Exposure to a Virtual Reality Mass-Casualty Simulation Elicits a Differential Sympathetic Response in Medical Trainees and Attending Physicians

Abstract

Background: Previous studies have demonstrated the use of virtual reality (VR) in mass-casualty incident (MCI) simulation; however, it is uncertain if VR simulations can be a substitute for in-person disaster training. Demonstrating that VR MCI scenarios can elicit the same desired stress response achieved in live-action exercises is a first step in showing non-inferiority. The primary objective of this study was to measure changes in sympathetic nervous system (SNS) response via a decrease in heart rate variability (HRV) in subjects participating in a VR MCI scenario. Methods: An MCI simulation was filmed with a 360º camera and shown to participants on a VR headset while simultaneously recording electrocardiography (EKG) and HRV activity. Baseline HRV was measured during a calm VR scenario immediately prior to exposure to the MCI scenarios, and SNS activation was captured as a decrease in HRV compared to baseline. Cognitive stress was measured using a validated questionnaire. Wilcoxon matched pairs signed rank analysis, Welch’s t-test, and multivariate logistic regression were performed with statistical significance established at P <.05. Results: Thirty-five subjects were enrolled: eight attending physicians (two surgeons, six Emergency Medicine [EM] specialists); 13 residents (five Surgery, eight EM); and 14 medical students (six pre-clinical, eight clinical-year students). Sympathetic nervous system activation was observed in all groups during the MCI compared to baseline (P <.0001) and occurred independent of age, sex, years of experience, or prior MCI response experience. Overall, 23/35 subjects (65.7%) reported increased cognitive stress in the MCI (11/14 medical students, 9/13 residents, and 3/8 attendings). Resident and attending physicians had higher odds of discordance between SNS activation and cognitive stress compared to medical students (OR = 8.297; 95% CI, 1.408-64.60; P = .030). Conclusions: Live-actor VR MCI simulation elicited a strong sympathetic response across all groups. Thus, VR MCI training has the potential to guide acquisition of confidence in disaster response.

Learner Evaluation of an Immersive Virtual Reality Mass Casualty Incident Simulator for Triage Training

“…Although, we screened for motion sickness prior to entry into the MCI-VR system, we did not ask participants about the impact of the system on them, either physiologically or psychologically, after the encounter. [34] While we assume from their positive evaluations that participants responded to the simulation similarly to a real-life incident, we were not able to verify this assumption.…”

Using High-Fidelity Virtual Reality for Mass-Casualty Incident Training by First Responders – A Systematic Review of the Literature

“…25,26,34 However, compared to live simulation, the perceived amount of physiological work was lower when training with VR. 25,35 Stress hormone levels measured in saliva 35 and the heart rate at the beginning of the training 25,34 were significantly lower when VR training was compared with live-simulation training. However, both heart rate and blood pressure increased during the training scenarios, and in total, there were no differences between VR and live-simulation training.…”

“…35 Nevertheless, the overall physiological demands were perceived higher with live simulation. 25,34 Improved Preparedness-The first responders became more confident in their overall disaster skills after training with VR, and they felt more prepared for real-life MCIs. 22,24,26,27,29,31,36 They highlighted that they felt more capable of prioritizing resources and identifying high-risk patients 21,30 and felt they could gather enough relevant cues to identify risk situations in general after training.…”

Training critical care teams for disaster response: Mass casualty incident simulation

“…Multiple simulation modalities are available for individuals and/or teams to aid training for disaster response. 11,13 Tabletop exercises, such as Emergo Train System, 14 involve simulation of an MCI event using roleplaying scenarios in a low-stress environment. These can involve a single department or multiple agencies and allow a team to step through MCI protocols and demonstrate adherence to MCI triage principles and management of available resources.…”

“…Multiple simulation modalities are available for individuals and/or teams to aid training for disaster response 11,13 …”