Introduction
Mass-casualty incidents (MCIs) are occurring with increasing frequency and complexity due to factors such as political instability, terrorism, and natural disasters.Reference Leaning and Guha-Sapir1, Reference Valiño, Castro and Castro Delgado2 In dynamic environments involving ongoing threats or evolving hazards, responders must make rapid decisions under pressure. These scenarios require a tactical triage approach that prioritizes immediate life-saving actions and fast evacuation rather than the more deliberate assessments suitable in stable settings.Reference Pepper, Archer and Moloney3, Reference Galant, Corcostegui and Marrache4 During the 2015 San Bernardino terrorist attack, responders trained in the conventional Simple Triage and Rapid Treatment (START) system reportedly did not apply the formal algorithm in practice. Instead, they relied on rapid clinical judgment based on obvious signs such as severe bleeding or unresponsiveness. Triage tags were initially used but later abandoned mid-response, as they were seen to hinder assessment and care in a fast-moving situation. These observations underscore the challenges of applying standard triage protocols in operationally complex environments requiring rapid decision-making and adaptability.Reference Pepper, Archer and Moloney3
The Rapid Assessment of Mentation and Pulse (RAMP) model addresses these limitations by using only 2 evidence-based indicators, mentation (ability to follow simple commands) and a palpable radial pulse, alongside a clear triage categorization (black = deceased, red = immediate, green = minor).Reference Pepper, Archer and Moloney3, Reference Keating, Masys and Masys5 As shown in Figure 1, these criteria allow responders to assess consciousness and circulation quickly, 2 of the strongest predictors of trauma mortality.Reference Meredith, Rutledge and Hansen6 This streamlines cognitive workload and enables rapid, standardized decision-making across diverse responder groups.Reference Marewski and Gigerenzer7
RAMP mass casualty triage algorithm. Source: Adapted from Keating et al. (2018), used with permission.Reference Keating, Masys and Masys5
Independent of the specific triage system employed, effectiveness relies on training that bridges theoretical knowledge with practical decision-making under operational conditions. Full-scale exercises are costly and infrequent, while classroom instruction may not sufficiently prepare responders for the realities of chaotic, high-stress incidents.Reference Abbas, Chu and Payton8, Reference Farra, Hodgson and Timm9
Immersive technology such as Virtual Reality (VR) offers a promising complement. It allows responders to repeatedly train in high-fidelity, interactive environments that replicate the physical and cognitive demands of MCIs without putting patients or providers at risk.Reference Abbas, Chu and Payton8, Reference Mandal10 Compared to live simulation, immersive VR-based training is more scalable, more cost-efficient once developed, and easier to deploy on demand without logistical burdens.Reference Farra, Hodgson and Timm9
Recent evidence supports this potential. In a systematic review, Heldring et al.Reference Heldring, Lindström and Jirwe11 found that high-fidelity VR training enhanced confidence, skill retention, and preparedness for real MCIs. Responders appreciated the realism, safety, and flexibility of VR, though technical glitches and lower physiological stress compared to live scenarios were noted as limitations. Importantly, the review emphasized that immersive VR should not replace live simulation entirely but rather serve as a powerful supplement that supports varied learning styles, repetition, and decision-making under pressure.Reference Heldring, Lindström and Jirwe11
Immersive VR supports stepwise learning progression, aligning with staged training models designed to build competence incrementally.Reference Ericsson12–Reference Liaw, Wu, Soh, Ringsted, Lau and Lim14 Although VR lacks tactile feedback and may under-represent the full sensory burden of real events, its effectiveness will improve as the technology evolves. Implementation success will depend on investment in high-quality scenarios, hardware, and strong institutional support.Reference Kip, Buitelaar-Huijsse and Kouijzer15
This study investigates how responders from police, fire and rescue, EMS (Emergency Medical Services), and volunteer services experience immersive VR-based RAMP training in a simulated MCI with 26 patients. We explored how participants perceived the usability and realism of the training, as well as its relevance for interagency practice.
To guide this inquiry, the study was structured around four thematic domains, each linked to specific research questions addressing critical aspects of immersive triage training. These are outlined in Table 1.
Research questions (RQs)
Method
Study Design
We conducted a qualitative observational study using VR simulation exercises followed by structured interviews. A qualitative approach was chosen to gain in-depth insight into participants’ experiences, perceptions, and attitudes toward both the RAMP triage method and the VR training modality. The study followed an IMRAD structure in reporting. The study did not require approval under the Norwegian Health Research Act, as it did not involve medical or health research. However, it was reviewed and approved by SIKT, the national agency responsible for ensuring compliance with General Data Protecction Regulations (GDPR) in research contexts. All participants provided informed consent.
Study Objects
Participants were recruited from a range of emergency and rescue services (Table 2). Sixteen participants were recruited across 4 emergency service categories, representing both medical and non-medical personnel, to capture interagency perspectives. All participants held operational positions with potential responsibility for mass-casualty response. No individual demographic data beyond agency affiliation were collected, as the study did not aim to analyze results by background variables. However, based on interviews, participants ranged approximately from their early 20s to mid-50s and varied in length of professional experience. They were anonymized in the data; identifying details are not reported. Recruitment followed a snowball sampling strategy, where initial contacts within each agency were asked to refer additional participants who met the inclusion criteria. This method is commonly used in qualitative studies to access information-rich participants within defined networks.Reference Noy16 Recruitment continued iteratively until thematic saturation was achieved, defined as the point at which no new relevant themes or insights emerge.Reference Guest, Bunce and Johnson17 Inclusion criteria required that participants be active members of one of the emergency responder agencies or a related emergency organization. Exclusion criteria included any health conditions incompatible with VR headset use, such as a history of severe motion sickness, epilepsy, migraines triggered by visual stimuli, or significant neck injuries.
Participant distribution by organization and example roles
Materials and Equipment
The VR simulation was delivered using an Oculus Quest 3 head-mounted display with accompanying hand controllers, enabling untethered navigation within a defined play area. We utilized the Core Decision Support System developed by Fynd Reality, configured with a custom-built mass-casualty scenario representing an urban disaster environment consistent with a dynamic, high-risk incident.
Participants were instructed to imagine the presence of an ongoing security threat. However, no explicit audio cues or visible aggressors were included, allowing participants to focus solely on triage tasks. The scenario featured 26 virtual casualties with varying injuries and clinical conditions (Figures 2 and 3 show visual representations of the MCI environment and patient interface).
Overview of the MCI.
How patients were presented in the VR scenario (text was originally presented in Norwegian, translated to English for illustration).
The RAMP triage model was introduced during a pre-briefing session, but no in-simulation tutorials or prompts were provided. Participant movement and triage-tagging decisions were recorded for subsequent performance analysis.
Simulation Procedure and Qualitative Data Collection
All participants received a standardized briefing on the RAMP triage model, covering its 2 assessment criteria: presence of a radial pulse and ability to obey simple commands. The briefing emphasized that RAMP does not require counting respirations or assigning numerical injury scores. The 3 color-coded triage categories (black, red, green) were explained to ensure consistent understanding.
Each participant then entered the immersive VR mass-casualty triage scenario individually. They were instructed to imagine themselves as the first responder arriving on scene, responsible for initial triage. Although there was no strict time limit, they were encouraged to proceed with urgency, simulating the conditions of an ongoing incident. Participants moved through the virtual environment and triaged all 26 patients using the RAMP criteria only.
The simulation was conducted in single-user mode, and participants from different agencies did not interact within the VR environment. During the exercise, researchers observed silently and documented technical issues or deviations from the triage protocol using a standardized checklist.
Immediately following the VR session, participants completed a face-to-face interview lasting approximately 30 to 45 minutes. Interviews were conducted in Norwegian by 2 researchers using a structured interview protocol, ensuring that all core topics were addressed uniformly across participants. Structured interviews are particularly suited for applied settings where comparability and thematic alignment are important, and have been shown to enhance analytical transparency and procedural rigor in qualitative designs.Reference Kallio, Pietilä and Johnson18, Reference Turner19
Audio recording was deliberately omitted in favor of detailed note-taking. This decision was based on contextual considerations: several participants had prior working relationships with one or both researchers, and some were expected to collaborate with the research team in future operational settings. In such cases, the presence of recording devices may inhibit openness and lead to socially desirable responding, especially in small professional communities where role boundaries are blurred.Reference Hammersley and Atkinson20, Reference Roulston and Shelton21 To mitigate these risks, the use of 2 interviewers allowed for concurrent note validation, reflexive checks during the interview, and immediate post-interview review of content to ensure completeness and fidelity.
While note-based documentation can limit verbatim capture and omit paralinguistic cues, prior research supports its validity in sensitive field-based contexts where trust and psychological safety are paramount.Reference Clausen22, Reference Rutakumwa, Murtagh and Martin23
The interview protocol covered 6 thematic domains:
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1. Professional background and prior training, including experience with MCIs or triage systems.
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2. Perceptions of the RAMP model, including perceived benefits, limitations, and comparisons to other triage tools.
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3. Interagency collaboration, focusing on coordination experiences, challenges, and the potential benefits of a shared triage language.
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4. Experience with VR training, including usability, realism, and comparisons to traditional training methods.
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5. Implementation considerations, such as feasibility, technical barriers, and suggestions for improving VR-based training.
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6. Impact on preparedness, exploring whether participants believed this form of training could enhance real-world triage performance.
Data Analysis
Interview notes were analyzed using thematic analysis as described by Braun and Clarke.Reference Braun and Clarke24 Researchers independently reviewed translated notes multiple times to immerse themselves in the data. An inductive coding approach allowed themes to emerge from participants’ own words rather than imposing a predefined framework. Initially, 45 distinct codes were identified, representing granular issues raised by participants, for example, codes such as “No time to train,” “Add more noise for stress,” and “Lack of a shared triage framework across services.” The researchers then met to discuss and refine these codes, grouping them into ten initial sub-themes based on conceptual similarity.
Through iterative comparison to the research questions, these sub-themes were further consolidated into 3 overarching themes that captured the most salient patterns in the data: (1) challenges with current mass-casualty training, (2) VR as a triage training method, and (3) prerequisites for successful VR implementation. The thematic structure was continually reviewed against the raw data to ensure accuracy and comprehensiveness; any discrepancies were resolved by returning to the data. To enhance trustworthiness, strategies such as investigator triangulation were employed, with multiple researchers independently coding and validating themes, and an audit trail documenting code definitions and theme development was maintained.
Results
Thematic Elaboration of Findings
The following sections present a detailed narrative elaboration of the 3 main themes and their associated subthemes outlined in Table 3. Each thematic area is grounded in participant reflections and linked to the corresponding research questions.
Thematic structure summarizing main themes, subthemes, and corresponding research questions
Challenges With Current Mass-Casualty Triage Training
Participants identified several critical gaps in existing triage training across emergency services. Many reported little or no formal preparation for mass-casualty triage. Some had never participated in a triage drill, while others had only received a single brief exposure years earlier, leading to poor retention and diminished confidence.
Training methods varied widely between agencies. For instance, some ambulance personnel had been introduced to the SALT model during their professional education, whereas most police officers and firefighters reported having no structured triage training at all. As a result, responders lacked a shared protocol, and communication during mass-casualty incidents was described as fragmented or prone to breakdown. One participant summarized, “We basically haven’t learned this, maybe a brief mention in a course, but we never practice it.”
Interagency training was also limited. Although some participants had attended joint exercises, such as active shooter simulations, these rarely included a common triage methodology. Agencies often trained in silos, each focusing on their own tactical tasks, which hindered mutual understanding. One paramedic explained that during actual incidents, “each agency tends to follow its own agenda,” which leads to confusion and slows coordination.
Participants further noted that while ambulance crews might occasionally engage in hospital-based drills, many police and fire departments relied on more generic mass-incident training that focused on containment or security. These exercises often appeared designed more to demonstrate preparedness than to build operational triage capability. This resulted in a fragmented landscape in which different services “spoke different languages” when attempting to prioritize and tag patients during multi-agency responses.
In sum, the findings highlight how infrequent, inconsistent, and poorly coordinated training creates significant barriers to effective triage during mass-casualty events. The participants expressed concern that without more unified and frequent practice, they would remain underprepared for high-stakes, multi-agency scenarios.
VR Simulation as a Triage Training Method
Participants viewed VR-based training as a promising response to many of the current challenges in mass-casualty preparedness. All successfully completed the VR triage scenario, and none reported confusion regarding the RAMP criteria after the session. Many praised the format for being more engaging and accessible than traditional drills.
They emphasized VR’s resource efficiency. Unlike conventional exercises, the simulation required no large venues, actor-patients, or equipment setup, significantly lowering logistical barriers. “We can run this in our own station on any day,” noted one police officer, highlighting the flexibility and convenience of the approach.
Participants believed this efficiency could enable more frequent training. In a single session, they triaged 26 virtual patients, far more than typical live drills allow. Several noted that the ability to repeat scenarios “anytime and anywhere” would likely support stronger learning retention over time.
Several participants noted that VR training supported better retention of triage concepts. One paramedic commented that “doing it here on the VR headset might actually stick in my head more than just reading about it.” However, many also identified clear limitations in the realism of the simulation. The scenario was calm and required little physical effort. There was no need to carry mannequins, feel a pulse, or move through a physically demanding environment. As one firefighter noted, important elements like “running, carrying equipment, dealing with real blood” were missing.
Accordingly, participants emphasized that VR should be viewed as a complement to, not a replacement for, hands-on training. While they considered VR useful for teaching the logic behind the RAMP triage system, they agreed that real-world practice is necessary to develop the physical and emotional readiness required in actual incidents.
Stress was another area where the simulation fell short. Most participants reported feeling calm during the VR scenario, in contrast to the heightened stress and urgency typical of real emergencies. While the lower stress level allowed for focused learning, some saw it as a drawback. They suggested adding stress-inducing elements such as more noise, time limits, and background distractions to better simulate the chaos and pressure of mass-casualty situations. Participants recommended using VR to build initial competence, followed by scenarios with increasing levels of realism and challenge.
Despite these limitations, the responders expressed strong support for the use of VR in interagency training. Several suggested that joint multi-user simulations, even when conducted remotely, could help standardize triage procedures and improve communication across police, fire, and emergency medical services. By engaging with the same virtual scenarios, different agencies could develop a shared understanding of roles, terminology, and expectations during mass-casualty incidents.
For effective implementation of VR training in emergency services, several prerequisites were identified by participants.
Equipment Accessibility and Standardization
Access to standardized and compatible VR equipment is paramount. The lack of uniform systems and uncoordinated scenarios among agencies would diminish the utility of shared training initiatives. Proposals included establishing regional VR training centers or portable VR kits for inter-agency rotation to ensure consistent and user-friendly equipment availability.
Scenario Quality and Contextual Relevance
The quality and contextual relevance of VR scenarios are critical. Participants emphasized the need for realistic simulations, incorporating environmental details (e.g., sirens, debris, weather) and reflecting local incident contexts (urban/rural). Involving experienced responders in scenario design was recommended to ensure that simulations effectively assess decision-making skills and adhere to official protocols. The consensus was that VR training must constitute a credible learning experience rather than a generic game.
Organizational Support and Integration
Robust organizational support and structural integration are essential to prevent VR training from being optional and underutilized. Participants advised integrating VR sessions into routine training schedules, similar to firearms or equipment drills. This necessitates the appointment of trained facilitators and the provision of technical support. Furthermore, dedicated time and financial resources must be allocated to ensure broader participation beyond highly motivated individuals.
Alignment With Real-World Protocols
A final key prerequisite is the alignment of VR training with real-world protocols across agencies. Participants stressed that inconsistencies between learned VR methods and operational practices would negate training benefits. Adopting a common approach, such as a unified triage system, was deemed critical for ensuring consistency between training and field operations.
Participants affirmed that sustainable VR training, capable of enhancing preparedness across emergency services, hinges on accessible hardware, realistic content, and strong organizational commitment.
Discussion
This study adds to growing evidence that standardized mass-casualty triage training remains limited or inconsistently applied among first responders.Reference Ryan, George and Liu25 Many participants in our sample reported little or no formal exposure to structured triage methods. This is consistent with earlier findings showing that interdisciplinary MCI drills are infrequent and that implementation of national triage guidelines varies across services.Reference Ryan, George and Liu25–27
Although national guidelines exist, many responders remain unfamiliar with them or rarely use them operationally.Reference Galant, Corcostegui and Marrache4 In practice, large-scale exercises often emphasize organizational readiness and system-level coordination rather than individual triage proficiency.Reference Ryan, George and Liu25 Several participants reported feeling unprepared to apply triage protocols in high-pressure situations, despite having some prior exposure to them. This perception highlights a critical gap between theoretical knowledge and operational readiness, suggesting that existing training may not adequately support skill retention or decision-making under stress. The findings align with previous research showing that infrequent or inconsistent practice leads to rapid decay in procedural skills, particularly in low-frequency, high-stakes tasks like MCI triage. This lack of rehearsal aligns with research showing that emergency responders seldom encounter mass-casualty incidents in the field and, when they do, often perform below standard due to skills degradation over time.Reference Risavi and Sabotchick28
Advantages of the RAMP Model and Unified Triage
The RAMP triage model was introduced to participants during the pre-briefing. Despite little or no prior exposure to RAMP, most participants quickly understood and applied its 2 core criteria. This rapid uptake supports the value of simplified, binary decision-making tools in high-stress settings. Such tools correspond well with the principles of System 1 thinking, where fast, intuitive judgments are favored over analytical processing.Reference Gigerenzer and Gaissmaier29–Reference Kahneman31 Participants viewed RAMP as more accessible than other triage systems, which often involve scoring, prioritization matrices, or multiple steps. The shared understanding fostered by RAMP also facilitated smoother interpretation of decisions across professional boundaries, laying the foundation for a common operational language.
Participants emphasized that if a model like RAMP is used consistently across agencies, it could streamline decision-making and reduce miscommunication on scene. The VR platform appeared to accelerate this adoption, offering a practical and engaging way to convey and test RAMP’s logic.
VR as a Scalable Learning Platform
In our study, participants consistently described VR-based training as a promising solution to many of the current limitations in triage education. They emphasized that it enables high-volume exposure to realistic scenarios without the need for physical venues, actor patients, or extensive logistical planning. These characteristics make it well-suited for low-cost and frequent implementation.Reference Liaw, Wu, Soh, Ringsted, Lau and Lim14
Participants appreciated the immersive environment and the ability to repeat scenarios, aligning with experiential learning theory.Reference Kolb32 Through repeated exposure and immediate feedback, learners engaged in a reflective learning cycle. Many participants discussed how they would approach triage differently if given a second chance, showing how VR enabled cognitive rehearsal and pattern recognition.Reference Klein, Klein, Orasanu, Calderwood and Zsambok33
Studies comparing VR to live simulation have found comparable results. In one study, VR-trained nursing students achieved similar triage accuracy to those trained through traditional drills.Reference Ferrandini Price, Escribano Tortosa and Nieto Fernandez-Pacheco34 In another, paramedic students demonstrated higher accuracy in virtual triage than in standard classroom formats.Reference Chumvanichaya, Yuksen and Nuanprom35 These findings are consistent with participants’ experiences in this study, where many achieved correct classifications with minimal prior RAMP exposure.
Unlike traditional debriefing, which often relies on subjective or delayed instructor evaluation, VR can provide immediate, standardized feedback. This feature could be especially useful in resource-constrained environments where instructor availability is limited.
Limitations of VR and Need for Realism
Despite its strengths, participants noted that VR currently lacks many of the psychological and physical stressors of real incidents. Without external cues such as noise, crowd behavior, or urgency, the scenarios may not fully replicate the emotional and sensory demands of a true MCI. This gap is important to consider in light of research on state-dependent learning, which suggests that skills learned in calm settings may not transfer well to high-stress environments.Reference Driskell and Johnston36
To address this, participants recommended incorporating stress-inducing elements such as time constraints, louder noise, or simulated chaos. These additions are consistent with findings in high-fidelity simulation literature, where increased realism is associated with stronger retention.Reference Rose, Spies and Riegel37
Progressive Learning
Several participants proposed using VR as part of a progressive training model. In this approach, responders would first engage in low-stakes, solo VR training to learn protocol fundamentals. Next, they could participate in multi-user VR drills to develop team communication and coordination. Finally, full-scale physical drills would serve as integration events to validate competence.
Participants viewed VR as an ideal tool for filling the often-missing intermediate step between classroom instruction and large-scale drills. The platform’s scalability and accessibility allow for more frequent training without overwhelming resources. This approach aligns with scaffolding theory and the principles of progressive simulation-based training, where competence is developed through graduated increases in scenario fidelity and cognitive challenge. Such structured progression has been shown to enhance skill acquisition and transfer to real-world performance.Reference Liaw, Wu, Soh, Ringsted, Lau and Lim14, Reference Brydges, Carnahan and Rose38
Team Coordination and Shared Mental Models
One of the most promising insights was the potential for VR to support interagency collaboration. Participants frequently imagined how joint VR scenarios could improve mutual understanding across police, fire, and EMS services. This reflects theories of shared mental models, which suggest that teams perform better when they have a common understanding of roles, tasks, and expectations.Reference Mathieu and Heffner39
VR was seen as a platform where responders could experience each other’s roles and perspectives, fostering empathy and trust. These experiences could be particularly valuable in mass-casualty contexts, where time is limited and coordination is essential. Research in medical team training has shown that interprofessional VR simulations can improve communication and collaboration as effectively as in-person sessions.Reference Liaw, Wu, Soh, Ringsted, Lau and Lim14, Reference Sezgin and Bektas40
Implementation and Organizational Support
Finally, participants discussed several organizational factors critical for successful VR adoption. They emphasized the need for reliable equipment, trained facilitators, and leadership support. Without these elements, VR was seen as likely to remain a niche tool used only by tech-enthusiasts.
These concerns align with implementation research in immersive learning. Factors such as perceived ease of use, institutional backing, and availability of technical support are key predictors of adoption success.Reference Kouijzer and Buitelaar-Huijsse41, Reference Mäkinen and Järvelä42 Participants proposed practical steps such as creating shared equipment pools, training internal facilitators, and embedding VR into standard training schedules to ensure long-term sustainability.
Limitations
This study has methodological limitations. The sample included 16 participants from a single Norwegian region, which may limit transferability. However, the aim was not statistical generalization, but to identify recurring patterns across diverse roles. Thematic consistency across agencies suggests the findings may be relevant beyond the immediate context.
The study also relied on self-reported perceptions. No objective performance data were collected, so conclusions about improved preparedness reflect participant experience rather than measurable outcomes. While many reported increased confidence after VR training, future research should test whether such training improves performance in drills or real incidents.
Despite these limitations, the study provides practice-relevant insights for developing immersive triage training and a basis for future research on effectiveness and implementation.
Conclusion
VR-based triage training was feasible, engaging, and well received across responder groups. Participants quickly understood the RAMP model and reported greater confidence in decision-making. VR-enabled frequent, low-resource training and was seen as a useful platform for interagency collaboration. However, it cannot replace hands-on drills. Physical stress and realism remain essential. To maximize effect, VR scenarios should include stress elements and align with shared protocols. Organizational support and structured integration are crucial. VR appears to be a valuable adjunct to conventional MCI exercises.
Acknowledgments/Funding
None.
Author contribution
BK, KLE, and ILK conceptualized and designed the study. BK developed the RAMP triage model used in the simulation. KLE constructed the VR scenario and adapted the Core Decision Support System (Core DSS) platform to align with the study’s objectives. Data collection was carried out by KLE, ILK, BCE, IAK, AB, SR, and NMS. All authors, including BK, participated in data analysis, interpretation of findings, and writing of the manuscript. Each author critically reviewed the manuscript for important intellectual content and approved the final version. All authors accept full responsibility for the accuracy and integrity of the work.
Competing interests
None.
