First Line of Care

The first line of care is sited very close to the front line for provision of basic casualty care immediately after injury. This primary care includes arrest of bleeding, establishment of intravenous access, pain relief, and fracture immobilization. There was a variety of types of tourniquets used, including a piece of twinned cloth to less-sophisticated military tourniquets consisting of a belt and buckle ( Fig. 26-4 ). Standard modern tourniquets were unavailable. The use of the former varieties of tourniquets was a lifesaving rather than a limb-saving exercise. Occasionally the lag time to reach a center for definitive vascular reconstruction was short enough to salvage the limb. The authors introduced intelligent packing to effectively control bleeding, replacing these tourniquets, while preserving collateral circulation to keep the limb viable.

Types of repair in 81 consecutive injuries at a civilian center.

PTEF, Polytetrafluoroethylene.

Second Line of Care

The second line of care consisted of the advance dressing station (ADS), the main dressing station (MDS), and field hospitals.

The ADS was sited close to three regimental aid points, sited 400 meters to 5 kilometers from the front line. It was manned by a single medical officer, two nurses, and three nurse assistants and was capable of emergency combat resuscitation, including intubation, chest-drain insertion, arrest of bleeding, and intravenous infusion of crystalloids.

Each MDS was sited close to 3 ADSs with the capability of stabilizing and airlifting casualties to specific care facilities. It was 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 uncross matched group O blood and to perform basic lifesaving surgical procedures such as tracheotomies, amputations, and wound exploration to achieve hemostasis.

Third Line of Care

The third line of care is the tertiary military base hospitals and general hospitals capable of definitive surgical care with specialized services that included vascular, cardiothoracic, and neurosurgical services supported by intensive care unit facilities.

In 2008-2009, the military base hospital (MBH) Anuradhapura, situated 180 kilometers from the conflict zone, was converted into a center for definitive extremity vascular care. General surgeons trained in vascular surgery were deployed to this hospital to minimize the delay to revascularization. The MBH was equipped with two operating theaters, a three-bed intensive care room, and an 80-bed ward ( Fig. 26-5 ).

(A, B, C) The military base hospital (MBH) Anuradhapura.

The civilian setting remains poorly organized. Prehospital care with ambulances is available in a few cities such as Colombo (the capital city) and Galle (a large city on the southern coast of the island). In Colombo and Galle, fire fighters and hospital ambulance staff, respectively, were trained and certified in prehospital care. However, the most common response to injury in Sri Lanka is the “scoop and run” method. Readily available transport facilities are commandeered to rush patients to hospitals, and these are often vans or the ubiquitous three-wheeler (also known as a “trishaw” or “tuk-tuk”), open-passenger transport vehicles. Patients are bundled into these small vehicles with little or no attention to the type, extent, and severity of injuries ( Fig. 26-6 ). Unlike the military system where discipline is a premium factor, the civilian system suffers from a lack of protocols. The quality of care given at first-contact hospitals, which are manned by medical officers or general surgeons, depends on many factors. Diagnostic acumen depends on the medical-school experience of the first contact doctor because only a minority of medical teaching hospitals provides a vascular service. The probability of the general surgeon attending to a vascular injury depends on his postgraduate training, commitment, and the workload in general. Thus most patients with a vascular injury are transferred to one of two vascular centers in Colombo or Kandy. In a study of 134 patients treated for extremity vascular trauma over a 9-month period, it was found that initiating wound débridement in the field contributed to significantly lower postoperative complication rates. The authors recommend pretransfer care consisting of early wound débridement, arrest of bleeding, and four-compartment fasciotomy. Compliance with such a protocol is unpredictable and generally poor, and there is no method to enforce this. Furthermore, in the case of mass casualties, it may not be possible for a single surgeon to deliver even basic care. In such instances, triage and transfer as quickly as possible to a tertiary-care center is the standard practice.

The trishaw (also known as a “tuk-tuk” or “three-wheeler”) is a common mode of casualty transport in Sri Lanka.

The use of temporary shunts in such a peripheral setting is contentious. Inexperienced surgeons using improvised shunts (i.e., pieces of cut, sterile, intravenous set tubing) that may damage the intima of adjacent healthy artery, causing dissection and promoting thrombosis, is a serious concern. On the other hand the author, a vascular surgeon, used temporary shunts successfully to buy time in instances where several patients with limbs dying from vascular injuries arrived at one hospital at the same time.