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Introduction: Virtual reality (VR) technologies have rapidly advanced and offer increasingly higher fidelity visually immersive learning environments. Several studies have shown promise for using VR in medical education. This pilot study evaluates the feasibility of using a novel VR trauma simulator that can function without an instructor, assessing potential challenges with the technology, perceived realism of the simulation, side effects experienced while completing the simulations, and overall perception of training utility from end-users.Methods: This was a single-center prospective cohort study completed at Madigan Army Medical Center Emergency Department. Participants were enrolled using convenience sampling. They completed surveys before and after completing a trauma simulation. Each participant underwent a 10-min simulation orientation and subsequently completed a self-directed trauma simulation involving massive hemorrhage, tension pneumothorax, or airway obstruction case. The simulation utilized a gaming laptop and a Microsoft Mixed Reality© headset and controllers. Survey data was analyzed using descriptive statistics and subgroup analyses.Results: Seventeen participants were enrolled and completed pre-and post-surveys. Study participants were predominantly male and represented all clinical roles in the emergency department (ED). Overall, participants indicated the training environment felt realistic (AV 8.3/10, SD 1.4, 95% CI 7.6, 8.0) and supported further use of this technology in training (AV 9.3/10, SD 0.99, 95% CI 8.8, 9.8). There was a statistically significant correlation between participants who responded, “I would support further use of this technology in my training” (likert greater than 8/10) and several other responses. Individuals who supported further use of VR in training were more likely to have fewer years of clinical experience, have more experience with 2D (desktop) computer training, reported realistic clinical changes within the simulator, indicated the environment was realistic, and supported the addition of VR to mannequin-based training.Conclusion: The results indicate it may be possible to create realistic dynamic VR simulations that function without an instructor, and that medical personnel may be supportive of integrating VR technology into medical education. This seems most likely for younger individuals, with less experience, who have found computer based medical training helpful in the past. Future research could focus on methods to minimize side effects, and how VR technology can best augment current training techniques and curricula.

Emergency medicine is recognized as a critical wartime specialty within the US military. Military emergency medicine contributes to medical literature in unique ways not seen with our civilian counterparts. The impact of this contribution, especially regarding innovations in military medicine, has not been previously examined. This study evaluates the numbers of citations for emergency medicine manuscripts published by members of the US military.Utilizing the Scopus database, we identified published manuscripts from 2000 to 2020 with an emergency medicine author affiliated with a US military treatment facility. We sorted manuscripts on the number of citations in Scopus and categorized each paper as to whether it addressed military unique topics.We identified 1,718 manuscripts through Scopus, and based on a 10-citation minimum, we further analyzed 508 manuscripts. After verification of military affiliation, we included 421 manuscripts. The mean number of citations per manuscript was 31.7 ± 40.5; the Mean Cite Score was 4.75 ± 6.17 with a Field Weighted Citation Index (FWCI) of 2.96 ± 6.25. Citation count of publications has been steadily increasing in recent years with significantly more citations for military relevant publications when compared to non-military relevant publications.These findings highlight the importance of military emergency medicine scholarly activity which has a history of contributions that address specific medical needs of the warfighter and advance the specialty. Military emergency medicine papers have seen rising numbers of citations in the medical literature, particularly those related to military relevant topics emphasizing combat casualty care and military readiness.

Retrobulbar hemorrhage (RBH) occurs in only 0.45% of ocular trauma, but failure to provide timely lateral canthotomy and cantholysis (LCC) risks permanent visual deficits. With ocular trauma rates as high as 8.5-10% amongst modern combat injuries, and more than 2,000 severe eye injuries documented over a 10 year span, this concern increases.12-15 However, given infrequent RBH occurrence in the non-combat environment, emergency medicine residents trained in stateside settings may not receive adequate LCC exposure prior to military deployment. Simulators should be evaluated for procedural confidence compared to expensive and cumbersome traditional live tissue training (LTT) options. We seek to compare procedural confidence and usability of emergency medicine military residents performing LCC on a novel simulator to those using LTT.This study randomized 32 emergency physician and physician assistant residents to perform LCC on a simulator or LTT model. All received a standardized brief on RBH recognition and LCC, then completed an 11-question survey using a 100-mm visual numerical rating scale about their ability to correctly identify RBH and perform LCC. The survey was repeated after LCC completion. All volunteers additionally completed a 10-question survey utilizing a 5-point Likert scale on the usability of the model to which they were randomized.No significant difference in reported confidence changes between groups was found; however, significant increases were found across all reported confidence measures between pre- and post-trainer use in the overall sample population. LCC simulator users reported significantly higher usability in 7 of 10 ratings.The lack of a statistically significant difference between groups in procedural confidence suggests artificial LCC simulators may offer an attractive alternative to logistically-complicated porcine models. Further research is needed to evaluate non-inferiority and procedural performance.

Acute urinary retention (AUR) is a common symptom evaluated in the emergency department. It is generally due to an obstructive process such as benign prostatic hyperplasia (BPH) and can be treated simply with an indwelling foley catheter and urological follow up. Perirectal abscess is a relatively rare cause of urinary retention with no documented prevalence but when present is almost universally accompanied by perirectal pain. We present a 53-year-old male with a four-day history of urinary retention without perirectal pain or additional symptoms, who was found to have a perirectal abscess on digital rectal exam (DRE) and confirmed on computed tomography (CT) imaging.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an emergency procedure designed to treat non-compressible torso hemorrhage. Because this is a high-acuity low-occurrence event, it is difficult to train providers on the procedure and difficult for trained providers to stay proficient. Our primary objective was to develop a low-cost, high-fidelity teaching model to increase emergency medicine (EM) resident knowledge, confidence, and proficiency in performing REBOA. We utilized readily available materials to allow for ease of replication and cost-effectiveness. The aorta was simulated by a bicycle tire inner tube, and the femoral artery was simulated by natural rubber tubing. Once connected, these simulated vascular structures were threaded through a plastic torso mold and filled with simulated blood. Participants then performed the REBOA procedure with very little time required for reset between participants. After completing the training using our model, participants completed a survey rating aspects of the session on a five-point Likert scale. Participants included 21 EM residents from all levels of training. Participants rated the fidelity of the REBOA insertion trainer very highly (mean = 4.05, SD 0.67) and felt that the training was overall very useful (mean = 4.29, SD 0.56). Comments regarding the model were universally positive. We present a novel low-cost REBOA task trainer that is easy to build, reusable, and portable, and can be utilized either in a hospital or austere training environment.

Acute testicular infarction requiring emergent surgical intervention is often the result of spermatic cord torsion; infrequently, infarction results from other etiologies. We report a case of epididymo-orchitis complicated by abscess resulting in testicular ischemia, not detected on ultrasonography. A high clinical suspicion of testicular ischemia should be maintained in any presentation of testicular pain and swelling, as recognition could lead to early salvage interventions.

Tube thoracostomy placement is a critical, life-saving procedure often performed in the setting of trauma for the treatment of intrathoracic injury, such as hemothorax or pneumothorax. It also represents a high-acuity low-occurrence (HALO) event for many medical providers who may have limited opportunities for practice and mastery, particularly those in austere or resource-limited environments, such as in the deployed setting. Simulation offers opportunities for practicing the techniques required to properly perform and master the procedure. Finding affordable and accessible models for training, however, still represents a significant obstacle for many medical providers. We present a novel tube thoracostomy simulation model assembled from low cost and readily available materials.

Background Medical and traumatic emergencies can be intimidating and stressful. This is especially true for early-career medical personnel.Training providers to respond effectively to medical emergencies before being confronted with a real scenario is limited by unnatural or high-cost training modalities that fail to realistically replicate the stress and gravity of real-world trauma management. Immersive virtual reality (IVR) may provide a unique training solution. Methods We created a working group of 10 active duty or former military emergency medicine physicians and two technical experts. We hosted 10 meetings to facilitate the development process. The program was developed with financial support from the Telemedicine and Advanced Technology Research Center (TATRC), through the primary vendor Exonicus, Inc, with support from Anatomy Next Inc, and Kitware, Inc. Development was completed using an agile project management style, which allowed our team to review progress and provide immediate feedback on previous milestones throughout its completion. The working group completed the resulting four simulation scenarios to evaluate perceived realism and training potential. Finally, testing of the technology platform off the network in a deployed role 3 was conducted. Results Upon completion, we created four IVR scenarios based on the highest mortality battlefield injuries: hemorrhage, tension pneumothorax, and airway obstruction. The working group unanimously indicated a high level of realism and potential training usefulness. Throughout this process, there have been a number of lessons learned and we present those here to show what we have created as well as provide guidance to others creating IVR training solutions. Conclusion Our team developed trauma scenarios that, to our knowledge, are the only IVR trauma scenarios to run autonomously without instructor input. Furthermore, we provide a potential template for the creation of future autonomous IVR training programs. This framework may offer a dynamic starting point as more teams seek to leverage the capabilities IVR offers.

Left ventricular assist devices (LVADs) are implantable mechanical devices that pump blood from the apex of the left ventricle to the aorta in order to assist the forward flow of blood; they are most commonly used as a bridge to transplant for patients with heart failure. As of February 2019, a total of 25,145 patients with ventricular assist devices have been reported in the Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs). As this number continues to grow, more and more of these patients will inevitably be seen in the acute care setting outside of their defined LVAD center. Currently, however, LVAD emergencies represent a high-acuity low-occurrence event with limited opportunities for exposure and mastery for most physicians. Therefore, a growing need exists for emergency care providers to familiarize themselves with these devices and the management of LVAD emergencies. We present a novel model for the simulation of LVAD emergencies created through simple modifications of a Laerdal 3G Manikin.

Ophthalmic artery occlusion is a rare condition with a high morbidity, typically associated with cardiovascular disease and embolic or thrombotic phenomena. We present an atypical case of a 22-year-old active duty airman without comorbidities, who presented with acute, painless, monocular vision loss, found to have a right-sided, ophthalmic artery occlusion. The etiology for his vision loss was likely secondary to a granulomatous process at the orbital apex, causing compressive ischemia.