# The Use of Virtual Reality in Training Parameters for a Mass Casualty Incident
## 1 Introduction  
START (Simple Triage and Rapid Treatment) triage is a tool available to paramedics in the event of mass casualty. In view of the fact that triage of mass casualties using the START methodology could significantly increase mortality by inappropriately assigning low acuity (undertriage) status to casualties with critical injuries, delaying vital treatment, as well as the fact that assigning high acuity status to stable patients (overtriage) could lead to overwhelming hospital infrastructure with non-critical patients, this method has been the subject of several exercises by paramedics and the integrated emergency response system [1, 2]. The basic idea of the international project GURD--a concept for the coordination and implementation of cross-border cooperation of emergency medical services--was to achieve permanent cooperation of emergency medical services of Bavaria and the Pilsen, Karlovy Vary and South Bohemia regions in creating conditions for fast, high-quality, effective, and legislation-compliant cross-border medical assistance to urgently ill persons, both in individual and mass cases. Its promoters were the Bayerisches Rotes Kreuz, Kreisverband Cham, the University of West Bohemia in Pilsen, the Medical Rescue Service of the Pilsen Region and the Technische Hochschule Deggendorf. It was one of the projects that focused, among other things, on joint exercises of integrated rescue system crews on bothsides of the Czech-German border. One of the key activities of the project was also the implementation of trainings as a key means of preparing all components of rescue systems, specifically trainings focused on events with the occurrence of injured or disabled persons, including emergencies with mass occurrence of injuries. Such trainings are considered as tools for ensuring theoretical and practical training, and thus maximum preparedness, of rescuers for possible real situations. The training was used as the initial phase of a planned action research to verify to what extent the training and exercises of paramedics in the field using masked figures in the form of real subjects--often classmates or colleagues--are effective and to what extent they could be complemented or replaced by another form of training. The subject of analysis and subsequent inspiration for the creation of a virtual module for teaching and training of paramedics was a tactical exercise, which is typical in that it takes place in the field using real people, means and resources. This is where the tactical exercise differs from the operational exercise, in which emergency situations are practised theoretically. However, a well-prepared tactical training encounters several barriers and limits. Each training requires time and money, which is on the other hand compensated by the increase in skills on the part of the participants. It is true that, if possible and cost effective, all medical personnel, doctors, and paramedics, should be trained to the highest possible level. One of the foundations of a tactical team is the ability to anticipate and plan for any possible outcome, including the so-called \"worst case scenario\" [3]. Action research was conducted, which included observation of a tactical exercise within the GURD project, a questionnaire survey among the participating mannequins in the roles of affected patients, interviews with a participant in the roles of paramedics, semi-structured interviews with professional paramedics focused on the needs of the training modules, and analysis of mass casualty incidents provided by the ambulance service and the Police of the Czech Republic. Based on the observation of a tactical exercise within the GURD project called Rozvadov 2018 (named after the location and year in which it took place) and follow-up interviews and analyses, an exercise module was prepared in a virtual reality environment with a scenario focusing on a traffic accident with mass casualties.