Enhancing En Route Care Training through Immersive Virtual Reality Medical Simulation

Introduction: The Department of Defense (DoD) has the operational mission requirement to provide en route care (ERC). The responsibility for this critical mission falls on aeromedical evacuation (AE) teams and critical care air transport teams (CCATT), who must constantly train to ensure the mastery of skills within a complex and dynamic operational environment. Current AE/CCATT training methods are logistically complex and often prohibitively expensive. The en route care force is geographically dispersed. It includes active duty, Guard, and Reserve units, many of which have limited access to training equipment and aircraft due to the prohibitive price of complete equipment sets and the dependence on aircraft from mobility and aerial refueling flying squadrons that have active operational missions. As a result, many current sustainment training methods involve aeromedical evacuation crews practicing patient care on mannequins and completing medical scenarios in classroom environments that do not resemble the conditions encountered during actual missions. The advent of virtual reality-based immersive training capabilities ("Immersive Virtual Reality" or IVR) presents an opportunity to address this capability gap by creating a virtual domain with replicated en route care environments and equipment sets to enable practicing the continuously evolving tactics, techniques, and procedures (TTPs) of the AE/CCATT mission. Here, we describe our work to develop a comprehensive AE/CCATT sustainment training curriculum using IVR as part of the Virtual Advancement of Learning for Operational Readiness (VALOR) program.

Capability Description: The novel capability, VALOR En Route Care (VALOR ERC), is a comprehensive, IVR-based simulation training solution for aeromedical evacuation and critical care air transport care, implemented on the pre-existing VALOR Virtual Reality Medical Simulation System (VRMSS, SimX, Inc.). To enable long-term repeatability, the system is designed to enable configuration of individual training scenarios at runtime. Facilitators may choose from a selection of platforms and environments (i.e., C-130, C-17, field hospital, etc.) and can then populate the selected setting with a set of patients based on training needs. Each simulated environment includes the full allowance standard of equipment and supplies, enabling trainees to practice with access only to what they would have available under operational circumstances. Critical capabilities of the underlying platforms were also implemented (i.e., control actuation, airframe environment segments, aircrew communications system, and transload capabilities) to ensure a comprehensive simulation experience. A variety of casualty configurations are available for selection, ranging from traumatic battlefield injuries (penetrating trauma, blast injury, etc.) and non-battle injuries (post-MI, seizure, anaphylaxis, sepsis, etc.). Acuity can be configured on a per-patient level and modified dynamically; the simulations are designed to enable AE and CCATT squads to train concurrently, and patients may be upgraded or downgraded as needed. The IVR platform enables fully immersive scenario training, free of menus and UI elements that interfere with operational realism. Participants interact with the patients directly; for example, point-of-care ultrasound is performed by picking up the virtual probe, walking to the patient, and placing the probe correctly on the patient’s body. Trainees may speak freely to patients, who can respond verbally if clinically appropriate. The system is wireless to enable full team participation; trainees may work together around the same virtual patients while freely walking around a large physical area. The system supports non-collocated multiplayer operation, enabling trainees at different sites to train together in the same virtual domain. The system also provides detailed after-scenario feedback that educators can use to debrief with trainees and measure their performance. The system is designed to be cross-platform compatible with various commercial off-the-shelf (COTS) headsets, such as the Oculus Quest 2 and HTC Vive Focus 3. Methods/Technical

Approach: The VALOR ERC capability was developed to extend the previously developed VALOR IVR simulation system, which is used operationally for medical simulation training in the special warfare and nursing communities. A multidisciplinary team of clinician-educators, instructional designers, VR designers, and VR engineers was formed to design the scenario curriculum and associated environments, patients, sets, kits, and outfits. This team was composed of experts from SimX, Inc., the United States Air Force School of Aerospace Medicine (USAFSAM), and Air Mobility Command (AMC). Curricular specifications and designs were developed using the three-phase ’concept-specification-engineering’ documentation process. In the concept phase, specifications were developed for each proposed feature, module, tutorial, and scenario by the clinical instructional design team, detailing the content overview, components, and medical context. Concept phase documentation was then iterated upon in collaboration with the assigned SMEs until mutual agreement was reached. During the curriculum specification phase, each scenario was designed with specific learning objectives, scenario state flows, medical assemblages, and psychosocial and environmental factors specified, again with iteration by the clinical instructional design team in collaboration with the SMEs. Once mutual agreement was reached on the specification documentation, the scenario production team developed implementation engineering design documentation to facilitate implementation and production. Virtual content implementation included the production of patients and non-player characters with dialogue, animations, appropriate vitals, and physical findings, scenario engine state flow and associated events and triggers, environmental state flow, XR interactions, learning objectives and assessments, scenario-specific facilitator controls, medical interventions and events, and appropriate in-scenario medical documentation, records, procedures, and laboratory findings. Scenarios underwent a multi-phase quality assurance (QA) process, including technical QA, clinical educator QA, and external subject matter expert QA, with feedback and iteration at every phase of implementation.

Results: An IVR-based dynamic simulation capability spanning AE and CCATT training requirements was designed and reduced to practice. Simulated virtual platforms developed included the C-130, C-17, and KC-135, with appropriate sets, kits, and outfits implemented and available, including approximately 300 instruments, supplies, and patient movement items and appropriate platform-specific aircraft systems, including litter stanchions, power systems, radio systems, and medical gas systems. Twelve patient-level clinical scenarios with variable acuity and spanning battle and non-battle conditions were specified and implemented in tandem with a flexible selection tool enabling runtime selection for multi-patient simulation.

Applicability and Significance: The VALOR ERC capability is applicable to en route care delivered during patient movement between any of the roles of care, from the point of injury to the most definitive Role 4 facilities. The development of the novel VALOR ERC capabilities will enable better, more frequent, and more affordable simulation training for AE and CCATT personnel, which will translate into improved readiness for the en route care mission. The overall impact on the Department of Defense will be improved casualty care during patient movement and enhanced survivability and recovery for injured Warfighters. The VALOR ERC capability is at TRL 7 and is undergoing testing and evaluation.