The papers contained in this edition of Philosophical Transactions present a wide selection of research currently being pursued within defence, in the science and clinical management aspects of care for wounded UK Armed Forces personnel. As in previous conflicts, the papers demonstrate that in the advancement of medicine, war is the great teacher. The current conflicts date from 2001, with operations in Afghanistan following the destruction of the World Trade Center, known universally as ‘9/11’, continued with the second Gulf War in 2003, and continues with operations in Afghanistan. The duration of the conflict, longer than either World Wars, has provided ample opportunity to learn. Initially, the casualty rates were far greater among US forces and most of the early lessons, therefore, emanated from their experience. Since 2006, the UK casualty rates have been significantly higher than in the preceding three years and increasingly the UK has also contributed to the emerging lessons.
Clinically, the most striking features have been the increased survival at the point of injury, and the recognition of the need to address coagulopathy early in order to sustain life. These have been associated with increased emphasis on first aid training using new materials and the introduction of the concept of damage control resuscitation to complement the much older concept of forward surgery, more recently characterized as damage control surgery. The overall result is a medical system that has been assessed externally as exemplary, in three separate reports from widely differing organizations, the House of Commons Defence Committee in 2008 , the Healthcare Commission in 2009  and the National Audit Office Report in 2010 .
The majority of the contributors to this edition are serving defence medical service officers or MOD scientists often working with the UK National Health Service and civilian academic colleagues. Much of the research links with that being undertaken by our international partners, in particular the US, with whom there is increasing collaboration to eliminate unnecessary overlap, develop synergies and fill gaps.
The papers herein fall broadly into six categories:
— The changing epidemiology of war injuries and their survivability in modern conflict (as described in the paper by Russell et al. )
— The specific epidemiology of blast injury, which sadly in this age of the suicide bomber, has become increasingly important, not only to military personnel, but also to civilian emergency services, and emergency planning authorities (see the papers by Pope , Kirkman et al.  and by Ramasamy et al. ).
— Patterns of blast injury in different body areas and systems, and the clinical challenges that these pose, as in blast lung (see the ‘special feature’ on this topic in this issue), management of blast amputation and limb injuries , eye injuries  and mild traumatic brain injury .
— Modern (and rapidly evolving) concepts of damage control resuscitation, which provide new clinical and organisational challenges, but which have now clearly been shown to improve the patients' chances of survival .
— Current developments in exploiting technology for training military doctors, nurses and paramedics for their deployed role, and for the daunting clinical challenges they will face in the modern war zone (see the paper by Stone ).
The papers do not comprehensively cover the whole area of clinical research endeavour, nor do they cover most of the organizational developments or the long-term impact on individuals and society arising from the increasing number of ‘unexpected survivors’.
Much of the clinical research output not covered here has been generated by the US; for example see the Journal of Trauma supplement (February 2008): Advances in combat casualty care: clinical outcomes from the war. The long-term impact of unexpected survivors, with increasingly complex injuries, has yet to be fully assessed as their injuries are of a severity not previously seen and their initial rehabilitation is not complete. For example, there is now a cohort of individuals with triple amputations that have not previously survived. Such survivors will need addressing through organizational changes in how such individuals are managed within the nations' health services, and there will also be an impact of advances in rehabilitative and regenerative medicine, emanating for example from ‘AFIRM’.
Foremost among the organizational changes, alluded to in the paper by Russell et al. , has been the development of clinical governance, whereby the system as a whole has sought to identify weaknesses and rapidly address them. Indeed, in many cases the clinical governance system has highlighted areas for research and development through highlighting variation and enabling association with outcomes to be identified. The introduction of the life saving measures at the point of injury (effective tourniquets, improved bandages and haemostatic dressings) required a major change in training of all military personnel , with advanced first aid training for some. The belief that the most seriously injured of these survivors would soon succumb led to the development of helicopter-borne, consultant led, critical care teams (termed ‘medical emergency response team—enhanced’, the enhanced referring to the presence of a consultant emergency physician or anaesthetist) . The two changes combined have enabled military operations to be undertaken beyond the previous limit of surgical support.
The presence of critical care teams on incoming helicopters has also enabled appropriate decisions to be made on surgical priorities whereby the casualty is diverted directly to the operating theatre for ongoing integrated resuscitation and surgery. The advances in pain management (mainly initiated in response to patient focus groups) described by Aldington et al.  led to significant changes in the training of aeromedical evacuation teams, and whereas previously any patient with an indwelling pain relief catheter would have required a critical care air support team, such casualties are now managed by generalist air evacuation teams; standardizing the patient controlled administration system used by the Army and RAF to facilitate seamless transfer of patients has led to changes in pain care within the receiving NHS hospital.
The research described in this edition, the practical outcomes of the clinical governance process, organizational lessons being learnt on the ground and research elsewhere as a result of the ongoing conflicts are directly relevant to civilian medical services. It has been stated for some time that the outcome of trauma in the NHS is sub-optimal [19–21] and the military successes reinforce this, as well as pointing to advances and changes that can, and in some cases already have been, introduced. A possible criticism of the thrust of the papers is a lack of controlled clinical trials. The purist is referred to Prussian military philosopher, Karl von Clausewitz who, writing during the Napoleonic Wars about the application of logical thought on the battlefield, wrote that in war ‘The light of reason is refracted in a manner quite different from what is normal in academic speculation’ . Many of our authors have recent vivid experience of the truth of that dictum. The work presented here shows that, despite that different refraction, scientific reasoning can be applied in combat casualty care, to the immediate benefit of the wounded, and in the longer term to the benefit of all mankind.
One contribution of 20 to a Theme Issue ‘Military medicine in the 21st century: pushing the boundaries of combat casualty care’.
- This journal is © 2011 The Royal Society