Immersive virtual reality for assessing decision-making in mass casualty incident and tactical combat casualty care scenarios among military personnel

Abstract

INTRODUCTION: Military personnel frequently act as first responders in complex tactical-medical scenarios where they must make critical decisions under pressure and coordinate with civilian emergency services. Traditional simulation methods have limitations in replicating the stress and cognitive load inherent to these contexts. Virtual reality (VR) allows the recreation of high-demand scenarios, enabling the assessment of decision-making under operational pressure. METHODS: A pre-post quasi-experimental study was conducted with 38 active-duty military personnel, who completed two VR scenarios: a mass casualty incident (MCI) and a tactical combat casualty care (TCCC) scenario, following a counterbalanced crossover design. The primary outcome was the accuracy of decision-making across two VR scenarios (MCI and TCCC). Secondary outcomes included physiological stress response through salivary biomarkers, neurophysiological metrics in a subsample and subjective experience assessed through a focus group. The analysis included descriptive statistics, paired t or non-parametric tests, linear mixed models for biomarkers and a qualitative thematic analysis. RESULTS: In the tactical scenario, participants showed a 76.7% accuracy rate, with variability in decisions under fire and airway prioritisation. In the MCI scenario, high accuracy was observed in triage items but errors occurred in more complex situations. Biomarkers showed moderate increases with no significance in univariate analyses but mixed models revealed effects of scenario type and exposure order. EEG metrics identified resilient, intermediate and vulnerable profiles, with signs of mental fatigue in high-demand phases. CONCLUSIONS: VR appears to be a useful tool for evaluating decision-making under pressure and for complementing training in tactical-medical scenarios, although this study does not provide direct evidence of improved learning outcomes.