Nicholas Edward Kman

BACKGROUND Mass-casualty and operational triage require rapid decisions under uncertainty, yet real-world labeled decision data from these settings are scarce, heterogeneous, and difficult to collect at scale. Immersive virtual reality (VR) simulation provides a controlled way to generate structured human triage data in realistic high-consequence scenarios. OBJECTIVE To evaluate whether simulation-derived human triage examples improve the performance and safety profile of a lightweight open-weight large language model (LLM) beyond zero-shot prompting and explicit triage guidance alone, and whether the pattern is observed in simulation datasets organized around Sort, Assess, Life-Saving Interventions, Treatment/Transport (SALT) and Tactical Combat Casualty Care (TCCC). METHODS We performed a retrospective computational evaluation using structured cases derived from immersive VR triage simulations. Four prompting conditions were evaluated: zero-shot, context/guideline only, simulation-derived few-shot examples only, and few-shot examples plus context. In the TCCC-oriented analysis, few-shot examples were evaluated from both a matched TCCC-derived source and a cross-source SALT-derived source mapped to the four TCCC labels. Outcomes included accuracy; F1 score, which balances precision and recall, summarized as macro-F1 and weighted-F1; per-category F1; under-triage; critical under-triage; pooled failure modes; attribute-stratified performance; few-shot sensitivity; and prompt-elicited model confidence. TCCC row-level evaluations contain repeated presentations and are interpreted descriptively. RESULTS For SALT, test accuracy was 68.2% with zero-shot prompting, 68.4% with context alone, 71.1% with few-shot examples, and 79.1% with few-shot plus context; macro-F1 was 51.7%, 57.2%, 70.7%, and 83.8%, respectively. In TCCC, few-shot-plus-context accuracy was 87.0% with matched-source examples and 88.1% with cross-source examples; the corresponding context-only accuracies were 68.6% and 70.9%. The gain from adding examples beyond context alone was 10.7 percentage points for SALT, 18.5 points for matched-source TCCC, and 17.2 points for cross-source TCCC (pooled descriptive gain, 17.8 points). Category-level results showed large gains for EXPECTANT with simulation examples, while SALT DELAYED remained the weakest category. SALT critical under-triage decreased from 11.1% with few-shot prompting to 0.4% with few-shot plus context. TCCC under-triage decreased from 9.8% to 5.5% in the matched-source analysis and from 9.8% to 4.9% in the cross-source analysis; critical under-triage was 0% in both few-shot-plus-context source conditions. Prompt-elicited confidence remained high even when predictions were wrong and did not provide a reliable case-level safety filter. CONCLUSIONS Simulation-derived human examples improved lightweight LLM triage performance beyond explicit framework guidance alone. The effect was observed with both matched-source TCCC examples and cross-source SALT-derived examples, and the strongest conditions reduced safety-relevant under-triage. These findings support immersive simulation as a practical source of reusable human decision data that preserve observed variation and experiential judgments not necessarily encoded in written guidance or reproduced by model-generated synthetic cases, with potential relevance to other high-consequence domains where real-world decision data are scarce. TCCC estimates are descriptive because many rows are repeated presentations of a much smaller number of patient identities, and the results do not establish readiness for autonomous or real-time clinical triage.

Objective: This study explored the prevalence and attributes of triage errors made by emergency responders during virtual reality simulations of mass casualty incidents. Methods: The study analyzed errors made by 99 emergency responders during their triage and treatment of a mass casualty incident in virtual reality. Responders received training on the Sort, Assess, Life-saving Intervention, Treatment, Transport (SALT) protocol, then responded to a virtual bombed subway station. Responder accuracy, efficiency, and application of treatments were tracked. Error analysis was performed through the lens of human factors. Accordingly, errors were categorized by their nature: either perception, proficiency, or procedure. Results: Responders correctly triaged 70% of virtual patients, and 78% demonstrated relative efficiency. Interaction times between responders and patients averaged 20 seconds. The time to assess and treat all patients for life-threatening bleeding injuries across the entire scene averaged six minutes. Most errors were related to proficiency (e.g., competence or experience). However, procedural errors (shortcomings of SALT) and perceptual errors (degraded sensory input from programmed environmental chaos, i.e., virtual smoke/debris and louder sound) were also observed. Most errors were related to patients with either respiratory issues or multiple injuries. Conclusion: Virtual reality (VR) offered a controlled environment for studying errors made by emergency responders in a mass casualty incident, which will lead to improved training and protocols to better prepare them for these events.

Introduction: Targeted identification, effective triage, and rapid hemorrhage control are essential for optimal outcomes of mass-casualty incidents (MCIs). An important aspect of Emergency Medical Service (EMS) care is field triage, but this skill is difficult to teach, assess, and research. Study Objective: This study assessed triage efficacy and hemorrhage control of emergency responders from different professions who used the Sort, Assess, Life-Saving Treatment (SALT) triage algorithm in a virtual reality (VR) simulation of a terrorist subway bombing. Methods: After a brief just-in-time training session on the SALT triage algorithm, participants applied this learning in First VR esponder, a high-fidelity VR simulator (Tactical Triage Technologies, LLC; Powell, Ohio USA). Participants encountered eleven virtual patients in a virtual scene of a subway station that had experienced an explosion. Patients represented individuals with injuries of varying severity. Metrics assessed included triage accuracy and treatment efficiency, including time to control life-threatening hemorrhage. Independent Mann-Whitney analyses were used to compare two professional groups on key performance variables. Results: The study assessed 282 participants from the ranks of EMS clinicians and medical trainees. Most (94%) participants correctly executed both global SALT sort commands. Participants triaged and treated the entire scene in a mean time of 7.8 decimal minutes, (95%CI, 7.6-8.1; SD = 1.9 decimal minutes) with a patient triage accuracy rate of 75.8% (95%CI, 74.0-77.6; SD = 15.0%). Approximately three-quarters (77%) of participants successfully controlled all life-threatening hemorrhage, within a mean time of 5.3 decimal minutes (95%CI, 5.1-5.5; SD = 1.7 decimal minutes). Mean time to hemorrhage control per patient was 0.349 decimal minutes (SD = 0.349 decimal minutes). Overall, EMS clinicians were more accurate with triage (P ≤ .001) and were faster at triage, total hemorrhage control (P < .01), and hemorrhage control per patient (P < .004) than medical trainees. Conclusions: Through assessments using VR simulation, it was observed that more experienced individuals from the paramedic (PM) workforce out-performed less experienced medical trainees. The study also observed that the medical trainees performed acceptably, even though their only formal training in SALT triage was a 30-minute, just-in-time lecture. Both of these findings are important for establishing evidence that VR can serve as a valid platform for assessing the complex skills of triage and treatment of an MCI, including the assessment of rapid hemorrhage control.

Background: To minimize loss of life, modern mass casualty response requires swift identification, efficient triage categorization, and rapid hemorrhage control. Current training methods remain suboptimal. Our objective was to train first responders to triage a mass casualty incident using Virtual Reality (VR) simulation and obtain their impressions of the training’s quality and effectiveness. We trained subjects in a triage protocol called Sort, Assess, Lifesaving interventions, and Treatment and/or Transport (SALT) Triage then had them respond to a terrorist bombing of a subway station using a fully immersive virtual reality simulation. We gathered learner reactions to their virtual reality experience and post-encounter debriefing with a custom electronic survey. The survey was designed to gather information about participants’ demographics and prior experience, including roles, triage training, and virtual reality experience. We then asked them to evaluate the training and encounter and the system’s potential for training others. Results: We received 375 completed evaluation surveys from subjects who experienced the virtual reality encounter. Subjects were primarily paramedics, but also included medical learners as well as other emergency medical service (EMS) professionals. Most participants (95%) recommended the experience for other first responders and rated the simulation (95%) and virtual patients (91%) as realistic. Ninety-four percent (94%) of participants rated the virtual reality simulator as “excellent” or “good.” We observed some differences between emergency medical service and medical professionals regarding their prior experience with disaster response training and their opinions on how much the experience contributed to their learning. We observed no differences between subjects with extensive virtual reality experience and those without. Conclusions: Our virtual reality simulator is an automated, customizable, fully immersive virtual reality system for training and assessing personnel in the proper response to a mass casualty incident. Participants perceived the simulator as an adequate alternative to traditional triage and treatment training and believed that the simulator was realistic and effective for training. Prior experience with virtual reality was not a prerequisite for the use of this system.

Background To minimize loss of life, modern mass casualty response requires swift identification, efficient triage categorization, and rapid hemorrhage control. Current training methods remain suboptimal. Our objective was to train first responders to triage a mass casualty incident using Virtual Reality (VR) simulation and obtain their impressions of the training’s quality and effectiveness. We trained subjects in a triage protocol called Sort, Assess, Lifesaving interventions, and Treatment and/or Transport (SALT) Triage then had them respond to a terrorist bombing of a subway station using a fully immersive VR simulation. We gathered learner reactions to their VR experience and post-encounter debriefing with a custom electronic survey. The survey was designed to gather information about participants’ demographics and prior experience, including roles, triage training, and VR experience. We then asked them to evaluate the training and encounter and the system’s potential for training others. Results Nearly 400 subjects experienced the VR encounter and completed evaluation surveys. Subjects were primarily paramedics, but also included medical learners as well as other emergency medical service (EMS) professionals. Most participants (95%) recommended the experience for other first responders and rated the simulation (95%) and virtual patients (91%) as realistic. Ninety-four percent of participants rated the VR simulator as “excellent” or “good.” We observed some differences between emergency medical service and medical professionals with regard to their prior experience with disaster response training and their opinions on how much the experience contributed to their learning. We observed no differences between subjects with extensive VR experience and those without. Conclusions Our VR simulator is an automated, customizable, fully immersive virtual reality system for training and assessing personnel in the proper response to a mass casualty incident. Participants perceived the simulator as an adequate alternative to traditional triage and treatment training and believed that the simulator was realistic and effective for training. Prior experience with virtual reality was not a prerequisite for the use of this system.

The COVID-19 pandemic has provided an opportunity for significant reflection on our public health response as providers. Throughout the past two years, we learned that administration of COVID-19 vaccines, rapidly and widely across all communities, has been key to halting the spread of the virus. One significant challenge in promoting a large-scale immunization program is the threat of vaccine hesitancy. A general mistrust in healthcare providers exists across the country, especially in underrepresented minority (URM) communities. This study aims to determine reasons for vaccine hesitancy in an urban emergency department and to provide targeted education on the safety and efficacy of the COVID-19 vaccines to patients. An interprofessional quality improvement team was assembled to develop an educational intervention addressing COVID-19 vaccine safety for vaccine-eligible patients receiving treatment in the emergency department at an urban community hospital where over 70% of patients identify as URM. A survey was conducted to elucidate patients’ concerns surrounding the COVID-19 vaccine. Upon completion of the survey, up-to-date safety information and education targeting their surveyed concerns were provided by trained medical students. A follow-up survey was conducted to assess the impact of education on patients’ attitudes toward the vaccine. Surveys were developed using standardized scoring systems from the Oxford coronavirus explanations, attitudes, and narratives survey (OCEANS) II study and the Kaiser Foundation. Hesitancy scores before and after education were tabulated to assess the effectiveness of targeted education in improving vaccine hesitancy. Patients cited a variety of concerns surrounding the COVID-19 vaccine. The three most common reasons for declining vaccines were potential side effects (67.3% were concerned or extremely concerned), the belief that COVID-19 vaccines are neither effective nor safe (64.5% were concerned to extremely concerned), and the risk of developing COVID-19 infection from the vaccine itself (38.8% were concerned to extremely concerned). This information was used to address these concerns directly with patients, answer questions, clarify information, and encourage patients to get vaccinated. Through this education program, vaccine hesitancy scores improved by an average of 29% indicating an increased likelihood of patients who would get vaccinated in the future. Of patients receiving education, 38% agreed to sign up for a vaccine appointment during the intervention. The emergency department often serves vulnerable patient populations. As such, its role in public health in these communities cannot be underestimated. This quality improvement project is a novel method that can be used to develop and implement public health education programs to address specific community needs in the emergency department. These results show that a multidisciplinary healthcare team can provide a measurable change in attitudes about vaccine safety with directed education in the emergency department that can help address vaccine hesitancy in the future.

Author(s): Ringwald, Bryce; Shawar, Suhair; Curren, Camilla; McCallister, Jennifer; Bazan, Jose; Mead, Christopher; Kman, Nicholas E.

Introduction: In disaster response, smartphone applications (or apps) are being used by the layperson, emergency first responders, and health care providers to aid in everything from incident reporting to clinical decision making. However, quality apps are often diluted by the overwhelming number of apps that exist for both the lay public and first responders in the Apple iTunes (Apple Inc.; Cupertino, California USA) and Google Play (Google LLC; Mountain View, California USA) stores.Hypothesis/Problem: A systematic review of disaster response apps was originally completed in 2015; a follow-up review was completed here to evaluate trends and explore novel apps.Methods: A search of the Apple iTunes and Google Play stores was performed using the following terms obtained from PubMed (National Center for Biotechnology Information; Bethesda, Maryland USA) Medical Subject Headings Database: Emergency Preparedness; Emergency Responders; Disaster; Disaster Planning; Disaster Medicine; Bioterrorism; Chemical Terrorism; Hazardous Materials; and the Federal Emergency Management Agency (FEMA [Washington, DC USA]). After excluding any unrelated apps, a working list of apps was formed and categorized based on topics. Apps were categorized by intended user (first responders or the public) and sub-categorized by topic for discussion. Sub-categories included News/Information, Reference/Education, Weather/Natural Disasters, Travel/Navigation, and Communication/Reunification.Results: A search of the Apple iTunes store revealed 394 unique apps and was narrowed to 342 based on relevance to the field and availability on the iPhone. A search of the Google Play store yielded 645 unique applications and was narrowed to 634 based on relevance. Of note, 49 apps appeared in both app stores using the search terms. An aggregate 927 apps from the Apple iTunes and Google Play stores were then critically reviewed by the authors. Apps were sub-categorized based on intended audience, layperson or first responder, and sorted into one of five disaster response categories. Two apps were chosen for discussion from each of the five sub-categories. The highest quality apps were determined from each group based on relevance to emergency preparedness and disaster response, rating, and number of reviews.Conclusion: After comparisons with the 2015 article, many new apps have been developed and previously described apps have been updated, highlighting that this is a constantly changing field deserving of continued analysis and research.

Monoclonal antibody therapy (MAT) was granted Emergency Use Authorization (EUA) by the U.S. Food and Drug Administration for treatment of mild to moderate coronavirus disease 2019 (COVID-19) in adults with positive SARS-CoV-2 viral testing and at high risk for progression to severe COVID-19 with up to 10 days of symptoms. This study assessed the impact of MAT on COVID-19-related ER visits, admissions, and mortality for patients diagnosed with COVID-19. This was a single-center, retrospective study at The Ohio State University Wexner Medical Center to compare COVID-19-related ER visits, admissions, and mortality at 30 days after receiving MAT in the outpatient setting with either bamlanivimab or casirivimab-imdevimab in adult patients diagnosed with SARS-CoV-2 between November 16, 2020 and February 2, 2021. Outcomes in patients who received MAT were compared to those of a control group of patients diagnosed with COVID-19 in the outpatient setting from May 16, 2020 through November 15, 2020 who would have qualified for MAT through EUA criteria had it been available. Statistical analysis used logistic regression analysis with backward selection to determine the odds ratios (OR) and the 95% confidence interval to evaluate the relationship between patient clinical characteristics and outcomes. This study cohort included 1,944 patients, including 943 who received MAT and 1,001 in the control group. The MAT group included 658 who received bamlanivimab and 285 who received casirivimab-imdevimab. Patients who received MAT compared to the control group had a lower rate of COVID-19 related ER visits (3.3% vs 7.4%, p = < 0.0001) and hospital admissions (4.0% vs 7.8%, p = < 0.0001). No statistically significant difference was seen in mortality between the MAT group (0.5%) and control group (1.1%, p = 0.17). After accounting for potential confounders, the difference between the monoclonal antibody and control groups remained significant for ER visits and hospital admissions as reflected in the table. Patients who received MAT for COVID-19 in the outpatient setting had a lower rate of COVID-19-related 30 day ER visits and hospitalizations compared to those who did not receive MAT, adjusting for potential confounders. Mohammad Mahdee Sobhanie, M.D., Regeneron (Scientific Research Study Investigator)Regeneron (Scientific Research Study Investigator, Was a sub-investigator for Regeneron 2066 and 2069) Carlos Malvestutto, M.D., Lilly (Scientific Research Study Investigator)Regeneron Inc. (Scientific Research Study Investigator)ViiV Healthcare (Advisor or Review Panel member)