Wednesday, September 29, 2021

Death is not the end

 



Why afraid to die
Death is not the end
There may be a life after death
Consider we all are travelers
We travel in the cycle of life
Sometimes we get exhausted
Death is an interval
Until we find the next root
Be a friend of death
It is not cruel
It had been always with us
Every minute and every hour
We walk towards the death
It will never betray us
It will never judge us
Rich or poor
Black or white
Young or old
Everyone is the same
When they meet death

Sunday, September 26, 2021

ජයවර්ධන පුරය



1982 දහය වසරේ අප සිටි ගොඩනැගිල්ලට කීවේ ජයවර්ධනපුරය කියාය​. ඒ අංශ භාර  ප්‍රධානියා ජයවර්ධන සර් වූ නිසාය​. මේ කලාපයෙ අපගේ පන්තිය වූ 10 එෆ් පන්තිය කළාපයේ එපාම කරපු පන්තිය ලෙස කුප්‍රකට විය​. මම , සකලසූරිය , ලාල් රූපතුංග , ඩබල් එන් පී රත්නායක​, සිදත් සුරේන්ද්‍ර , රජිත් හෙවත් මීයා, රණසිංහ , මොරේ , ලියනපතිරණ ඉතා ව්‍යාල සුසංයෝගයක් වූයේය​. මේ නාස්ත්‍යාත්මකතාවය කෙසේදයත් සමහර ගුරුවරියන් දහය එෆ් පන්තියට ඉගැන්වීමට ඒමට පවා බිය වූහ​. 

දහය වසරේදී මම , රත්නායක , සකලසූරිය​, ලියනපතිරණ සහ මිනී ඔළුවා පන්තියේ පිස්සු නටන නිසා ෆිසික්ස් ඉගැන්වූ අත්කොට හැට්ට ඇඳි ගුරුතුමිය අපගේ පන්තියට ඒම ප්‍රතික්ශේප කළාය​. අත්කොට හැට්ට ඇඳි ගුරුතුමිය බ්ලැක් බෝඩ් එකේ ධරය , භාරය ආයාසය කියා රූප සටහන් අඳින විට කොල්ලෝ ඇයගේ කිහිල්ල දෙස ඇසිපිය නොහෙලා බලා සිටිති. මේ නිසා පසුව ඇය බ්ලැක් බෝඩ් එකේ රූප සටහන් නොඇඳ ගුරු පුටුවේ වාඩිවී සටහන් කියවූවාය​. කෙසේ නමුත් 10 එෆ් පන්තියේ කොල්ලන් ගේ පිස්සු නැටීම නිසා ඇය පන්තියට ආවේ නැත​. 

බුද්ධාගම ඉගැන්වූ කොක්මාදූවේ ගුණසිරි හාමුදුරුවන්ටද මොවුන්  විකාර කතා කීමෙන් බාධා කලහ​. එම නිසා හාමුදුරුවන් ඉදිරි පේලි වල සිටි ඉගෙන ගැනීමට උනන්දුව දැක්වූ ළමුන්ට පමණක් ඇසෙන සේ පාඩම කරගෙන ගිය අතර ටික වෙලාවක් යන විට මොවුන් ද හාමුදුරුවන් අසලට විත් ඉතා උනන්දුවෙන් පාඩමට සවන් දෙන්නාක් මෙන්  නෙත් අයාගෙන සිටියහ​.    වරක් බුද්ධාගම පීරියඩ් එකකදී ඈතින් අපගේ පන්තියෙ වෙත වඩින කොක්මාදූවේ ගුණසිරි හාමුදුරුවන්  දුටු රත්නායක සහ ගැන්සිය එක වරම හයියෙන් ගෙල වට බැන්දා  වූ මුතු පොටේ ගීතය ගැයුවෝය​. පන්තියේ අනෙකුත් ළමෝද ගැයීමට හවුල් වූ අතර පන්තියේ ගෝසාව නිසා හාමුදුරුවන් ආපසු හැරී ගුරු විවේකාගාරයට වැඩි සේක​. අප අහම්බෙන් මෙන් ලැබුනු  ෆ්‍රී පීරියඩ් එකේ ගීත ගයමින් විනෝද වූයෙමු. මේ විනෝදය කැඩී ගියේ අල්ලපු පන්තියක උගන්වමින් සිටි නිලවීර මයා වේවැල සමග කඩා වැදීම නිසාය​.

අපගේ පන්තිය තිබුනේ තෙවන මහලේ පාර අද්දරට වන්නය. ​එම පන්තියේ කොරිඩෝවට ගිය විට කිත්‍යාකාර පාරේ තිබෙන පාසල් ගේට්ටුව පෙනේ. පන්තියේ ජනෙල් විශාලය​. ජනෙල් විවෘත වන්නේ තාර පාරටය​. ඉන් එහා විද්‍යාලීය ක්‍රීඩා පිටියටයි. 

දිනක් ගමනායක වෙරළු තොගයක් පන්තියට ගෙනාවේය​. රත්නායක ඇතුළු කණ්ඩායම වෙරළු කා ඇට වලින් කොල්ලන්ට ගැසූහ​. වැඩියෙන්ම ගැසුවේ කොකටුවාටය. හිසට වැදෙන වෙරළු ඇට නිසා කොකටුවා කුඩයක් ඉහලාගෙන සිටියේය​. මෙය දුටු සකලසූරිය කොල්ලෙක් ගේ පොත් බෑග් එකක් කුඩය ඉහලාගෙන සිටි කොකටුවා ගේ හිස මතට යැවීය​. කුඩයද කඩාගෙන පොත් බෑග් එක කොකටුවා ගේ හිස මත වැටුණි. කොකටුවා ජයවර්ධන සර් ගේ කාර්‍යාලයට ගොස් පැමිණිලි කරන බවට තර්ජනය කොට නැගිට්ටා පමණි ඩබල් එන් පී ඔහුව බදා ගත්තේය​. ඉන් ටික වේලාවකට පසුව සෞඛ්‍යය පාඩම සඳහා ජයමහ සර් ආවෙන් කොකටුවා සන්සුන්ව වාඩි විය​. ඔහුට කොල්ලන් කොකටුවා කීවේ ඔහුගේ නාසය කොකටුවෙකුගේ මෙන් වක් වී තිබීම නිසාය.

අපගේ පන්තියේ  යම් අයෙකු පොතක් පතක් කියවන විට අහිංසක ළමයෙකුගේ පොත් බෑගයක් උදුරාගෙන පොත කියවන සිසුවාගේ හිස මතට පොත් බෑගය එවීම මේ පන්තියේ කොල්ලන් අතර තිබූ පුරුද්දක් විය​. මගේ හිසටද පොත් බෑග් කීපයක් වැටුනු නිසා මම සිටියේද රිටන් එක දීමටය​. 

වරක් මම හිස පහත් කරගෙන චිත්‍ර කතා පත්තරයක් බලමින් සිටි සකලසූරියගේ හිස මතට  කොකටුවාගේ පොත් බෑගය විසි කලෙමි. මින් උරණ වූ සකලසූරිය කොකටුවාගේ පොත් බෑගය ජනේලය හරහා තෙමහල් ගොඩනැගිල්ලෙන් බිමට විසි කලේය​. තම පොත් බෑගය මහල් තුනක් ඉහලින් පියෑඹීම නිසා කොකටුවා විලාප දුන්නේය​. මගේ බත් එකත් තිබ්බා ඔහු නහයෙන් අඞන ගමන් කීවේය​. මම  වහ වහා පහළට දිව ගියෙමි. 

කොකටුවාගේ පොත් මල්ල  තාර පාරේය​. ඒ අසල අමරබන්දු අයියා  කණයා හෙවත් ජයසූරිය  සර් සමග කතා කරමින් සිටියේය​.  ​ හිටි හැටියේ උඩින් පාත් වූ පොත් මල්ල දුටු ජයසූරිය  සර් මවිත විය​. 

" සර් මගේ බෑග් එක උඩ ඉඳන් වැටුණා "   එසේ කියමින් මම කොකටුවාගේ  බෑග් එක රැගෙන යලි පන්තියට දිව්වේ ජයසූරිය  සර් ගෙන් සිතාසියක් ඒමට පෙරය​. 

අපගේ පන්තියේ ළමයි උදෑසන පන්සිල් ගන්න වේලාවට පන්සිල් නොගෙන කොරිඩෝවේ කෑකෝ ගසමින් සිටින බව කිත්‍යාකාර පාර ගේට්ටුවේ සිටි ශිෂ්‍ය නායකයන්ට පෙනුනි. මේ නිසා කිහිප වතාවක් උදෑසන පන්සිල් ගන්නා වේලාවට ජයවර්ධන සර් හිටි හැටියේ වේවැල රැගෙන අපගේ පන්ති නිරීක්‍ෂණයකද යෙදීමට පුරුදුව සිටියේය​. මීට අමතරව අමරබන්දු අයියාද අපගේ පන්තිය ගැන සෝදිසියෙන් සිටියේය​. 

වරක් පන්සිල් ගන්නා වේලාවේදී කොරිඩෝවට පැනගත්  රණසිංහ උස් හඞින් රෑන ගිරා ජෝඩුවයි කියා ගැයුවේය​. ඒ අතර වාරයේ ගේට්ටුව අසල සිටි ශිෂ්‍ය නායකයන් කීප දෙනෙක් රණසිංහ දෙස බලමින් ඔහුව හඳුනා ගැනීමේ උත්සහයක යෙදී සිටිනු මම දුටුවෙමි. 

" රනේ වැඩේ දෙල් අන්න ප්‍රිෆෙක්ස්ලා වගයක් මේ පැත්තට එනවා මම ඔහුට අණතුරු ඇඟවූයෙමි. 

රණසිංහ යළි පන්තියට ගොස් දොහොත් මුදුන් දී පන්සිල් ගත්තද ශිෂ්‍ය නායකයන් ඔහුව හඳුනාගෙන ජයවර්ධන සර් ලඟට ගෙන ගියහ​. එදා රණසිංහට ජයවර්ධන සර් ගෙන් බුරියානි ලැබුණි. 

ඊලාම් යුද්දයේදී සුවිශේෂ මෙහෙවරක් කල රණසිංහ වර්තමානයේ විශ්‍රාමික යුද හමුදා නිලධාරියෙකි. 


වෛද්‍ය රුවන් එම් ජයතුංග 


Thursday, September 23, 2021

ඒලියන්තව හදාරමු



සමහර දොස්තරලා ඒලියන්ත වයිට් මිය ගිය එකට අනියමින් සතුට පල කරලා. ඒක හොඳ දෙයක් නෙවෙයි. කෙනෙකුගෙ මරණය ඒ අයගේ පවුලේ අයට වේදනාවක්. සමහර වෛද්යවරුන්ට ඒලියන්ත එක්ක ඉරිසියාවක් , ඔහු පිලිබඳ කුහක ස්ථාවරයක් තිබුනු බව ඇත්ත​. බොහෝ උපාධි සහතික තිබෙන වෛද්යවරුන්ට සිහිනෙකින් වත් යාමට බැරි උඩකට ඒලියන්ත ගියා. ඒලියන්ත වයිට් ගේම ගැහුවේ ස්ටෙරොයිඩ් අධි මාත්රා කසාය වලට කවලම් කරලා , ඒ වගේම ප්ලැසිබෝ ඉෆෙක්ට් එක 100 % අරගෙන . ඒවගේම ඔහු හොඳ තෙරපියුටික් සන්නිවේදකයෙක්. හිමාල වනයෙන් ගෙනාපු බෙහෙත් කිව්වම බොහෝ උගත් මිනිස්සුනුත් ඇන්දුනා. ඒ වගේම අධි විශ්වාසය නිසා ඔවුන් ගේ රෝගත් සුව උනා.

තෙරපියුටික් සන්නිවේදකයෙක් ලෙස බැලුවම ඒලියන්ත ඉදිරියේ වෛද්ය චන්දිම ඩිමෙල් වගේ පතාකයෝ ළදරුවෝ. නියම මාර්ගයේ ගිහින් වෛද්ය උපාධිය හදාරලා සායනික අත්දැකීම් අරගෙන තිබුනා නම් ඒලියන්තට ලංකාවේ ඉතා හොඳ වෛද්යවරයෙක් වෙන්න තිබ්බා.
අපේ කනිෂ්ඨ වෛද්යවරු ඒලියන්ත ගේ කොමියුනිකේෂන් ස්කිල්ස් හදාරන්න ඕනේ. නමුත් ඔහු කල ව්යාජයන් බොරු විජ්ජාවන් ඉගන ගන්න එපා. රෝගියෙකු සමහ ඔහු කතා කල හැටි, විශ්වාසය ගොඩනගා ගත්ත හැටි, ඒවා හදාරන්න​. ඔබලාට අනාගතයේ හොඳ වෛද්යවරයෙකු වෙන්න පුලුවන් ඒ ස්කිල්ස් අධ්යනය කලොත්.

Wednesday, September 22, 2021

ඒලියන්ත වයිට් යනු .....



ඒලියන්ත ලින්ඩ්සේ ,  ඉමේෂ් රංගන ,  ඒලියන්ත වයිට්  යනාදී විවිධ නම් භාවිතා කරමින් කිසිදු වෛද්‍ය උපාධියක් නොමැතිව Prednisolone ඖෂධය අධි මාත්‍රා කල්ක සහ කසාය සමග මිශ්‍ර කරමින් හිමාලයෙන් ( ජම්බුගස්මුල්ලෙන් ?) ගෙනා දිව්‍ය බෙහෙත් ලෙස රෝගීන්ට දෙමින් මිත්‍යාව සහ විජ්ජාව ජන ගත කරමින් කොරෝනාවට කුණ්ඩලනී මුට්ටි ගංගා වලට දැමූ ඔහු අවසානයේ තමන් ගේම මිත්‍යාවේ ගොදුරක් වී අකාලයේ මිය ගියේය​. ඒලියන්ත වයිට් යනු ඒකභාවී නිශ්පාදනයක් නොවේ. මිත්‍යාව දේශපාලන උපක්‍රමයක් ජීවන මාර්ගයක් ලෙස භාවිතා කරන දේශපාලකයන් මෙන්ම වෘත්තිකයන් සිටින රටක ඒලියන්ත වයිට් යනු බයි ප්‍රඩක් එකකි. ඔහුව ඔසවා තබන්නේද තමන් ගිනස් වාර්තා පොතේ දේශීය ඒජන්තයෙකු ලෙස බොරුවට හඳුන්වා දුන් සහ මුදලට ආචාර්‍ය උපාධි විකිනීමට සහාය දුන් වෛද්‍ය ගීතාංජන මෙන්ඩිස්‍ ය​. අවාසනාවකට මෙන් වෛද්‍ය ගීතාංජන මෙන්ඩිස්‍ ද පරලෝ සැපත් වන්නේ ඒලියන්ත වයිට් ගේ හිමාල වනයෙන් ගෙනා  අධි මාත්‍රා බෙහෙතක් ශරීරගත වීමෙනි. 

ඒලියන්ත වයිට්  ඉතා හොඳ සන්නිවේදකයෙකි. දොස්තර උපාධි තිබූ වෛද්‍යවරුන්ටත් නොතිබූ ලෙස ඔහු තුල කොමියුනිකේෂන් ස්කිල්ස්  තිබුනි. එම නිසා ඔහුට බොහෝ පරාසයක මිනිසුන් අන්දන්නට පුලුවන් විය​. යම් ලෙසකින් සුදුසුකම් සපුරා වෛද්‍යවරයෙකු වීමට හැකි වූයේ නම් ඒලියන්ත වයිට් හට ලංකාවේ ප්‍රමුඛ පෙලේ වෛද්‍යවරයෙකු වනු නොඅනුමානය​. එහෙත් තමන් විසින් නිශ්පාදනය කරන ලද මිත්‍යාවට යටවී ඔහු අකාලයේ මිය යන ලදි 

Sunday, September 19, 2021

අපි සංවේදී කළා කාරයෝ - පනම් අටෙන් ශේප් වෙන්න






අපි සංවේදී කළා කාරයෝ
අපි අමතන්නේ මනුෂ්‍යත්වයට
මනුෂ්‍යත්වයේ නාමයෙන්
ගහලා හරි බලය ගන්නැත්තේ ඇයි?
පොල්ලෙන් ගහන්න
වෙඩි තියන්න
පිහියෙන් අනින්න
වස දෙන්න
පුච්චලා දාන්න
කාර් එකට හප්පන්න
ගල් ගස්සවලා මරවන්න
බෙල්ල මිරිකන්න
බරු ගහලා දාන්න
හූනියං කරන්න
අනේ බුදු මාස්ටර් සර්
කඹ ඇදිල්ලේ තරඟය නවත්තලා දාන්න
මාස්ටර් සර් පනම් අටෙන් ශේප් වෙන්න 
ඔවුන් ගේ හිමි තැන ඔවුන්ට දෙන්න
අනේ සර් අනුකම්පා නොසිතේදෝ
ගහලා හරි බලය ගන්න දවස උදා වේවිදෝ


Wednesday, September 15, 2021

Life without you

 




Although you had gone 
I still feel your warmth
I still hear your voice 
You are softly whispering  to my ear 

The war took you from me unexpectedly 
When I heard the bad news 
I felt devastated 
I really felt 
The paradise was lost 

Tell me my love 
About your last moment 
Did you feel pain ?
Were you numbed ?
I am most certain 
You remembered me 
with your last breath 

They brought your body 
They buried you 
with full military honors
They gave you the final salute 
Then I was given a folded flag

You left me so soon 
You left with unanswered questions 
Are we gonna meet again ?
I cannot imagine a life without you 

 
 

Monday, September 13, 2021

Life is a crazy train

 


Ozzy, you said it correctly 
Life is a crazy train 
Going on tracks but to a wrong direction 
The passengers  know that its not a perfect journey
It is a  Journey to insanity 
They are going towards MAD; Mutually Assured Destruction
They have  a fear of annihilation
Despite of their deplorable conditions
They are living as foes
They will never learn how to love
Their mental wounds are not healing
All are in agonizing pain 
Yet they try to hate each other 
Compete with each other
For them  life is a bitter shame
They just live the role
Ozzy , you are the prophet 
You are the  preacher
you are the enlightened one

Friday, September 10, 2021

කාවින්දි අනුත්තරා / Culpable Homicide



කාවින්දි අනුත්තරා 14 වියැති පාසල් සිසුවියක්.  එදා කාවින්දි ලග ඡංගම දුරකතනය තිබී ගුරුවරියක​ට හමු වෙනවා..... ඒ ගුරුවරියක​ට කාවින්දිට මෙහෙම කියනවා.....,දැන් තමුසේ ඉවරයි දැන් තමුසෙට ලොකු ප්‍රශ්නයක් ඇතිවෙයි..තමුසෙට දැන් ඉතිරිවෙලා තියෙන්නෙ මැරෙන්න විතරයි.... ඉන් පීඩනයට පත් කාවින්දි ශනිකව වැසිකිලියට ගොස් තම ටයි පටියෙන් ගෙල වැලලාගෙන මිය යනවා. කාවින්දි අනුත්තරා පිලිබඳ මා විසින් ලියූ කවිය


Culpable Homicide

**************************
The teachers of our time
Committed a murder in silence
Although they deny
She died in their hands 
When they found a cellular in her possession
All the sadistic instincts came in to their minds
With a savage interest
They started the interrogation
Confess , confess, confess
Did you do that ? Did you do this ?
How did you do  it ? confess  you little slut
They derived satisfaction with every tiny answer she gave 
She was the modern day Mary Magdalene
Who committed an unforgivable sin
The teachers decided to stone her
Unfortunately there was no Christ to save her 
The school motto was follow the light
Instead they dragged her to the dark
They used the ultimate weapon of humiliation
And they pressed her buttons
When that school girl took her life
Inside a dark washroom
How could the interrogators avoid the responsibility?
When the blood in their hands






Thursday, September 9, 2021

මොහොමඩ් සම්සුදීන්



මොහොමඩ් සම්සුදීන් උඹ ආගමික පොත් නොකියවා ඛලීල් ජිබ්රාන්  ගේ පොත් කියෙව්වා නම් උඹ මිනිසුන්ට කවදාවත් පිහියෙන් අනින්නේ නෑ. එහෙම නම් උඹ මිනිසුන්ව සෙනෙහසින් වැළඳ ගනියි

Tuesday, September 7, 2021

Traumatic Brain Injury Among The Sri Lankan Combat Veterans



Ruwan M Jayatunge M.D. 

A significant number of Sri Lankan soldiers sustained head injuries during the Eelam War that lasted from 1983 to 2009. These head injuries mainly occurred due to gunshot wounds, mortar blast injuries, grenade explosions and artillery blasts. Traumatic Brain Injuries increased High morbidity and mortality rates among the Sri Lankan combatants. Traumatic Brain Injury (TBI) had been one of the signature injuries of the Eelam War.  

Traumatic brain injury has short and long term consequences. It affects the physical, social, psychological and occupational aspects of a combatant's life.  The combatants with severe TBI have permanent neurobiological damage with profound psychosocial problems. TBI has been identified as one of the disabling conditions among the combatants.

Traumatic brain injury (TBI) refers to a physiologically significant disruption of brain function resulting from the application of external physical force, including acceleration/deceleration forces (Silver et al, 2009). The victims experience emotional lability, sensory impairments, neuro- cognitive deficits and spasticity following traumatic brain injuries.

Traumatic brain injury is a common cause of neurological damage and disability among civilians and servicemen (Auxéméry, 2012). Schneider and colleagues (2009) elucidate that behaviorally the military population in general is considered to be a high risk group for TBI.  According to Scherer et al., (2013) within the last decade, more than 220,000 service members have sustained traumatic brain injury (TBI) in support of military operations in Iraq and Afghanistan.

In Sri Lanka from 1983 to 2009 over 200,000 military personnel were deployed in the operational areas and considerable numbers sustained mild to severe head injuries following enemy attacks. In a convenience sample of 824 Sri Lankan Army servicemen who were referred to the Psychiatric ward Military Hospital Colombo during August 2002 to March 2006 time period 29 combatants (3.51%) were diagnosed  with TBI. These diagnoses were based on International Classification of Diseases- Tenth Revision (ICD-10) criteria and done by the Consultant Psychiatrist of the Sri Lanka Army. 


The Immediate Impact of TBI

Traumatic brain injury has immediate impacts. TBI combines mechanical stress to brain tissue with an imbalance between cerebral blood flow and metabolism, excitotoxicity, oedema formation, and inflammatory and apoptotic processes (Werner & Engelhard, 2007). The immediate effect of head trauma could be loss of consciousness followed by headaches and dizziness. Sometimes confusion and disorientation could occur from mild to moderate form of head injuries. In a severe form of TBI prolonged periods of loss of consciousness, seizures and paralysis could occur.


Traumatic Brain Injury in the War Zone

During the Eelam War some of the combatants who sustained head injuries were not immediately evacuated due to technical difficulties. Intensify heavy fighting and weather conditions affected evacuation of the battle casualties. However the wounded received first aid and then brought back to the rear zone medical aid point where they were examined by a qualified medical officer.  The head injuries were assessed and then transferred to the Palali Military Hospital or to a nearby hospital. Some battle casualties who sustained severe head trauma were airlifted and transferred to major hospitals in Anuradhapura or in Colombo. In these hospitals the war casualties received specialized treatment by the Neurosurgeons.


TBI and Cognitive Impairments

The combatants who sustained serious head trauma later found with cognitive impairments. Neurocognitive impairments are prevalent in TBI. Among the debilitating conditions, memory impairments, difficulty with attention and concentration, difficulty with new learning, and impaired problem solving skills are frequently identified. As indicated by Arciniegas (2003) cognitive impairments are among the most common neuropsychiatric sequelae of traumatic brain injury at all levels of severity. Traumatic brain injury (TBI) can produce persistent attention and memory impairment that may in part be produced by impaired auditory sensory gating (Arciniegas et al., 2000).

Cognitive dysfunctions associated with TBI were known to military psychologists since World War One. The British Physician Frederic Mott (WW1) and Dr Alexander Luria of the Soviet Army (in the WW2) extensively studied the impact of combat related head injuries. Caveness , Walker, & Ascroft (1962) believed that World War I, World War II, and the Korean war produced a large number of combatants with TBI and other associated complications. In the Vietnam War 12 to 14 percent of all combat casualties had a brain injury (Okie , 2005).

TBI-related cognitive impairment is common in veterans who have served in recent conflicts in the Middle East and is often related to blasts from improvised explosive devices (Halbauer et al., 2009). The Sri Lankan combat veterans who sustained severe form of head injuries reported drastic impairments in memory and concentration. Some were found with post-traumatic amnesia.  A large percentage of combatants were found with intellectual disabilities and impaired language skills.


Personality Changes Following Head Injury

Personality change has been reported in 49% to 80% of patients with traumatic brain injury (Brooks et al., 1986). A significant number of Sri Lankan combatants with TBI were found with subsequent Personality changes. Some of the personality changes such as agitation, paranoia, mood swings, aggression, lack of inhibition, inappropriate sexual activity and impaired self control have caused major barriers to their military and personal lives.

Prominent behavioral characteristics in TBI patients have included altered emotion (including restricted emotions with occasional inappropriate or uncontrolled emotional outbursts); impaired judgment and decision–making (including difficulty arriving at decisions as well as poor decisions); impaired initiation, planning, and organization of behavior; and defective social comportment (including egocentricity and impaired empathy). These impairments tend to be accompanied by a marked lack of insight. (Fowler, 2011: Barrash et al.,2000). According to Oddy et al. (1985) two thirds of individuals with TBI experience personality changes for long periods and sometimes over 15 years.


TBI and Depression

Mood disturbances are common sequelae of traumatic brain injury (Hurley &   Taber, 2002). Bay and colleagues (2004) are of the view that Pre-injury factors (such as mood and anxiety disorders, psychosocial dysfunction, and alcohol abuse), injury factors (such as left ventrolateral and dorsolateral injury and serotonergic dysfunction), and post-injury factors (such as postconcussive symptoms, psychosocial dysfunction, and lack of social supports) contribute to the development of depression after TBI, although the relevance of each factor varies among patients.

Combatants with TBI have a large array of psychosocial problems that affect their professional and family lives. Jorge et al. (2004) observed strong association between posttraumatic depression and psychological and psychosocial factors.

Sometimes post TBI depression could   increases anger, aggression and   suicide risk (Fann , Katon , Uomoto & Esselman, 1995). An increased suicide risk has been identified among the combatants who fought in the Eelam War.  According to the Military Spokesperson of the Sri Lanka Army from 2009 to 2012 postwar period nearly 400 soldiers had committed suicide (Sriyananda, 2012).


TBI and Posttraumatic Stress Disorder

Post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI) often coexist because brain injuries are often sustained in traumatic experiences. In addition evidence suggests that mild TBI can increase risk for PTSD (Bryant, R 2011).

Some investigators have argued that individuals who had been rendered unconscious or suffered amnesia due to a TBI are unable to develop PTSD because they would be unable to consciously experience the symptoms of fear, helplessness, and horror associated with the development of PTSD. Other investigators have reported that individuals, who sustain TBI, regardless of its severity, can develop PTSD even in the context of prolonged unconsciousness. (Sbordone & Ruff, 2010).

Despite the discrepancies, a strong connection between Post-traumatic stress disorder and traumatic brain injury has been reported from battlefields around the world. Hoge et al. (2008) point out that mild traumatic brain injury (i.e., concussion) occurring among soldiers deployed in Iraq is strongly associated with PTSD and physical health problems 3 to 4 months after the soldiers return home. Elder & Cristian (2009) too report high association of mild traumatic brain injury with posttraumatic stress disorder among the veterans of the wars in Iraq and Afghanistan. A notable number of Sri Lankan combatants have been diagnosed with TBI and PTSD during the Eelam War.


Posttraumatic Epilepsy

Posttraumatic epilepsy is a major source of disability following traumatic brain injury (TBI) and a common cause of medically-intractable epilepsy (Guo et al., 2013).  As indicated by Diaz-Arrastia and colleagues (2009) posttraumatic epilepsy is a common complication of traumatic brain injury (TBI), occurring in up to 15-20% of patients with severe brain trauma. There are a number of risks associated with Posttraumatic epilepsy. Yeh et al. (2012) hypnotize that the risk of epilepsy after TBI varied by patient gender, age, latent interval and complexity of TBI.

Combat veterans with head trauma are at high risk of developing posttraumatic epilepsy. As indicated by Chen and colleagues (2009) both Korean and Vietnam War veterans with penetrating TBI had a 53% risk of developing PTE.

Neurologist Ranjani Gamage (2003) reported that in Sri Lanka there were 300,000 persons with epilepsy.   This number would have included combatants with epilepsy due to TBI


Psychiatric Symptoms Followed by TBI

The intersection between traumatic brain injury and Psychosis has become one of the major concerns. Some of the Sri Lankan combatants with TBI were later found with psychosis and these individuals had disorganized thought and speech, paranoid delusions with loss of contact with reality.

Koponen et al. (2002) suggest that traumatic brain injury may cause decades-lasting vulnerability to psychiatric illness in some individuals. In addition they hypnotize that traumatic brain injury seems to make patients particularly susceptible to depressive episodes, delusional disorder, and personality disturbances. In one of the studies that was conducted by Deb and colleagues (1999) found that in comparison with the general population, a higher proportion of adult patients had developed psychiatric illnesses one year after a traumatic brain injury. Fann et al. (1995) point out that psychiatric disorders are a major cause of disability after traumatic brain injury.


Chronic Traumatic Encephalopathy in Combatants 

Chronic Traumatic Encephalopathy (CTE) is thought to be a neurodegenerative disease associated with repeated concussive and subconcussive blows to the head (Mez ,Stern & McKee , 2013).  During military training soldiers repetitively sustain mild head trauma that has a negative impact on their mental health. According to Zhang et al. (2013) subconcussive blows can result in cognitive function changes that are consistent with mild traumatic brain injury of the frontal lobes.

The soldiers who served in the artillery batteries during the Eelam War were frequently exposed to blast impacts. Furthermore they faced artillery attacks, mortar fire, grenade and claymore blasts initiated by the enemy. Although a large number of combatants did not sustain any head trauma a considerable percentage experienced the blast shockwaves.  The shock waves   may have had a negative cumulative effect on them. A considerable fraction of combatants who were exposed to   blast shockwaves complain of chronic headaches, tremors and generalized body pain.  This factor was evident in the numerous battles that were fought in different countries.

Military physicians of World War One believed that artillery blasts could cause miniature hemorrhages in the brain causing tremors and long lasting headaches in soldiers. Teland,& Huseby (2102) of the Norwegian Defence Research Establishment  (FFI) hypothesize  that  military personnel who are exposed to blast waves during training and combat are at a significant health risk.

The combat-related traumatic brain injuries (TBI) resulting from exposure to explosions is highly prevalent among military personnel who have served in current wars. Blast trauma can be understood as experiencing a shockwave on the brain and as a psycho-traumatic event (Auxéméry, 2012). Chronic pain is a common complication of TBI. It is independent of psychologic disorders such as PTSD and depression and is common even among patients with apparently minor injuries to the brain. (Nampiaparampil, 2008).

Head trauma could cause degenerative changes in the brain tissue. Byrnes et al. (2012) point out that traumatic brain injury initiates biochemical processes that lead to secondary neurodegeneration.  Traumatic brain injury causes progressive neurodegeneration associated with chronic microglial activation (Xue et al, 2013). Atrophic changes of the brain that are resulted by TBI can have a lasting impact on soldiers. Symptoms can range to prolong headaches to severe neurological and psychological consequences.


Treatment Options

TBI has drastic impacts on independent living skills of the combatant. The survivors need effective psychosocial rehabilitation. The outcome and impact evaluation following combat related TBI is highly essential in the rehabilitation process.  The concept of “the outcome of brain injury” needs to be viewed in the context of a dynamic and changing series of events which occur throughout a person’s life Gainer, 2010).

Various risk factors for poor outcome after TBI have been identified. Most of these are fixed at the time of injury such as age, gender, mechanism of injury, and presenting signs (Glasgow Coma Scale and pupillary signs), but some such as hypotension and hypoxia are potential areas for medical intervention (Moppett, 2007).

Cerebral metabolic derangement and excitotoxicity play critical roles in the evolution of traumatic brain injury (Hwabejire et al., 2013). Expert opinion suggests that combination therapies will be necessary to treat any stage of TBI recovery (Shear & Tortella, 2013). Drug management is important in seizure control. Chen and colleagues (2009) are of the view that optimal seizure control is essential to the physical and emotional health of veterans with TBI and to their ability to lead productive lives.

Psychotherapy is an important component of the treatment of neuropsychiatric problems following TBI (Arciniegas et al., 2000).  Cognitive rehabilitation may also be useful for the treatment of impaired attention, interpersonal communication skills, and executive function following TBI (Arciniegas et al., 2002).  Bédard et al. (2003) suggest mindfulness-based intervention to improve quality of life among individuals who sustained traumatic brain injuries. In addition occupational therapy, speech language therapy and physiotherapy play a key role in the rehabilitation process.


 Case Discussion

1)    Private SNX764 joined the Army in 1991 and served in the operational areas. He took part in several major military operations against the LTTE. In 1995 he was posted to Mallakam -Jaffna. There he had to face fierce enemy attacks. Once the enemy attacked them with mortars. Following nonstop mortar attacks, Private SNX764 was stunned and disoriented. His bunker was damaged severely and he wanted to crawl to a safe area.  When he tried to reach the next bunker an incoming mortar blasted a few meters away from him. Suddenly he could feel bleeding from his ears and he lost consciousness. After a few hours of fighting the enemy retreated.  Then he was evacuated and taken to the Palali military hospital. He was treated for a head injury. Although he survived the mortar blast his speech was impaired. He experienced severe intermittent headaches and insomnia. By 1996 he had intrusions, flashbacks and marked avoidance for combat related settings.   His mental health started deteriorating further. Several times Private SNX764 had tried to commit suicide while serving in the operational areas. Finally he was referred for a psychological evaluation and found with chronic PTSD.


2)    Capt. KXXC385 was an experienced field officer who participated in numerous commando operations. He sustained a head injury as a result of a parachuting accident. He was unconscious for over two weeks and treated at the Neurological unit.  After the acute phase he was referred for rehabilitation therapy. After years of treatment he returned to his unit as a completely changed person. He had difficulty in concentration, Emotional lability and cognitive impairments. His personality changed tremendously after the head trauma.  Once a skillful professional soldier turned into a dependent unsteady person with marked psychosocial dysfunctions. His professional and private life fell apart.  His decision–making and initiation were significantly deteriorated and sometimes he engaged in socially inappropriate behavior failing to detect social cues. Capt. KXXC385 was diagnosed with Personality changes following head injury.


3)    Major WXX856 sustained a head injury due to a grenade blast in a training mission. He was unconscious and treated at the Neurosurgical unit of the National Hospital Colombo. Major WXX856‘s injury was reordered as a moderate type of head injury based on the Glasgow Coma Scale (GCS). After the injury he experienced frequent headaches and irritability. He had low frustration tolerance and often became very impulsive. His family members observed drastic changes in his behavior. Frequently he engaged in family violence. His personality started to change with head trauma. The senior officers found that Major WXX856 was neglecting his duties. A number of times he was reprimanded. To displace his psychosocial difficulties Major WXX856 started to drink alcohol in large quintiles in daily basis. His treatment schedule was interrupted and eventually in the final two years he did not receive any treatment at all. Major WXX856 became more and more isolated and had homicidal urges. In 2004 Major WXX856 committed several murders secretly and enjoyed the brutal acts. He took his final victim – a cab driver to his remote camp and intoxicated him and then killed him by cutting the victim’s throat. He had no remorse or any regrets after committing these murders. Major WXX856 was looking for more victims to fulfill his homicidal urge.  In his final attempt he tried to abduct a victim near a remote tea estate but the attempt was unsuccessful. Some estate workers alerted the Police. Hence he was arrested and sent to the remand prison. The investigators found several other murders that were committed by Major WXX856. While his trial was pending Major WXX856 committed suicide by hanging.


4)     Private KXXT342 met with a landmine explosion in Chunnakam –Jaffna in 1996 while travelling in a military vehicle. Some of his buddies got killed due to the blast. He could only remember the black smoke and fatal outcry of his buddies. The soldiers from the second vehicle took the wounded to the hospital immediately. Private KXXT342 sustained a head injury and was treated at the Palali military hospital and then referred to the National Hospital -Colombo. He underwent treatment for several months. He had impaired hearing, slurred speech and loss of coordination after the injury. In addition he suffered epileptic fits. Private KXXT342 was diagnosed with Posttraumatic Epilepsy. After becoming a battle casualty Private KXXT342 experienced a number of psychosocial problems which affected his life. He was treated with antiepileptic drugs and CBT. Following treatment he was able to overcome most of his psychosocial problems.


5)    Corporal BXVX486 served in an artillery battery for over 9 years. During this time period his team had fired a large number of artillery rounds. Although he was physically unharmed throughout the war his luck changed dramatically. Corporal BXVX486 complained of tremors in both hands, frequent headaches and myalgia after serving lengthy years in the artillery battery. The physicians who examined him found no organic factor associated with his condition. There were no Electroencephalography (EEG) changes and his brain scan and other reports were normal. He was suspected as a malingerer at one point but later found that his symptoms were real. Corporal BXVX486 poorly responded to the painkillers. His condition started to improve with relaxation therapy and EMDR.


6)    L/ Cpl AXXCX831 sustained a TBI following a gun short injury. After he became a battle casualty L/ Cpl AXXCX831 experienced a number of psychosocial problems. He could not control his anger and became extremely hostile. He used to physically abuse his wife and children. He had depression and several times he planned to end his life. Once he took poison and immediate hospitalization saved his life. He was treated with Selective serotonin reuptake inhibitors (SSRI ) and mood stabilizers with CBT. Following drug therapy and psychotherapy L/ Cpl AXXCX831’s condition improved notably.


Conclusion

Although Traumatic Brain Injury has impacted a large number of Sri Lankan combatants who fought in the Eelam War, the psychological sequelae of brain trauma were not adequately studied. The combatants who sustained TBI have persistent headaches, memory impairments, sleep difficulties, low frustration tolerance, impaired life skills, emotional difficulties, impaired decision making and behavioral changes.TBI has caused profound psychosocial problems among the veterans. These problems affect their private and professional lives. The combatants with TBI need effective psychosocial rehabilitation to overcome their current difficulties. Further research is needed to estimate the overall impact of TBI among Sri Lankan combat veterans.


Acknowledgements

1)    Dr. Rolf B. Gainer – Consultant Neurologist – Brookhaven Hospital Tusla Oklahoma

2)    Professor Daya Somasundaram – University of Adelaide Australia

3)    Dr. (Mrs) N.K Ariyarathne – Consultant Physician – Military Hospital Colombo.


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