On Jan 29, 226 sick and wounded civilians, 51 of them children, were evacuated by the International Committee of the Red Cross ( ICRC) and the United Nations (UN), from the Vanni region. Delays at the government checkpoint in Omanthai meant that patients were arriving throughout the evening and night and into the very early morning in Vavuniya Hospital. Some were newly wounded during the recent fighting, while others were suffering from festering wounds up to two or three weeks old. In the fighting many patients lost limbs due to shrapnel and shells. “I saw one man with a missing leg and a missing arm, a young boy with two missing arms, and countless others," explained Lisabeth List, MSF deputy head of mission, from the hospital. "Most have been wounded by shrapnel. One young boy stated that all of his siblings were killed from a shell.” MSF is providing medical and logistical support at the hospital in Vavuniya, and will deploy a surgeon at the request of the hospital. MSF also supports the hospital with mental health counselling for patients traumatised by the fighting. People are in shock, and extremely worried about the relatives they had to leave behind. Most lost everything but the clothes on their backs as they fled to safety. Nearly 250,000 people remain trapped under heavy fire in an increasingly small area in northern Sri Lanka. MSF has received information that nearly 600 civilians have been treated in small hospitals inside the LTTE controlled area for conflict-related injuries since the beginning of January. Hospitals are overburdened and in need of medical supplies and medical staff. MSF is preparing to deploy mobile clinics to provide assistance either in the Vanni or outside, if civilians are able to move to safety, and if and when they may be required. Reports suggest that in Puthukkudiyiruppu, on the northern coast of the Vanni, there are still between 300 to 400 wounded patients in the hospital needing urgent transport to Vavuniya and people are still seeking safety on the Puthukkudiyiruppu hospital grounds. Humanitarian assistance in the Vanni has been extremely restricted since the government forced all NGOs and UN agencies to leave in September 2008. Though the UN has been permitted to send food into the area, the amount has not been adequate for the needs of the population. "We supported a severely malnourished child whose father is dead, the mother very thin; he has two other siblings, and the grandmother had an amputated arm," said List. "They all arrived in the hospital together. We expect that there will be more severely malnourished children to arrive eventually. We hope to do a nutrition screening of all of the children in the hospital and admit malnourished children into the feeding program." MSF provides mental health support by strengthening existing structures in the Vavuniya area and has been working for some time in the Vavuniya Hospital, providing laboratory support. Until March 2008, MSF had a surgical team in the hospital. MSF also runs ambulatory feeding programmes for malnourished children in the Vavuniya area. MSF is also working in the Point Pedro hospital in Jaffna Peninsula, at the northern tip of Sri Lanka, with medical and surgical activities, obstetric and gynecological treatment and training to hospital staff.