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The Royal College of Surgeons of England & Support to Military Surgery
Large Scale Combat Operations: The challenge for Defence Medical Services, the Armed Forces and the United Kingdom
Proteomic analysis of trauma plasma identifies discrete signatures of damage-associated molecular patterns and host-protective molecules in the hyperacute post-injury window —
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London
- Major Trauma Service, Royal London Hospital, Barts Health NHS Trust
This abstract is not included in the conference proceedings.
The Transcriptomic Basis of Systemic Dysregulation: Identifying "Protective" and "Destructive" Gene Signatures in Multi-Complicated Trauma Recovery —
- Uniformed Services University (USU) Surgical Critical Care Initiative (SC2i), Bethesda, Maryland, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
- Department of Surgery, Emory University, Atlanta, Georgia, USA
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
Introduction: Severe traumatic injury often leads to divergent clinical paths, with many patients suffering from persistent systemic dysregulation. While proteomic studies have identified cytokine imbalances, the underlying genomic drivers of these differential outcomes and their associated protein signatures remain poorly understood. This study uses bulk RNA-seq to characterize the transcriptomic landscape that differentiates patients without complications from those experiencing a high burden of multiple complications.
Methods: We analyzed 460 blood samples from a longitudinal cohort of 245 adult patients with acute traumatic injuries who received medical care during 2015–2022 at three geographically distinct hospitals in the US. Samples were collected from the date of injury through +10 days of recovery. We assessed 105 samples from patients without complications and 355 samples from multi-complicated patients. We performed differential expression analysis (via DESeq2), pathway enrichment (clusterProfiler), and network modeling (STRINGdb). Systemic shifts in leukocyte proportions were identified (CIBERSORT).
Results: Genetic analysis identified 230 significant differentially expressed genes that establish a protective and an opposing, destructive transcriptomic signature. These signatures are detectable throughout recovery (out to +10 days), but they stabilize within the first 48 hours post-trauma. During this early window, uncomplicated patients shift toward a protective signature enriched in scaffolding proteins as well as immune and cellular regulatory pathways, whereas multi-complicated patients experience a destructive signature characterized by genes linked to tissue degradation. Patients with destructive signatures exhibited significant increases in pro-inflammatory monocytes (25.8% vs. 20.4%, p=0.0004) and concurrent decreases in activated NK cells, suggesting a state of combined hyper-inflammation and immune exhaustion.
Discussion: This analysis identifies a 48-hour period during which a transcriptomic signature of systemic dysregulation sets in after trauma. Our findings provide a genetic basis for previously observed cytokine profiles and suggest that the balance between protective and destructive gene expression trajectories significantly impacts the risk of multi-complication outcomes.
Disclaimer: The contents of this presentation are the sole responsibility of the author(s) and do not necessarily reflect the views, opinions, or policies of the Uniformed Services University of the Health Sciences (USUHS); the Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc.; the Department of War (DoW); or the Departments of the Army, Navy, or Air Force. Mention of trade names, commercial products, or organizations does not imply endorsement by the U.S. Government.From Detonation to Triage: A Fast-Running Framework for Injury-Predictive Blast Risk Evaluation —
- Department of Bioengineering, Imperial College London
- Academic Department of Military Surgery and Trauma
- Academic Department of Military Trauma and Orthopaedics
Explosive threats continue to pose significant operational challenges across military, security, and civilian domains. Rapid, credible prediction of casualty numbers and injury severity is essential for force protection, infrastructure resilience, and emergency preparedness. However, existing tools often lack anatomical realism, clinical integration, or runtimes compatible with operational decision-making.
SHIELD (Simulation for Human Injury and ExpLosion Dynamics) is an integrated blast-injury simulation platform designed to deliver rapid, clinically meaningful casualty predictions within complex environments. Developed in the Unity gaming engine, SHIELD combines empirical blast physics, fragment dynamics, anatomical surrogates, and clinical mapping within a single framework suitable for operational planning and design iteration.
The platform imports standard CAD geometries of buildings, vehicles, and infrastructure which can be populated with virtual humans and threats. Threat specification includes explosive type, charge mass, configuration, and fragment properties. Blast propagation is modelled using established Kingery-Bulmash scaling laws and Friedlander pressure curves. Shock fronts are represented using dynamically refined discretisation to preserve collision fidelity, while fragment kinetics derive from modified Gurney energy formulations and aerodynamic laws.
Virtual human populations reflect anthropometric variability and comprise 17 anatomically segmented collider elements per individual. The framework registers primary (overpressure), secondary (fragment penetration), tertiary (blast-driven displacement and impact), and quaternary (thermal) injury mechanisms. Element-level accelerations and associated masses permit estimation of impact forces. Injury metrics are accumulated and translated via a governed clinical engine into injury-severity distributions, lethality estimates, and triage categories informed by published experimental relationships and operational trauma expertise.
The demonstrator supports repeatable batch simulations, shock-front visualisation, clothing and PPE interaction modules, and statistical analysis of casualty outcomes. A structured validation programme is underway, targeting prediction of fatalities within 10% and injury-severity distributions within 20%. SHIELD provides a rapid, anatomically informed injury-prediction capability for defence force protection, PPE evaluation, infrastructure resilience assessment, and mass-casualty planning.
Project ARIES — Modernising the Medical Reception Station for Contemporary Operations —
- 7 Royal Horse Artillery
- 16 Medical Regiment
Background: Modern conflict places increasing demands on deployed medical capabilities, requiring greater mobility, survivability and functional breadth from Role 1 assets. Project ARIES is a multi-phase initiative designed to modernise the Medical Reception Station (MRS), creating a leaner and more agile medical system while preserving essential legacy capabilities.
Methods: ARIES is delivered across four phases: Understand & Analyse — identification of functional limitations, capability gaps and doctrinal misalignment; Directed Improvements Within Constraints — targeted enhancements to workforce structure, training and equipment; Explore Future Concepts — development of proposals for future force design, procurement and employment policy; Validate & Institutionalise — evaluation of new models and transition into doctrine and training pathways. A core component is the reconfiguration of personnel into three multifunctional generalist teams capable of delivering broader capability in austere and high-tempo operational environments.
Results: The introduction of the Health Support Section formalises expanded training for allied health professionals, including Tactical Combat Casualty Care Combat Lifesaver (TCCC CLS), unmanned aerial systems (UAS) operation, and emergency donor panel management. This enhances surge capacity while maintaining specialist outputs such as dental, radiographic and physiotherapy support. In parallel, the creation of the Casualty Support Unit and Aid Post provides scalable and modular prolonged hold capability. These elements can combine to project a larger footprint in permissive environments or disperse to enhance survivability in non-permissive settings. Additionally, they are designed to integrate ("bolt on") with forward surgical teams to optimise casualty flow and improve resilience within the Role 2 continuum.
Conclusion: Project ARIES offers a coherent, future-facing redesign of the MRS, aligning clinical capability, workforce structure and operational employment with the demands of modern conflict. The resulting modular, agile and multi-skilled construct enhances both survivability and clinical effect, representing a substantive step toward the next generation of deployed surgical and medical support.
Digital Twins — A promising approach to connect surgical decision making and rehabilitation in the care of complex combat extremity injuries — a proof of concept study —
- Department of Trauma Surgery, Orthopedic Surgery and Septic Reconstructive Surgery, Hospital of the German Armed Forces, Berlin
- Bundeswehr Centre of Sports Medicine, Warendorf, Germany
- Saarland University, Saarbrücken
Introduction: Complex multiextremity injuries are the signature injuries of recent conflicts. While reconstructive strategies and techniques, as well as amputee care have significantly evolved, rehabilitation remains a separate process following sequentially after surgical care is completed. In complex extremity trauma there are typically different surgical strategies at hand. Decision making cannot target the best functional outcome because there are no means to anticipate the actual outcome after rehabilitation in the individual case. We hypothesize that it is possible to create a digital twin of a severely wounded warfighter such that the effects of different surgical strategies on the rehabilitation process can be integrated into the decision making process.
Method: Anthropometric (bone lengths) and clinical data (TTA right leg; distal femur fracture, sciatic nerve lesion left leg) of a wounded soldier were mapped into OpenSim (Stanford University, CA, USA). Different surgical strategies (exoprothesis right, knee reconstruction left; exoprothesis right, TKA left; exoprothesis right, knee arthrodesis left; exoprothesis right, end-exoprothesis left) were simulated and analyzed with respect to parameters relevant to rehabilitation like metabolic demand of individual muscles.
Results: The digital twin of the soldier was implemented in the OpenSim environment with a reasonable effort of time and skill. Default gait patterns proved functional with the different configurations of the digital twin. Different surgical strategies were implemented successfully as well. For each of the above named configurations the analysis of metabolic need of muscle(group)s essential for successful rehabilitation showed distinct patterns.
Discussion: This work provides the proof of concept that the implementation of a digital twin in an established, validated and open source full body simulation is possible given a reasonable effort of time and skill. Thus it becomes possible to embark on those surgical strategies that can be expected to successfully match the individual patient's functional demands and rehabilitative capabilities.
Integration of numerical injury models to provide a unified approach towards simulating ballistic and blast threats —
- Defence Science and Technology Laboratory, Portsdown West, Fareham
- Academic Department of Military Surgery & Trauma, Birmingham
- Centre for Blast Injury Studies, Imperial College London
UK governmental organisations require the capability to simulate wounding from a variety of threats and estimate the number of casualties and injury severity. Plausible scenarios of interest range from a gunshot wound sustained by a single individual, to multiple casualties from an explosive device in a terrorist event. Simulations increase in complexity with the inclusion of personal protective equipment, anthropometry, and building architecture that requires the inclusion of complex blast waveforms and threats that can initiate from new orientations such as unmanned aerial vehicles.
There is no single model currently existing that can achieve all these objectives, and multiple organisations individually hold expertise, including their own software. Dstl have expertise in quick-running numerical modelling, with the Weapon Target Interaction (WTI) enabling simulation of the penetration of blast and ballistic projectiles into armour and the human body, and their effect on anatomical structures, which can then be mapped to a mortality output. The Human Injury Prediction (HIP) simulates the detonation of an improvised explosive device in civilian infrastructure and utilises medical evidence collected by the Defence Medical Services (DMS) from terrorist events to predict number of casualties and injury severity. Medical intelligence is used to identify the threats and validate how projectiles interact with human tissues, including the effect of armour and medical interventions. Imperial College London, together with the DMS, is developing SHIELD, which will be a fast-running numerical simulation of an explosive event based upon a gaming platform to maximise the user interface. We aim to demonstrate how an integration of multiple models and expertise from these different organisations will be cohered to provide a unified approach to modelling such events, to benefit a range of stakeholders across UK Government.
Refreshments
Total Hip Arthroplasty following gunshot and blast injuries in Ukraine: a prospective observational study — (virtual)
- Shupyk National Healthcare University of Ukraine
- Traumatology and Sports Medicine of Clinical Hospital "Feofaniya" in Kyiv
- Military Medical Clinical Center of Southern Region, Odessa National Medical University
- Academic Department of Military Surgery and Trauma
Introduction: Gunshot and blast injuries to the hip joint are increasingly prevalent in modern armed conflicts, accounting for a significant portion of combat trauma. These high-energy injuries often cause extensive bone and soft tissue destruction, presenting substantial challenges for functional restoration. This study evaluates the outcomes of total hip arthroplasty (THA) as a primary or staged treatment for severe hip joint destruction following combat-related trauma.
Methods: A prospective analysis was conducted on 16 patients (mean age 40.0 ± 11.77) treated between March 2022 and March 2025. Patients were divided into two groups: Group I (n=8) included blast/shrapnel injuries with open wounds treated via a two-stage approach using an articulating antibiotic spacer; Group II (n=8) included bullet wounds with healed soft tissues treated via one-stage THA. Functional outcomes were measured using the Harris Hip Score (HHS) over a 12-month follow-up.
Results: The mean interval from injury to THA was significantly longer for Group I (275.3 ± 21.5 days) compared to Group II (147.4 ± 33.9 days). While Group II achieved higher absolute HHS at one year (84.00 ± 3.12 vs. 80.50 ± 2.27, p=0.024), Group I demonstrated significantly greater overall functional improvement (Delta HHS: 45.00 ± 6.05 vs. 35.00 ± 7.43, p=0.011). Group I faced a higher risk of infectious complications, with three patients requiring repeated debridement during the spacer stage. No implant loosening or lead toxicity was observed at the final follow-up.
Conclusion: Total hip arthroplasty is an effective solution for non-restorable hip destruction in military settings. A two-stage protocol is mandatory for high-energy blast injuries with extensive tissue damage to mitigate infection risks, whereas one-stage THA is a viable option for lower-energy bullet wounds without active infection markers.
Laparoscopy in Combat-Related Abdominal Trauma: A Single-Center Experience from war in Ukraine —
- National Academy of Medical Sciences of Ukraine, Kyiv, Ukraine
- State Institution of Science "Research and Practical Center of Preventive and Clinical Medicine", State Administrative Department, Kyiv, Ukraine
- Zaporizhzhia Military Hospital, Zaporizhzhia, Ukraine
- Armed Forces Medical Command, Ministry of Defense of Ukraine, Kyiv, Ukraine
- Department of Surgery, Verum Expert Clinic, Kyiv, Ukraine
Introduction: War in Ukraine demonstrates surgical challenges due to severe and complex trauma, which requires non-standard decisions and adaptations to changes in tactical conditions or limited medical resources. The open surgical approach is suggested by most war surgery guidelines, whereas Ukrainian experience from the ongoing war suggests application of minimally invasive surgery in selected patients with ballistic injury to abdomen. The aim of the study was to evaluate utility of laparoscopic surgery in hemodynamically stable combat patients who were injured in the battlefield of the Russo-Ukrainian war.
Patients and Methods: 238 hemodynamically stable patients with combat-related abdominal trauma (213 penetrating, 25 blunt) were surgically treated at Zaporizhzhia Role 3 deployed field hospital from November 2022 to July 2025. All patients were treated according to ATLS protocol, and damage control surgery was also applied. Optimal outcomes were observed in Grade I–II injuries according to the American Association for the Surgery of Trauma (AAST) scale.
Results: The following laparoscopic procedures were performed: diagnostic laparoscopy in 78 (33%) patients, foreign body removal in 60 (25%), hemorrhage control in 23 (10%), diaphragmatic repair in 19 (8%), hollow viscus perforation repair in 15 (6%), splenectomy in 5 (2%), and colectomy/colostomy in 12 (5%). Conversion to laparotomy was required in 28 cases (11.8%), while secondary laparotomy was necessary in 5 patients (2.1%) due to missed bowel injuries, abscesses, or hemorrhage.
Conclusions: Laparoscopy is a safe and effective approach for selected hemodynamically stable combat patients. Laparoscopy is associated with lower surgical trauma, and faster recovery of the patients.
Out-of-Hospital Control of Non-Compressible Haemorrhage Using the Abdominal Aortic and Junctional Tourniquet — Stabilised (OCCLUDER): A Prospective Feasibility Study —
- Academic Department of Emergency Medicine
- Cambridge University
- Academic Department of Military Surgery & Trauma
- C4TS Queen Mary University London
- London Air Ambulance
- Barts Health
Introduction: Non-compressible haemorrhage (NCH) remains the leading cause of potentially preventable death following traumatic injury in both military and civilian settings, with most fatalities occurring in the pre-hospital phase. Existing interventions have limited applicability at the point of wounding. The Abdominal Aortic and Junctional Tourniquet — Stabilised (AAJT-S) is a non-invasive, externally applied device designed to achieve temporary aortic occlusion and control pelvic, junctional, or proximal lower-limb haemorrhage. Despite regulatory approval and supportive pre-clinical data, there is a critical absence of real-world clinical evidence regarding feasibility, safety, and physiological effects.
Methods: OCCLUDER is a prospective, pragmatic, single-arm observational feasibility study conducted within the London Major Trauma System. Adult trauma patients aged ≥16 years presenting with suspected pelvic, groin, or very proximal lower-limb injury and severe haemorrhagic shock will be eligible. The AAJT-S will be applied pre-hospital by trained Advanced Paramedic Practitioners or London's Air Ambulance enhanced care teams, in addition to standard care. Twenty patients will be recruited over 24 months, followed by six months of analysis. Feasibility outcomes include successful device application, usability, procedural timings, and protocol adherence. Safety outcomes include device-related adverse events and ischaemic complications. Physiological response and mortality will be recorded across pre-hospital and in-hospital phases.
Results: As a planned feasibility study, outcomes will be descriptive. The study will quantify successful pre-hospital application rates, characterise haemodynamic responses to device inflation and deflation, document adverse events, and report short- and medium-term mortality. These data will provide the first structured clinical evaluation of AAJT-S use in real-world trauma care.
Discussion: OCCLUDER will address a major evidence gap in the management of NCH by establishing whether pre-hospital AAJT-S application is feasible and safe in civilian trauma systems. Findings will inform Defence Medical Services and civilian providers regarding operational viability, risk–benefit balance, and the design of future definitive trials and clinical guidelines.
Wartime Carotid Injuries: an experience from Role 2 and Role 3 deployed field hospitals in Ukraine —
- National Academy of Medical Sciences of Ukraine, Kyiv, Ukraine
- State Institution of Science "Research and Practical Center of Preventive and Clinical Medicine", State Administrative Department, Kyiv, Ukraine
- Zaporizhzhia Military Hospital, Zaporizhzhia, Ukraine
- Armed Forces Medical Command, Ministry of Defense of Ukraine, Kyiv, Ukraine
- Department of Surgery, Verum Expert Clinic, Kyiv, Ukraine
Introduction: The Russo-Ukrainian war is associated with severe injuries. Vascular injury is frequent and associated with lethal outcome in most cases. Ballistic injury to carotid arteries is also fatal in many cases and saving patients' lives in such injuries is usually a surgical challenge. The aim of this study was to evaluate clinical features of combat-related carotid artery injuries and the utility of damage control surgery (DCS) application on Role 2 and Role 3 deployed field hospitals in Ukraine.
Patients and Methods: 10 male patients were diagnosed with ballistic penetrating extracranial carotid injuries. These patients were treated with application of DCS, integrating initial stabilization at Role 2 deployed field hospital and vascular reconstructions at Role 3 deployed field hospitals.
Results: Upon admission to Role 2 facilities, 6 (60%) patients presented with pulsatile hemorrhage (n=4) and expanding cervical hematoma (n=2). DCS included the placement of temporary intravascular shunts (TIVS) in 4 (40%) patients. Definitive surgical stabilization at Role 3 hospital included primary repair in 4 (40%), therapeutic ligation in 2 (20%), and interposition grafting in 4 (40%). Shunt-related thrombosis occurred in two patients with TIVS, both involving the use of non-standardized, improvised shunts due to lack of medical resources. Stroke was diagnosed in 3 (30%) patients, comprising one non-disabling and two disabling events. One patient died due to stroke. Patients remaining in follow-up demonstrated superior neurological outcomes, particularly those who underwent primary arterial repair.
Conclusions: Combat-related carotid injuries are severe; however, appropriate surgical management might include improvised shunts as a temporary measure at Role 2 hospital. Application of DCS is a useful approach in severe vascular trauma.
Selective non-operative management for abdominal trauma in the deployed military setting; a review of evidence and considerations for Large Scale Combat Operations (LSCO) —
- Academic Department of Military Surgery and Trauma
- Aneurin Bevan University Health Board
- Joint Hospital Group South-East, Frimley Park Health NHS Foundation Trust
- Torbay and South Devon NHS Foundation Trust
- Joint Hospital Group North, Leeds Teaching Hospitals NHS Trust
- Royal Centre for Defence Medicine
- Cardiff & Vale University Health Board
- Royal London Hospital
- Joint Hospital Group North, The James Cook University Hospital
- University Hospitals Birmingham NHS Foundation Trust
- University Hospitals Birmingham NHS Foundation Trust
Background: In recent decades there has been a recognition that selective non-operative management (SNOM) is both safe and feasible for selected patients following blunt and penetrating abdominal trauma. SNOM has been shown to reduce the rate of non-therapeutic laparotomies in the civilian context, even in the management of some patients with gunshot wounds (GSW). SNOM in the military context is both more controversial and challenging given the different patterns of injury, resource constraints and extended evacuation chain.
Methods: A review of the available literature was undertaken to help inform the development of best practice for military decision-making for deployed personnel. In anticipation of minimal military data regarding SNOM, attention was paid to translational evidence from the combined civilian-military literature.
Results: Suitable patients must be haemodynamically stable, without evidence of peritonitis, evisceration, bleeding or injury to hollow viscera and without associated significant head, spinal cord or other major extra-abdominal injury. SNOM in the deployed setting may help to avoid the morbidity associated with non-therapeutic laparotomy and conserve limited resources. However, caution is advised when translating mostly civilian data to the military setting, and future investigations should focus on military-specific injury patterns and resource limitations. Furthermore, the application of SNOM guidelines into the context of Large Scale Combat Operations (LSCO) is more complex and close monitoring of patient outcome data must be undertaken to evaluate the impact of SNOM in this context.
Conclusion: SNOM may be appropriate in a highly selected sub-group of military patients, in favourable circumstances.
Clinical management and outcome of gunshot injuries in four low- and middle-income countries —
- University of Birmingham, Birmingham, UK
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
- Stellenbosch University, Cape Town, South Africa
Background: Gunshot injuries vary in clinical presentation, management, and outcomes across settings, yet evidence from low- and middle-income countries (LMICs) remains limited. This study describes the epidemiology, care pathways, and hospitalisation outcomes of gunshot injuries across four LMICs.
Methods: We enrolled all patients with moderate to severe injuries presenting to 19 hospitals in Ghana, Pakistan, Rwanda, and South Africa between February 2023 and August 2024. Data were collected on patient demographics, injury characteristics, pathways from injury to definitive care, and hospitalisation outcomes, including mortality, length of stay, critical care admission, surgery, and blood transfusion.
Results: Among 8,811 eligible injured patients, 380 (4%) sustained gunshot injuries: Ghana 26/2,211 (1%), Pakistan 148/2,611 (6%), Rwanda 1/1,934 (<1%), and South Africa 205/2,055 (10%). Patients were predominantly male (93%), with a median age of 30 years (IQR 23–37). Overall, in-hospital mortality was 12%, with 73% of deaths occurring within 12 hours of admission. Mortality varied significantly by country, ranging from 0% in Ghana and Rwanda to 3% in Pakistan and 20% in South Africa (p<0.001). Median hospital stay was 8 days (IQR 4–15), ranging from 4 days in South Africa to 11 days in Ghana. Critical care admission occurred in 10% (37), 80% (304) underwent surgery, and 35% (132) received blood transfusion, with similar rates across countries. Ambulance transport was used in 57% (217), 47% (153/324) arrived after the first "golden hour," and 57% visited another facility prior to definitive care. Fear for personal safety and lack of ambulance availability were the most frequently perceived reasons for delays.
Conclusion: Gunshot injuries in LMICs disproportionately affect young adults and are associated with high early in-hospital mortality, substantial delays in accessing care, and frequent inter-facility transfers. Strengthening trauma system preparedness for gunshot injury is warranted to improve timely care and patient survival in high-burden settings.
Lunch and Poster Review
Preparation for Large Scale Combat Operations — what this means for me and surgical colleagues
Chief, Joint Trauma System
Construction of Fragment Simulating Projectiles to better simulate wounding mechanisms in contemporary Large Scale Combat Operations (ELECTORATE) —
- Defence Equipment and Support
- Academic Department of Military Surgery and Trauma
- Defence Science and Technology Laboratory
- Cranfield University
Introduction: The 1.10g Chisel-Nosed Fragment Simulating Projectile (CN FSP) is the standard for testing fragmentation protection of personal armour, and wound penetration into ballistic gelatin. Evidence from the current conflict in Ukraine would suggest that this may not be the most representative choice compared to naturally occurring explosively propelled fragments. No evidence exists to ascertain the effect of a random shape on penetration compared to a cylinder.
Method: A randomly shaped fragment of 0.98g (FSP-1) was identified as the most similar in mass (from the samples available) to the 1.10g CN FSP. FSP-1 and a commercially procured 1.10g CN FSP (FSP-2) were three-dimensionally (3D) scanned and subsequently 3D printed in stainless steel filament and then sintered. A gas gun was used to propel these saboted 3D printed FSPs as well as a standard commercially procured 1.10g FSP (FSP-3) into 20% ballistic gelatin. High Speed Video captured measurements including temporal and permanent cavities as well as Depth of Penetration (DoP).
Results: Randomly shaped fragments were successfully printed from measurements made from low-cost scanning devices, and print settings were optimised to achieve successful, repeatable samples. Several iterations of sabot design for random fragment shape ensured stable flight dynamics and impact point. Variances in behaviour of CN FSPs and natural fragments were noted across all measurements made of the wounding profiles in ballistic gelatin.
Discussion: At comparable velocities, no significant difference in DoP was found between FSP-2 and FSP-3; this would validate that printing and sintering produces a projectile with comparable physical properties to one cast and machined. FSP-1 demonstrated significantly different DoP than the CN cylinder of equal nominal mass, suggesting geometry and sharpness play a part. It is recommended that further testing be undertaken on different sizes and shapes of random shaped FSPs, against ballistic gelatin and representative armour materials.
Towards optimising body armour plate coverage using Open 0.5T MRI: interim results showing posture-induced changes in torso organ boundaries —
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, UK
- School of Physics and Astronomy, University of Nottingham
- Defence Equipment and Support, Ministry of Defence, United Kingdom
- Defence Science and Technology Laboratory, Fareham, United Kingdom
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, United Kingdom
Introduction: Body armour plates are crucial in protection against ballistic threats. To optimise their coverage, we need to know the size, shape and position of torso anatomies in combat-relevant postures: standing, sitting or prone. Conventional MRI cannot provide this information as images are acquired in supine posture. In this study, we used an Open 0.5T MRI (oMRI) scanner to image the torso anatomy in more combat-relevant postures to quantify posture- and breathing-induced changes in their boundaries and evaluate coverage of an armour with known dimensions.
Methods: We scanned 27 military personnel (12 males) supine and upright at complete-inhale or tidal-exhale breath-holds. A purpose-built X-shaped receiver coil enabled scanning whilst standing or wearing armour. In-house Python software combined thoracic and abdominal images to create complete, torso image sets. Organs were manually segmented using 3D slicer. The absolute distances of lateral and longitudinal boundaries of liver, heart, and spleen (organs requiring hard-plate coverage) were measured from the suprasternal notch (SN) for each posture. Coverage boundaries were plotted against the known NIJ(USA) armour dimensions.
Results: At upright, coverage boundaries often lie outside the NIJ armour plates. There are longitudinal and lateral shifts in organs as posture changes from supine to upright.
Discussion: This preliminary analysis shows the utility of oMRI in acquiring crucial information for optimal armour design. All organs shift downwards, and some (heart and spleen) laterally, when standing, due to redistribution related to the effects of gravity. Trends in lateral movement were similar, while deep breathing caused a more pronounced downward shift, compared to supine. NIJ-USA armours do not completely cover all organs, particularly during deep breathing. Future work will produce a normative model of organ distribution to allow selection of more tailored body armour plates for service personnel.
Determining the size and position of torso organs using Magnetic Resonance Imaging to inform body armour coverage —
- Defence Science and Technology Laboratory, Fareham, United Kingdom
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, United Kingdom
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, UK
While a large body of work has been undertaken on the coverage of torso organs by body armour, there are substantial information gaps remaining. This study aims to cover some of these gaps by: showing how widths and depths of the heart, liver and spleen correlate to chest breadth and depth; determining if correlations exist between the size and position of medically essential torso organs and the external anatomical landmarks of the suprasternal notch, lower border of 10th rib and iliac crest; developing three-dimensional (3D) Computer Aided Design (CAD) geometry of a range of sizes of males and females; and capturing the current position and coverage of UK body armour plates, as worn.
We outline the method and initial outputs for a study utilising Magnetic Resonance Imaging (MRI) scans in the supine and standing positions, that captured the size and position of medically essential torso organs (heart, great vessels, liver and spleen) and compared to external body markers (suprasternal notch, 10th rib and iliac crest) and anthropometric measurements (chest width and depth). Scans in the standing position were repeated while wearing UK hard armour plates with fiducial markers emplaced to enable their capture during MRI, which is used to determine the position of hard plates in the standing posture as worn, for the first time. Examples of coverage boundaries, actual plate coverage and correlation to external measurements are presented.
Thirty UK armed forces participants were chosen to represent a range of torso sizes of males and females. The analysis of the scan data provides new information that quantifies the armour coverage on a range of sizes of males and females representative of the UK armed forces, that will help the MOD to procure body armour that provides an effective fit and coverage to military personnel.
Designing hard armour plates specifically for women using ballistic coverage and anthropometric data —
- NP Aerospace Limited
Hard armour plates that are designed for men, such as the industry-standard ESAPI, are well-known to be uncomfortable when worn by women. However, this paper highlights that alongside discomfort are worrying concerns that women are less protected when compared to men wearing the same armour systems. A woman's breast volume causes a standoff between the torso and the hard armour plate, creating areas of ballistic exposure not apparent on men. Curving the hard armour plate to accommodate the breast volume is the most appropriate solution. At present, the international community has not widely accepted any hard armour plates designed for women.
This paper discusses the approach to designing hard armour plates specifically for women, using ballistic coverage requirements defined by Breeze et al. 2023, and world-leading anthropometric data from the UK Ministry of Defence's Anthropometric Data 2024. A bespoke method of assessing ballistic coverage in 3D was developed in lieu of a women's iteration of Dstl's Coverage of Armour Tool (COAT). This bespoke tool allowed the consideration of curvature throughout the design approach.
MIND YOUR HEAD: potential of Open MRI brain imaging at combat-relevant postures to compare coverage and suspension of combat helmets —
- Sir Peter Mansfield Imaging Centre, University of Nottingham, UK
Introduction: Traumatic brain injuries are one of the major causes of death in recent conflicts. While high-cut helmets are increasingly popular due to being lightweight and their ability to accommodate attachment of communication devices during combat, limited evidence is available on the anatomical coverage of 'high-cut' and 'full-cut' helmets and how these change between different combat-relevant postures, padding and suspension system. This study proposes using Open MRI (oMRI) to compare the brain and brain-stem protection efficacy of different combat helmets. While conventional MRI scanners can only acquire images laying down, oMRI scanners can provide the coverage and suspension information at different combat-relevant postures (e.g. standing, seated, and prone) for optimising head safety in warfare.
Proposed Method: We have developed a purpose-built RF coil to scan heads while wearing helmets at upright and prone postures, with the following analysis pipeline: three anatomical landmarks (vitamin E tablets) will be placed on the bony part of the head (nasion, external auditory meatus and superior nuchal line) to mark the desired coverage margin; three to four additional landmarks will be drilled into test helmets to delineate helmet geometry on the MRI scans; head MRI data at different postures will be segmented to extract the brain, brainstem, major vessels and other vital features; and finally, surface geometry with helmet landmarks will be superimposed on the brain areas to quantify coverage.
Discussion: We are currently optimising the sequence, set up and protocol for imaging, to be ready to present at the conference. University of Nottingham, in collaboration with DSTL, DE&S, DMS, and MOD, has successfully completed body armour coverage study implementing oMRI scans. Our target is to extend this expertise into investigating helmet coverage. This study will enable MOD to make informed choices by considering the safety, agility and comfort aspects of different helmets for diverse battle environments, e.g. high-risk vs high-mobility.
Medical Intelligence in Large Scale Conflict Operations: Implications for UK Personal Protective Equipment design —
- Project RENOVATOR, Defence Medical Services, Cyber & Specialist Operations Command, Northwood HQ, Sandy Lane, Northwood, Middlesex
- Academic Department of Military Surgery and Trauma, Research & Clinical Innovation (RCI), ICT Centre, Vincent Drive, Edgbaston, Birmingham
Current PPE requirements are based upon timelines to Damage Control Surgery of 1–2 hours, yet in Ukraine this is closer to 10–12 hours. Medical intelligence confirms that evacuation will be protracted and hazardous. Greater coverage against energised fragmentation should be prioritised. Death from extremity haemorrhage can be mitigated with a tourniquet but will require protective material to be added to the upper arms of the UBACS shirt and adjustment to either pelvic coverage or the combat trousers.
Urgent testing is required to ascertain whether our soft armour optimally protects against the latest threats. The use of ear protection is essential but should never compromise combat helmet coverage, which must always be maximised. Brain coverage would be improved by moving from a suspension system to pads, and the incorporation of sensors would enable even the most rudimentary triage of traumatic brain injury further forwards.
A more flexible approach towards scalability is required. Ballistic protection does not have to be in conventional armour — the war in Ukraine shows that reinforced clothing, specialised outwear such as jackets/hoods and portable shields are all potentially effective in different scenarios. A baseline of protection should be considered within combat shirts and trousers. This could be supplemented by SAF in a conventional manner such as a body armour vest, but as materials science increases it could even be worn with a plate carrier alone.
Ukraine has demonstrated that we must challenge the convention that heavy all-protecting ceramic plates are the default option. Instead, they should be seen as the extreme end of protection, with lighter weight polyethylene plates capable of protecting against the most likely threats. We describe 14 urgent recommendations to alterations in current UK PPE design, based upon contemporary medical intelligence, that must be embraced to enhance soldier survivability in the predicted LSCO battlefield.
Refreshments
Panel 1 — Research In Contact: the LSCO Challenge
Conclusion of Day 1; arrangements for evening reception and dinner
for 1930
Gala Dinner at the Army & Navy Club
–0915
How to get published in military and conflict trauma science
Coffee
Opening Comments
Conflict Wound Science — the questions to answer before Large Scale Combat Operations
A Two-Stage Deep Learning Framework Achieves Generalizable Military Wound Segmentation Using Civilian Training Data —
- Uniformed Services University (USU) Surgical Critical Care Initiative (SC2i), Bethesda, MD, USA
- Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Birmingham, UK
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
- Department of Surgery, Emory University, Atlanta, GA, USA
Background: Accurate wound boundary segmentation supports objective trauma assessment, yet acute extremity wounds span diverse mechanisms whose heterogeneity likely exceeds any single-institution dataset. We hypothesized that pairing a lightweight wound-detection model with an adapted general-purpose segmentation model could generalize from civilian to military trauma populations without an exhaustive combat-wound dataset.
Methods: A first-stage model detects the wound and then passes a bounding box to the Segment Anything Model (SAM2.1) for boundary segmentation. We trained two lightweight, mobile-compatible first-stage models (EfficientNet-B0 and FastViT-T8) and adapted SAM2.1 to wound images, both using the same training data. Training used 599 extremity wound images from 101 patients at a civilian trauma center, with patient-level splitting to ensure no patient appeared in both training and testing sets. Internal testing used 116 images from 21 held-out patients; external testing used 100 military extremity trauma images from 27 patients at a separate institution. Dice coefficients (a measure of segmentation overlap) are reported with patient-level bootstrap 95% confidence intervals (CIs).
Results: With SAM2.1 refinement, EfficientNet-B0 improved the Dice coefficient from 0.961 to 0.969 internally and from 0.956 to 0.962 (95% CI 0.950–0.970) externally. FastViT-T8 improved from 0.955 to 0.965 internally and from 0.947 to 0.962 (0.950–0.970) externally. FastViT-T8+SAM2.1 significantly outperformed standalone FastViT-T8 on external data (Wilcoxon p=0.005), improving wound boundary predictions for 24% of images while degrading 8%, a 3:1 benefit-to-harm ratio; internally, the ratio was 7:1. The already-stronger EfficientNet-B0 by itself benefited less from refinement (12% improved, 7% degraded externally; p=0.269), consistent with SAM2.1 preferentially rescuing the weakest predictions.
Discussion: A segmentation framework trained exclusively on civilian wounds generalizes to military trauma, reducing reliance on scarce combat-specific datasets. The refinement step adds resilience by rescuing suboptimal predictions while rarely degrading strong ones. The lightweight architectures support mobile deployment, potentially enabling objective wound assessment across all echelons of care.
Disclaimer: The contents of this presentation are the sole responsibility of the author(s) and do not necessarily reflect the views, opinions, or policies of the Uniformed Services University of the Health Sciences (USUHS); the Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc.; the Department of War (DoW); or the Departments of the Army, Navy, or Air Force. Mention of trade names, commercial products, or organizations does not imply endorsement by the U.S. Government.Towards a Digital Twin Framework for Combat Wound Management: A Systematic Scoping Review —
- School of Engineering and Materials Science, Queen Mary University of London, London, UK
- Digital Environment Research Institute, Queen Mary University of London, London, UK
- University Hospitals Birmingham NHS Foundation Trust, UK
- Academic Department of Military Surgery and Trauma, Defence Medical Services, Lichfield, UK
- Department of Trauma Surgery, Barts Health NHS Trust, London, UK
Introduction: Combat wounds, including blast, ballistic, and thermal injuries, present complex, multidimensional management challenges inadequately addressed by current clinical decision support tools. Digital twin (DT) technologies, computational modelling and simulation (CM&S), artificial intelligence and machine learning (AI/ML) have shown increasing utility in wound care, yet their application to military trauma remains poorly characterised. This review maps DT and CM&S approaches in combat wound management, assesses integration of military-relevant data and injury mechanisms, and defines components for a Digital Twin for Combat Wounds (DTCW) framework.
Method: A systematic scoping review was conducted following PRISMA guidelines. PubMed, Scopus, and IEEE Xplore were searched (January 2015 – present) using a strategy targeting: (1) wound and injury types, including blast, ballistic, and thermal mechanisms; (2) CM&S, DT, and AI/ML approaches; and (3) clinical wound management and decision support. Following deduplication, 585 records were screened in EndNote, and the full texts were reviewed against the eligibility criteria. Data extraction employed a structured seven-dimensional coding framework (wound type, model purpose, approach, data inputs, availability, validation stage, and uncertainty reporting).
Results: Preliminary synthesis indicates that most computational wound care studies rely on imaging data and civilian trauma registries, focusing predominantly on chronic wound classification and monitoring. Emerging ML-assisted, sensor-integrated smart dressing systems demonstrate feasibility for real-time adaptive wound monitoring, highlighting the translational potential of AI-driven approaches in wound management. Military-specific data sources and blast or ballistic injury mechanisms remain underrepresented.
Discussion: This review identifies substantive gaps between current computational approaches for modelling military wound progression and the requirements of combat casualty management. We propose a research roadmap for a DTCW framework integrating injury mechanism modelling, pathophysiological simulation, uncertainty-aware prediction, and deployable clinical decision support. This work aligns with international digital twin health initiatives, including EDITH, and aims to inform capability development for frontline and hospital-level military trauma management.
Project CIRCUIT — Conflict Injury Response and Characterisation Using Isolated, perfused Tissue —
- Academic Department of Military Surgery and Trauma (ADMST)
- Institute of Biomedical Engineering, University of Oxford
The current geopolitical climate has led to a sharp rise in large-scale conflict, causing significant casualties from high-energy trauma. However, the biological and cellular responses to such trauma remain poorly understood. In this unstable and evolving context, with likely prolonged timelines to definitive medical care, there is a critical need for high-fidelity models that replicate traumatic injury to enhance our understanding and early treatment of such complex conditions.
Ex vivo perfusion (EVP) is an emerging research field offering promise in perfusing whole limbs and tissue composites. EVP preserves the complex and specific cytoarchitecture of human tissue in ways that current models cannot. EVP involves circulating an oxygenated solution through tissues via a perfusate reservoir and pump system. Innovations in this area have been driven by teams in Manchester and Oxford, primarily for solid organ transplantation.
This project aims to develop a portable, benchtop model of perfused composite human tissue to study the biology of high-energy traumatic injuries. It will leverage the validated OrganOx metra platform to perfuse human muscle tissue. Ultimately, through collaboration with the Defence Science & Technology Laboratory (Dstl), this project aims to expose live, perfused human tissue composites to high-energy injury (e.g. blast shock wave or penetrating ballistic insult) in order to capture cellular and sub-cellular responses.
Unlike existing porcine hindlimb models, this work proposes to use ethically sourced human tissue and will be tailored to interface with capability to induce relevant injury (e.g. at Dstl Porton Down). The goal is to provide a translational model that better represents human trauma and supports future research into military-specific injury mechanisms and therapeutic interventions that will confer better clinical outcomes during large scale combat operations (LSCO).
A Novel intact brown seaweed scaffold (BSS) for Early Management of Complex Contaminated Combat Wounds —
- University of Iceland
- Landspitali University Hospital, Reykjavík, Iceland
- University of Iceland, School of Health Sciences, Medical Department
- University of Reykjavik, School of Science and Engineering
- University of Iceland, Industrial Engineering and Computer Science Department
Introduction: Modern combat injuries frequently result in contaminated wounds with extensive tissue destruction. Prolonged field care may be required due to delayed access to definitive care. Current field dressings primarily provide coverage and absorption but do not actively support early tissue regeneration or inflammatory modulation. There remains a critical need for advanced deployable wound products that can be applied prior to secondary dressings for enhanced haemostasis, bacteriostatic properties, and early tissue regeneration. This study evaluates a novel intact decellularized BSS as a candidate for such applications.
Methods: Biocompatibility was assessed; cytotoxicity, dermal sensitization and irritation as well as acute systemic toxicity were tested in accordance with ISO 10993 standards. Additionally, in a full-thickness porcine wound model, 3×3 cm excised square wounds were randomised to BSS, standard of care (SOC), or Aquacel®. Macroscopic images and histological biopsies were collected on days 7, 14, 21 and 60.
Results: BSS extracts demonstrated non-cytotoxicity, maintaining keratinocyte viability ≥70% at all time points. Standardized acute systemic toxicity, skin sensitization and irritation showed favourable results. The scaffolds facilitated direct cell attachment and ingrowth in vitro. In vivo porcine results indicate that BSS is biocompatible and elicited immunological responses comparable to both SOC and Aquacel®. Additionally, granulation tissue, macrophage activity, and re-epithelialisation were more pronounced in BSS-treated wounds.
Discussion: The brown seaweed scaffold demonstrated favourable biocompatibility and regenerative characteristics in vitro and in vivo. These findings support further investigation of BSS as a potential early-applied wound product for complex contaminated injuries in military and austere environments, including evaluation of its potential haemostatic and innate antimicrobial properties in prolonged field care models. Particular attention should be given to retained fucoidan and alginate, sulfated polysaccharides known for antibacterial activity, biofilm inhibition, platelet interaction, and possible promotion of early clot stabilization and hemostasis.
Diphoterine®: Scoping Review and Potential Future CBRN First Aid Applications —
- Academic Department of Military Surgery & Trauma
- Defence Science & Technology Laboratory
- Consultant Burns & Plastic Surgeon, Royal Army Medical Service
Introduction: There is a potential threat of chemical weapons against British soldiers in Large Scale Combat Operations (LSCO). Current decontamination and first aid measures include removal of contaminated clothing, irrigation with water, and use of dry absorbents. Delays in treatment and prolonged evacuation times in LSCO require treatments to be pushed further forward and into the hands of non-vocational healthcare providers. Diphoterine® is a hypertonic, amphoteric and chelating rinsing solution effective against acids or alkalis, which prevents further tissue damage and is sight saving. Diphoterine® has increasing use in chemical manufacturing and law enforcement. Authors aimed to perform a scoping review of the literature to assess the potential utility of Diphoterine® in Defence CBRN first aid and decontamination.
Methods: In accordance with PRISMA guidelines, a scoping systematic review was performed. Systematic searches of PubMed/MEDLINE and Web of Science were conducted, followed by a bibliographic review and grey literature search to ensure a full capture of Chemical Warfare Agents related literature.
Results: Searches found 714 references; following exclusions 42 papers were included in final full text analysis. Diphoterine® was found to reduce severity and duration of symptoms following chemical exposure; reduce severity of injury in ocular and skin chemical exposure as well as reduce healing time. Diphoterine® has been shown to be safe, with no reported systemic toxicity effects. Diphoterine® showed greater effectiveness against ocular injury in Nitrogen Mustard exposure versus saline, as well as reducing symptoms and recovery time following CS gas exposure. Lack of homogeneity in the literature meant meta-analysis was not possible.
Conclusions: Diphoterine® is a safe, practical and effective option for first aid following chemical exposure and is a potential avenue to more effective self or buddy-buddy treatment, allowing soldiers to return back to the fight. Potential military applications and targets for future research will be discussed.
Refreshments
A Surgical Night Vision Device Suitable for Military Operations —
- Madigan Army Medical Center, Tacoma, Washington, USA
- The Geneva Foundation, Tacoma, Washington, USA
- Department of Electrical and Computer Engineering, University of Iowa, Iowa City, Iowa, USA
Night vision devices (NVDs) are essential for military tactical advantage, but their utility extends to the medical field, permitting the performance of medical operations in low-light environments. In large-scale combat operations (LSCO), where casualty evacuation is often delayed, the ability to conduct procedures effectively and discretely in a forward-operating environment is critical. However, standard tactical NVDs have various limitations for such an application. Within the past decade, we sought to develop a medically-optimized NVD for identifying and treating life-threatening injuries in austere conditions.
Initial studies in our lab using a porcine polytrauma model have confirmed the feasibility of performing life-saving surgical interventions with standard NVDs. Importantly, it also highlighted the shortcomings of these devices for medical interventions. Our first surgical NVD prototype featured improved ergonomics, dynamic magnification, autofocus, and the ability to display data from ultrasound and vital sign monitors. This system used stereoscopic imaging, adjustable microdisplays, and high-power near-infrared (NIR) LEDs controlled by a handheld device.
The current prototype improves upon this design, offering better resolution, faster autofocus, and a smaller, self-contained device, eliminating the need for an external laptop. To validate the prototype, military surgeons will perform procedures from the Advanced Surgical Skills for Exposure in Trauma (ASSET) course on cadaveric and live-tissue porcine models in early 2026, comparing its efficacy to standard NVDs.
Future refinements will focus on integrating peer-to-peer connectivity directly into the device as integrating telemedicine capabilities for expert consultation may enhance its life-saving potential. Though developed for the military, this technology also has the potential to significantly improve pre-hospital care in the civilian sector.
A Blended, Scalable Approach to Surgical Training for Military and Austere Environments: Virtual Reality and Low-Cost Physical Models with Smartphone-Based Augmentation —
- Imperial College London, London, United Kingdom
- Department of Surgery, Imperial College NHS Trust, London, United Kingdom
- Department of Burns and Plastic Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
- Portsmouth Hospitals University NHS Trust, Portsmouth, United Kingdom
- Brighton and Sussex Medical School, Brighton, United Kingdom and Queen Victoria Hospital, East Grinstead, United Kingdom
Introduction: Surgical education within military and austere environments is constrained by limited operative exposure, variable case mix, and restricted access to high-fidelity simulation infrastructure. There is a need for integrated, scalable training frameworks that combine digital education with practical simulation, adaptable to deployed, humanitarian, and resource-limited settings.
Method: Over a twelve-month period, a blended surgical education programme was developed and delivered, combining three complementary modalities: (1) an immersive virtual reality (VR)–based procedural training surgical library through the Virtual Reality in Medicine and Surgery (VRiMS) platform; (2) hands-on porcine simulation models for burns excision, skin grafting, and amputation training; and (3) low-cost, self-constructed physical simulation models for core reconstructive and orthoplastic techniques, including local flaps, external fixation principles, and cleft-related repair. These models were supported by a smartphone-based application providing anatomical guidance, touchscreen-based procedural walkthroughs, and interactive decision-making modules. Educational impact was evaluated via multiple workshops across medical schools and NHS trusts using pre- and post-session knowledge assessments, five-point Likert-scale confidence measures, and Objective Structured Assessment of Technical Skills (OSATS), with non-parametric statistical analysis.
Results: Across modalities, over 1000 participants demonstrated significant improvements in procedural knowledge, anatomical understanding, and technical performance following training (p < 0.05). VR-based training was associated with marked gains in procedural confidence and knowledge acquisition, while porcine and physical simulation models produced consistent improvements in tissue handling, instrument use, and procedural flow on OSATS assessment. Participants rated the combined approach highly for realism, and accessibility.
Discussion: This integrated training framework demonstrates a pragmatic approach to surgical education that aligns with the operational needs of military and trauma systems. By combining immersive VR, biologically realistic porcine models, and low-cost self-constructed simulators with smartphone augmentation, this model supports decentralised training, pre-deployment preparation, and skills sustainment across diverse environments.
Code Red Trauma Simulation: from MOSTT to civilian readiness at the South Wales Major Trauma Centre —
- School of Medicine, Cardiff University
- Academic Department of Military Surgery and Trauma
- Aneurin Bevan University Health Board
- Swansea University, Cardiff and Vale University Health Board
- Royal Centre for Defence Medicine
- Cardiff and Vale University Health Board
Background: Managing major trauma requires rapid co-ordination and understanding of Damage Control Surgery (DCS) protocols. However, exposure to DCS is limited in many UK Major Trauma Centres (MTCs). Given the increasing possibility of Large-Scale Combat Operations (LSCO), there is a need to develop scalable models to upskill large numbers of civilian clinicians to military trauma standards. Based on the Military Operational Surgical Team Training (MOSTT) course, this Code Red Trauma Simulation course was developed to improve the confidence of trauma team members at the South Wales Major Trauma Centre (MTC).
Methods: Following a 2024 pilot, the course evolved into a comprehensive one-day multidisciplinary course in April 2025. Training for Emergency Medicine (EM), anaesthetists, general surgeons, orthopaedics, theatre nurses and EM nurses focused on Code Red pathways, human factors, and technical skills. Confidence changes were measured using a Global Perceived Effect (GPE) scale (-5 to +5).
Results: The 2024 pilot demonstrated significant confidence gains across all roles, though it identified a need for broader MDT inclusion and improved realism. Surgeons benefitted most from the opportunity to practice DCS skills on realistic mannequins. By the 2025 iteration, confidence in trauma team collaboration and inter-specialty communication rose significantly (+4.3 and +4.2 respectively). EM physicians reported increased confidence in leading resuscitations (+2.6), and nurses gained technical proficiency with Belmont rapid transfusers (+1.0). Qualitative feedback emphasised the value of "mental models" and understanding the ED-to-theatre trajectory.
Conclusion: This iterative, military-inspired simulation course effectively standardises DCS protocols in civilian settings. It provides a scalable training framework essential for national readiness and the rapid upskilling of civilian clinicians in the event of LSCO and mobilisation of civilian clinicians.
The Creation and Evaluation of an AI-Based Educational Tool for Military Surgical Readiness in a Deployed Setting —
- Vanderbilt University, Nashville, Tennessee, USA
Introduction: Maintaining surgical readiness among reservists and civilian-augmentee surgeons remains a persistent challenge. Current training opportunities, including classroom instruction and field exercises, provide limited exposure to casualty care in austere, resource-constrained environments. These gaps are particularly acute where clinical reasoning must account for Role 2/3 capabilities, evacuation timelines, and material limitations. A validated AI-based clinical education platform was adapted to address these military-specific training requirements. We sought to (1) configure the platform to incorporate military casualty care workflows, doctrinal guidelines, and resource-constrained decision pathways, and (2) evaluate its operational relevance and training utility for military surgical education.
Methods: The platform delivers case-based scenarios through a speech-to-text interface with adaptive branching logic that challenges clinical reasoning under evolving tactical conditions. TCCC-aligned workflows, damage control surgery decision trees, and resource allocation constraints reflecting austere operational environments were integrated into the scenario architecture. A structured evaluation framework assessed fidelity to military surgical doctrine, operational relevance, and capacity to drive context-appropriate clinical decision-making. The tool was tested across multiple military case scenarios and reviewed against this framework.
Results: The adapted platform generated Role 2/3-relevant scenarios emphasizing damage control decision-making, resource-limited resuscitation, and casualty receipt. Evaluation showed alignment with correct interventions and damage control resuscitation and surgery guidelines, and moderate-to-strong alignment in resource constraint integration. Alignment with military casualty workflow and TCCC protocol was predominantly moderate, and multi-casualty capability was demonstrated when indicated. Handoff artifacts also showed to be moderately aligned. Limitations included blood product specificity and the incorporation of team-based and operational stress variables.
Conclusions: An AI-based educational platform can be adapted to deliver case-based surgical training for deployed settings, offering a scalable, on-demand modality addressing readiness gaps for surgeons with limited access to field exercises. Further development should target multi-user scenarios, tactical communication integration, and prospective validation with military surgical trainees.
Global surgical preparedness through Defence Engagement: a multi-national Training Needs Analysis (TNA) to guide surgical system strengthening —
- Academic Department of Military Surgery and Trauma
- Global Surgery Policy Unit
- Aneurin Bevan University Health Board
- SUUBAN – Center for Health System Strengthening, Somaliland
- LSE Health, London School of Economics and Political Science
- Cardiff and Vale University Health Board
Background: During Large Scale Conflict Operations (LSCO) the UK will be reliant on host nation support to provide care for the large volumes of expected casualties. Ensuring host nation surgical systems are capable and resilient is in the UK national interest. However, surgical system strengthening is often hampered by a lack of objective data regarding specific skill gaps. This research sought to apply a validated Training Needs Analysis framework to quantify training needs among surgical and anaesthesia providers in Somaliland and South Africa.
Methods: A mixed methods study was conducted using the psychometrically validated Hicks-Hennessy Training Needs Analysis (TNA) tool. The tool was evaluated in collaboration with partner organisations to ensure it was relevant to the host nation system. Clinicians in Somaliland (n=110) and South Africa (n=59) rated each task for its 'importance to their role' and their 'current performance' along with the importance of 'improving training' against 'improving work situation'.
Results: In Somaliland, emergency cricothyroidotomy, reliable oxygen monitoring and the use of the WHO Surgical Safety Checklist were identified as priority interventions. In South Africa, while surgeons felt well prepared for practice, training needs were identified in sub-specialist procedures, simulation methods and non-technical skills. Despite the vast differences in healthcare infrastructure between the two nations, the systemic lack of research training emerged as a universal barrier to surgical system strengthening.
Conclusion: Preparedness is not purely the number of clinicians, but the ability of the clinician and the system to deliver those skills where and when it matters to patients. This research demonstrates that a standardised TNA is pragmatic, cost-effective and can provide data to potentially strengthen surgical systems. This methodology offers a scalable model for Defence Engagement and to strengthen host nation trauma care pathways ahead of support during Large Scale Combat Operations.
AI-Enabled Distributed Training Infrastructure to Support Rapid Scaling of Procedural Competence in Conflict and Mass-Casualty Settings —
- University College London
Introduction: Future large-scale conflict scenarios will require rapid expansion of a clinically competent workforce to manage mass-casualty trauma. Training capacity is constrained by reliance on expert faculty, limited scalability, and challenges in standardising competency assessment across distributed environments. Scalable systems that support both training and objective assessment are needed to enhance operational readiness.
Methods: An AI-supported platform combining video and audio capture with automated assessment against predefined procedural checkpoints was evaluated in UK medical education settings. In a mixed-methods pilot study at a single institution, students performed procedural tasks (e.g., venepuncture, digital rectal examination), with performance assessed by both expert clinicians and the AI system. Agreement was evaluated using Cohen's kappa. A second pilot study at a separate institution explored usability, perceived educational value, and engagement with AI-generated feedback during simulated skills training.
Results: Agreement between AI and human assessors demonstrated moderate reliability (κ ≈ 0.47–0.56 following adjustments), comparable to inter-rater agreement reported between clinicians in similar procedural assessment contexts. Users reported high usability and educational value, highlighting benefits including immediate feedback, opportunity for repeated independent practice, and enhanced reflection. Analysis of disagreement patterns identified systematic sources of error, informing iterative system refinement.
Discussion: AI-enabled assessment platforms may provide a scalable method for training and verifying procedural competence across distributed settings. In military contexts, this approach could support rapid upskilling of combat medics, reservists, and civilian personnel, while reducing reliance on expert trainers and enabling standardised competency verification during surge scenarios.