of platelets and plasma (i.e. the whole blood 1:1:1 system) on casualties with massive trauma as a result of this study and others like it (7) . This method is advantageous as it replaces all lost components of the blood leading to higher survival rates. The extra viscosity of the whole blood mixture as opposed to component-based transfusion helps to counter the extreme loss of blood pressure that can cause circulatory failure in patients with Massive Trauma. Subsequent studies confirm that for Massive Trauma patients whole blood transfusion is beneficial in both a civilian and military setting and contributes to higher survival rates (2,8) . The use of a 1:1:1 ratio in a transfusion does, however, have some disadvantages when performed in a civilian setting. Soldiers, by their very nature, are generally in good physical condition and as they tend to be injured during combat will have a high level adrenaline, which might provide a higher pain tolerance at the point of injury. This makes them, in a sense, ideal casualties. The main disadvantage of the whole blood ratio is that due to the increased viscosity of the mix it can put undue stress on the circulatory system, specifically the heart itself as it is effectively pumping extra blood. There have not yet been definitive links drawn between this and harm to civilian patients, apart from casualties sustained in the early 1920s where whole blood was used, but this could be due to the lack of proper equipment at that time. There is still a lot of debate as to whether the whole blood ratio is suitable for a civilian setting and while it has been adopted by many Trauma Centres across Britain and the US, some major hospitals, such as Great Ormond Street, still use component-based transfusions (7,9) . This illustrates the way in which some military advances are not applicable in a civilian context. In the recent war in Afghanistan American and British military casualties who survived long enough to receive treatment (i.e. on the evacuation vehicle) have a survival rate of 90-95%, the highest rate in any war (5,10) . The fraction of those who do not survive often have injuries such as massive head trauma or were in situations so dangerous that evacuation was delayed. It could be said that Trauma medicine might be reaching a point where there is little room for further improvement. The Army is not, of course, perfect at dealing with casualties and Trauma medicine will advance in the future along with all medical science. The leading cause of death in Britain, however, is Heart Disease and Respiratory Disease and the leading causes in America are Heart Disease and Cancer (11,12) . All three of these diseases are, by their very nature, things that the Royal Army Medical Corps neither treat nor research as all soldiers with them are referred to a civilian hospital. These diseases are diseases of age and lifestyle, not trauma (which is only really a major killer in the younger sections of the population) and will become increasingly prevalent as the proportion of those living longer increases (11) . So one can see that despite military advances from the War on Terror definitely helping more civilians survive trauma, the broader battlefields of modern medicine lie in the fight against degenerative diseases. Now of course from third world countries to the highest echelons of the economic scale the advances in trauma medicine that the military have developed will always be useful. I would hope that through a lack of conflict and the endless march of medical progress, we will reach the stage where we can safely contradict Hippocrates and war will not be the only proper school for a Surgeon.
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