles of management of high velocity missile injuries are quite different to management of low velocity injuries. This is related to the fact that effects of temporary cavitation require a larger area to be debrided and the wounds left open in view of extensive contamination. All dead and devitalised tissues had to be excised and the wounds irrigated with saline thoroughly to get rid of particulate material. These principles were learnt and re-learnt by military surgeons in managing casualties in many wars throughout the world and was first learnt in World War 2.

This principle of treating war wounds caused by high velocity missiles is called delayed primary closure and had to be practiced by surgeons in Sri Lanka as well. This included the delayed closure of amputation stumps as well. Failure to practice this principle would result in wounds getting heavily infected with the danger of developing sepsis, gas gangrene and tetanus.

Data collection

Documentation, photographs of casualties taken at admission, during surgery and after recovery together with audit helped me in presenting many scientific papers locally as well as overseas thus helping in the dissemination of knowledge to others. The many publications that I have made on this subject have also enabled a comparison of the injured with those of other conflicts around the world.

Psychological aspects of war & physical rehabilitation

Victims of war suffer severe psychological trauma and need prolonged psychological rehabilitation. This includes not only physical rehabilitation but also psychological rehabilitation. Physical rehabilitation entails the provision of prosthesis for those who have lost limbs and rehabilitation of these victims so that they can lead a productive life. While those with lower limb amputations were rehabilitated satisfactorily, those with upper limb amputations did not receive “functional upper limbs’’

The lower limb prosthesis used consisted of many varieties . The “Jaipur limb” was used initially, followed by many other varieties of Japanese, German, Israel technologies which were much more expensive when compared to the Jaipur limb. The Jaipur limb was not only cheap but enabled the amputee to walk without shoes or slippers and he could even get back to the paddy field to cultivate. The majority of the civilians used the Jaipur limb, while the injured service personnel preferred the western style limbs manufactured at the rehabilitationcentre at Ragama.

Reconstructive surgery & rehabilitation

War leads to injury, death, disability and loss of function of vital regions of the body. The early phase of management of injuries has to be followed by repair, reconstruction and rehabilitation. This phase of reconstruction and rehabilitation has been undertaken by teams of surgeons. They comprise of orthopaedic surgeons, plastic and reconstructive surgeons and facio-maxillary surgeons drawn mainly from the National Hospital and the Military Hospital, Colombo.

There are also a significant number who are permanently disabled- totally blind, unconscious or paralysed. These are managed in special homes built and maintained by the armed forces. 

Another feature of victims of war both combatants and civilians is a syndrome called, Post Traumatic Stress Disorder (PTSD) which needs prolonged and extensive psychological support by experienced personnel rather than drugs used in the treatment of psychiatric patients.

In conclusion, three decades of conflict in Sri Lanka has caused a heavy burden on the people and the resources of the country. The medical personnel of the armed forces and the civilian medical personnel in government hospitals combined effectively in the management of the victims, while learning many lessons in military surgery which will be useful in treating the occasional missile injury that we may see in peace time in our hospitals.

Changes in military medical services

Following the war many changes have taken place in the Army Medical Services. A new hospital with over 1000 beds was opened in 2014 in Colombo to cater to the medical needs of the army personnel. Further expansion with all specialist facilities is envisaged in the near future.

A medical faculty was opened at The General Sir John Kotelawala University, Ratmalana in 2009 to produce more medical officers for the armed forces to avert a shortage in the future.  The Sri Lanka College of Military Medicine (SLCOMM) comprising all medical personnel (officers) in the Army, Navy and the Air Force has been established to take Military Medicine to a higher level in Sri Lanka. This College will be organising conferences, annual academic sessions, symposia, workshops etc in association with other sister Colleges in the country and overseas to develop the field of Military Medicine in Sri Lanka.