Royal Navy

Abstract Simulation training involving a live anaesthetised animal is used worldwide to educate surgeons in learning the technical skills associated with trauma surgery and the management of major haemorrhage. So-called ‘live tissue training’ (LTT) is rarely conducted in the UK, with the false assumption that it is forbidden by legislation. Undoubtedly, it is an ethically contentious topic. The debate centres around balancing surgeons’ requirements for high-quality training against the rights of animals. The RCS England council have previously deliberated on this issue, concluding they were unsupportive of LTT, largely due to the availability of alternative simulators. However, LTT remains highly desirable, particularly due to the perceived higher-fidelity of animals in comparison to the preferred alternative of fresh frozen cadavers. There is a requirement for many surgeons to be appropriately trained in the management of trauma, and acquiring relevant clinical experience is challenging. Military medical personnel conduct LTT in a deployed setting, with surgeons employed by certain NATO nations regularly using LTT to acquire and maintain their skills. UK surgeons may choose to travel overseas, for example, to participate in LTT as part of the international Definitive Surgical Trauma Care (DSTC) course. This presentation draws on empirical findings from doctoral research exploring the educational use of LTT, alongside international literature, to consider whether there is a role for live animal simulation in the management of major haemorrhage in trauma. Should live animal simulation be completed replaced, limited to those working within the military, or perhaps an opportunity afforded to all UK surgeons?

Introduction: Gamification, the use of game elements in non-game contexts, has shown promise in enhancing engagement and motivation in educational settings. In military trauma training, simulations incorporating game elements can replicate austere conditions, providing a safe environment for medics to practise essential skills. Despite this potential, the literature remains inconsistent, with controversies likely arising from a lack of understanding of how game elements and their combinations work. This systematic review aims to examine the use of game elements in the design of military trauma simulations and to evaluate the outcomes reported. Methods: We systematically searched multiple databases, screening 1,168 abstracts and narrowing them down to 630 after removing duplicates. A total of 34 studies met our inclusion criteria. Two reviewers independently extracted data using a structured form. We coded game elements based on established gamification frameworks and assessed study quality using MERSQI and Côté and Turgeon’s tool. A reflexive thematic analysis was conducted to understand the motivations—both deliberate and unintentional—behind the use of these game elements in the included studies. Results: The reflexive thematic analysis identified five themes: Recognizing the World; Believing and Feeling; Play by Choice; Varying Challenges; and Keep on Playing. The game elements most frequently used were plot, scoring, time pressure, avatars, and imposed choice. Multimedia was commonly used to enhance immersion. Conclusion: The reflexive thematic analysis revealed that game elements in military trauma simulations are often motivated by the need to create realism, facilitate immersion, empower learner agency, promote variation, and sustain motivation. While some elements were included intentionally, many were integrated without a deliberate gamification strategy. Our results suggest that simulations could benefit from a more intentional approach to gamification, making them more flexible and engaging in supporting military trauma training.

Commotio retinae (CR) resulting from retinal trauma can lead to focal photoreceptor degeneration and permanent vision loss. Currently no therapies exist for CR-induced retinal degeneration, in part because of the lack of a large-animal model that replicates human injury pathology and allows testing of therapeutics. Severe CR is clinically characterized by subretinal fluid and focal photoreceptor outer nuclear layer thinning. To develop a porcine CR model, we developed a laser-guided projectile apparatus and optimized projectile delivery procedure using porcine cadaveric eyes embedded in a 3D-printed porcine skull. Scleral and corneal impacts resulted in retinal damage consistent with patient injury, but corneal impacts also led to cornea damage and opacification, which precluded follow-up imaging. In live porcine eyes, scleral impacts of 39.5 m/s induced transient blood-retinal barrier breakdown evidenced by subretinal fluid on optical coherence tomography (OCT), leakage observed on fluorescein and indocyanine green angiography, and transient photoreceptor outer segment disruption seen by OCT and multifocal electroretinography. Impacts above 39.5 m/s induced longer-lasting photoreceptor degeneration but only transient blood-retinal barrier breakdown. This porcine model, combined with clinically relevant imaging and diagnostic modalities, will be valuable for testing the safety and efficacy of therapies to restore vision after focal photoreceptor degeneration.

Delivering balanced blood resuscitation at the point of injury remains a significant logistical challenge in prehospital trauma care. To inform optimal transfusion strategies in austere environments, we conducted a simulation-based study comparing the operational demands of three prehospital transfusion approaches. Three doctor-paramedic teams (six clinicians) undertook a crossover simulation of traumatic haemorrhage, completing all three arms in random order: two units red-cells-in-plasma (RCP), two units red blood cells plus two units thawed fresh frozen plasma (RBC+FFP), and two units red cells plus two units lyophilised plasma (RBC+LyoP). Outcomes were flow time (defined as time from decision-to-transfuse to completion of transfusion of all units), touch time (hands-on time) and process burden (steps, equipment, checks, personnel), timed in real-time and verified on video. A postscenario questionnaire captured user perceptions. All scenarios were completed without missing data. RCP consistently required the least time and operational effort. Median flow times (min:s) were 06:31 (RCP), 12:20 (RBC+FFP) and 16:29 (RBC+LyoP) (p=0.019). Median touch times (min:s) were 02:31 (RCP), 05:21 (RBC+FFP) and 13:03 (RBC+LyoP) (p=0.017). Touch/flow ratios were lowest for RCP (0.39), indicating reduced cognitive and physical load. Standardised process mapping identified 26 steps for RCP versus 46 for RBC+FFP and 52 for RBC+LyoP, reflecting a single set-up and one repetition for RCP compared with multiple repetitions and added reconstitution steps for LyoP. Equipment (4, 10, 12), checks (8, 16, 16) and personnel required (2, 2, 3) followed the same efficiency gradient. Five of six participants rated RCP as optimal for the patient, and all six for the crew; LyoP was unanimously judged as the most demanding. In a simulated trauma scenario, a combined RCP component was delivered more quickly and with substantially less process burden than separate components. These operational gains support combined-component strategies for prehospital haemorrhage resuscitation in both military and civilian settings.

Arterial tortuosity syndrome (ATS) is a rare autosomal recessive connective tissue disease. It is mainly featured by elongation and tortuosity of the large and medium-sized arteries, along with connective tissue manifestations. In this report, we present a case of a one-year-old male who was diagnosed during the neonatal period after an episode of desaturation at birth, which required admission to the neonatal intensive care unit (NICU) for respiratory support. Imaging revealed tortuosity and kinking of the aortic arch along with left main pulmonary artery stenosis. The family was counselled and offered genetic testing. A multidisciplinary team meeting was held, which concluded with planning for left pulmonary stenosis stenting. The aim of this case is to emphasize the importance of early recognition and diagnosis of rare conditions like ATS through imaging in situations where genetic testing is unavailable.

Musculoskeletal injuries (MSKIs) are a leading cause of medical downgrades and reduced operational effectiveness in the UK military. Initial military training presents a high-risk period for sustaining MSKI but also provides an important opportunity for promoting positive health-related behaviours to mitigate future MSKI risk. Self-determination theory suggests that environments supporting basic psychological needs of autonomy, competence and relatedness can foster intrinsic motivation regulation and positive health-related behaviours. However, this link between environment and behaviour remains underexplored in military populations. Weight-related health risk (determined from individual body weight, height and waist circumference) and health behaviours (relative to the Defence Health Behaviour Index) were assessed in 1591 Royal Navy participants (15.6% females; age range 16-61 years), comprising 941 recruits, 190 officer cadets and 460 trained personnel. Participants also completed the Work Behaviour Regulation Questionnaire and Basic Psychological Need Satisfaction and Frustration Scale. Linear regression and Multivariate Analysis of Covariance were used to explore relationships and group differences. Supporting basic psychological needs in the workplace was positively associated with autonomous motivation (p<0.002), which was also associated with more favourable health behaviours (β=0.119, p<0.001). Frustrating psychological needs were associated with controlled motivation (p<0.001) and poorer health behaviours (β=0.082, p=0.006). Trained personnel reported higher weight-related ill-health risk, poorer health behaviours and greater psychological need frustration than trainees (p<0.001). Recruit trainees had the highest psychological need satisfaction but also the greatest introjected and external motivation regulations (driven by internal pressures or external rewards). Female and trained personnel exhibited greater weight-related ill-health risk (OR=0.51, p<0.001). The data suggest that creating need-supportive military environments fosters autonomous motivation-promoting positive health-related behaviours. Establishing need-supportive environments during early-career phases could improve effectiveness in supporting positive health behaviours and mitigating MSKI risk.

Scuba diving requires situational awareness, cognitive flexibility, and the ability to adapt to changing conditions. For individuals with autism spectrum disorder (ASD), these demands may pose unique challenges due to differences in executive functioning, sensory processing, and social cognition. This article explores the key considerations in assessing fitness to dive in individuals with ASD, including the impact of comorbidities, medication use, and cognitive abilities on diving safety. To provide a broader perspective, we examine research on ASD and high-risk activities such as driving, where similar cognitive and decision-making challenges exist. Additionally, we discuss the role of neuropsychological assessments in evaluating a diver's cognitive fitness and the limited but emerging evidence on scuba diving interventions for individuals with ASD. While ASD is not an absolute contraindication to diving, a careful, individualised assessment is essential to determine suitability. This review aims to provide guidance for diving professionals and medical examiners in making informed decisions regarding ASD and scuba diving.

Lipomas of the hand are rare, particularly in the hypothenar region. We present a case of a 43-year-old male patient with a slow-growing, painless mass in the right hypothenar area causing intermittent tingling and paresthesia in the ulnar nerve distribution. Magnetic resonance imaging (MRI) confirmed a lipomatous lesion. Surgical excision revealed the mass adherent to the superficial branch of the ulnar nerve. Histopathology confirmed a benign lipoma. The patient experienced complete sensory recovery six months postoperatively, with no recurrence. This report discusses the importance of early diagnosis and nerve-sparing excision in hypothenar lipomas.