Background: Virtual reality (VR) is increasingly used as simulation technology in emergency medicine education and training, in particular for training nontechnical skills. Experimental studies comparing teaching and learning in VR with traditional training media often demonstrate the equivalence or even superiority regarding particular variables of learning or training effectiveness. Objective: In the EPICSAVE (Enhanced Paramedic Vocational Training with Serious Games and Virtual Environments) project, a highly immersive room-scaled multi-user 3-dimensional VR simulation environment was developed. In this feasibility study, we wanted to gain initial insights into the training effectiveness and media use factors influencing learning and training in VR. Methods: The virtual emergency scenario was anaphylaxis grade III with shock, swelling of the upper and lower respiratory tract, as well as skin symptoms in a 5-year-old girl (virtual patient) visiting an indoor family amusement park with her grandfather (virtual agent). A cross-sectional, one-group pretest and posttest design was used to evaluate the training effectiveness and quality of the training execution. The sample included 18 active emergency physicians. Results: The 18 participants rated the VR simulation training positive in terms of training effectiveness and quality of the training execution. A strong, significant correlation (r=.53, P=.01) between experiencing presence and assessing training effectiveness was observed. Perceived limitations in usability and a relatively high extraneous cognitive load reduced this positive effect. Conclusions: The training within the virtual simulation environment was rated as an effective educational approach. Specific media use factors appear to modulate training effectiveness (ie, improvement through “experience of presence” or reduction through perceived limitations in usability). These factors should be specific targets in the further development of this VR simulation training.

Background: Adequate training and preparation of medical first responders (MFRs) are essential for an optimal performance in highly demanding situations like disasters (e.g., mass accidents, natural catastrophes). The training needs to be as effective as possible, because precise and effective behavior of MFRs under stress is central for ensuring patients’ survival and recovery. This systematic review offers an overview of scientifically evaluated training methods used to prepare MFRs for disasters. It identifies different effectiveness indicators and provides an additional analysis of how and to what extent the innovative training technologies virtual (VR) and mixed reality (MR) are included in disaster training research. Methods: The systematic review was conducted according to the PRISMA guidelines and focused specifically on (quasi-)experimental studies published between January 2010 and September 2021. The literature search was conducted via Web of Science and PubMed and led to the inclusion of 55 articles. Results: The search identified several types of training, including traditional (e.g., lectures, real-life scenario training) and technology-based training (e.g., computer-based learning, educational videos). Most trainings consisted of more than one method. The effectiveness of the trainings was mainly assessed through pre-post comparisons of knowledge tests or self-reported measures although some studies also used behavioral performance measures (e.g., triage accuracy). While all methods demonstrated effectiveness, the literature indicates that technology-based methods often lead to similar or greater training outcomes than traditional trainings. Currently, few studies systematically evaluated immersive VR and MR training. Conclusion: To determine the success of a training, proper and scientifically sound evaluation is necessary. Of the effectiveness indicators found, performance assessments in simulated scenarios are closest to the target behavior during real disasters. For valid yet inexpensive evaluations, objectively assessible performance measures, such as accuracy, time, and order of actions could be used. However, performance assessments have not been applied often. Furthermore, we found that technology-based training methods represent a promising approach to train many MFRs repeatedly and efficiently. These technologies offer great potential to supplement or partially replace traditional training. Further research is needed on those methods that have been underrepresented, especially serious gaming, immersive VR, and MR.

Haemostatic impairment can have a crucial impact on the outcome of emergency patients, especially in cases of concomitant antithrombotic drug treatment. In this prospective observational study we used a point of care (POC) coagulometer in a prehospital physician-based emergency medical system in order to test its validity and potential value in the treatment of emergency patients. During a study period of 12 months, patients could be included if venous access was mandatory for further treatment. The POC device CoaguChek® was used to assess international normalized ratio (INR) after ambulance arrival at the scene. Results were compared with in-hospital central laboratory assessment of INR. The gain of time was analysed as well as the potential value of POC testing through a questionnaire completed by the responsible prehospital emergency physician. A total of 103 patients were included in this study. POC INR results were highly correlated with results of conventional assessment of INR (Bland-Altman-bias: 0.014). Using a cutoff value of INR >1.3, the device’s sensitivity to detect coagulopathy was 100 % with a specificity of 98.7 %. The median gain of time was 69 min. Treating emergency physicians considered the value of prehospital POC INR testing ‘high’ in 9 % and ‘medium’ in 21 % of all patients. In patients with tracer diagnosis ‘neurology’, the value of prehospital INR assessment was considered ‘high’ or ‘medium’ (63 %) significantly more often than in patients with non-neurological tracer diagnoses (24 %). Assessment of INR through a POC coagulometer is feasible in prehospital emergency care and provides valuable information on haemostatic parameters in patients. Questionnaire results suggest that POC INR testing may present a valuable technique in selected patients. Whether this information translates into an improved management of respective patients has to be evaluated in further studies.

Background: Immersive virtual reality (iVR) has emerged as a training method to prepare medical first responders (MFRs) for mass casualty incidents (MCIs) and disasters in a resource-efficient, flexible, and safe manner. However, systematic evaluations and validations of potential performance indicators for virtual MCI training are still lacking. Objective: This study aimed to investigate whether different performance indicators based on visual attention, triage performance, and information transmission can be effectively extended to MCI training in iVR by testing if they can discriminate between different levels of expertise. Furthermore, the study examined the extent to which such objective indicators correlate with subjective performance assessments. Methods: A total of 76 participants (mean age 25.54, SD 6.01 y; 45/76, 59% male) with different medical expertise (MFRs: paramedics and emergency physicians; non-MFRs: medical students, in-hospital nurses, and other physicians) participated in 5 virtual MCI scenarios of varying complexity in a randomized order. Tasks involved assessing the situation, triaging virtual patients, and transmitting relevant information to a control center. Performance indicators included eye-tracking–based visual attention, triage accuracy, triage speed, information transmission efficiency, and self-assessment of performance. Expertise was determined based on the occupational group (39/76, 51% MFRs vs 37/76, 49% non-MFRs) and a knowledge test with patient vignettes. Results: Triage accuracy (d=0.48), triage speed (d=0.42), and information transmission efficiency (d=1.13) differentiated significantly between MFRs and non-MFRs. In addition, higher triage accuracy was significantly associated with higher triage knowledge test scores (Spearman ρ=0.40). Visual attention was not significantly associated with expertise. Furthermore, subjective performance was not correlated with any other performance indicator. Conclusions: iVR-based MCI scenarios proved to be a valuable tool for assessing the performance of MFRs. The results suggest that iVR could be integrated into current MCI training curricula to provide frequent, objective, and potentially (partly) automated performance assessments in a controlled environment. In particular, performance indicators, such as triage accuracy, triage speed, and information transmission efficiency, capture multiple aspects of performance and are recommended for integration. While the examined visual attention indicators did not function as valid performance indicators in this study, future research could further explore visual attention in MCI training and examine other indicators, such as holistic gaze patterns. Overall, the results underscore the importance of integrating objective indicators to enhance trainers’ feedback and provide trainees with guidance on evaluating and reflecting on their own performance.

(1) Background: Currently, no data are available in the literature investigating the influence of radiotherapy (RT) on endotracheal intubation success in patients with esophageal cancer. This study aims to evaluate the impact of RT on endotracheal intubation quality metrics in patients with esophageal cancer. (2) Methods: Patients with esophageal cancer who underwent RT followed by surgery between 2012 and 2023 at the University Hospital Heidelberg, Germany, were retrospectively analyzed. (3) Results: Fifty-five patients, predominantly males 65.5% with a mean age of 64 years, were enrolled. Overall, 81.8% of the patients had an ASA class of III, followed by 27.2% ASA II. The mean prescribed cumulative total dose to the primary tumor and lymph node metastasis was 48.2 Gy with a mean single dose of 1.8 Gy. The mean laryngeal total dose was 40.0 Gy. Direct laryngoscopy was performed in 80.0% of cases, followed by 12.1% videolaryngoscopy, and 7.2% required fiberoptic intubation. Overall, 96.4% of patients were successfully intubated on the first attempt. (4) Conclusions: It has been demonstrated that post-RT effects can increase the risk of airway management difficulties and complications. The results of our study did not indicate any evidence of impaired advanced airway management in patients with esophageal cancer who had undergone RT.