Health Technologies

Interview: HART paramedic Steven Thompson on developing a virtual reality simulation for mass casualty triage training – htn

For our latest interview we spoke to HART paramedic Steven Thompson about his work co-developing and testing a virtual reality simulation for mass casualty triage.

Following an MSc in Emergency Medicine and Resuscitation, Steven started the project with the aim of improving training and increasing confidence in the Hazard Area Response Team (HART). HART is formed of specialist paramedics who attend mass casualty incidents where they have to apply triage tool to identify the most critically injured casualties.

Steven’s background

I joined the army at 16 and became an Army Commando, specialising in bomb disposal and deployed on multiple tours of duty in hostile environments. During this time I was involved in what I now know to be a mass casualty incident in Afghanistan. It was a very traumatic event where five people lost their lives and many more were severely injured.

I didn’t feel like I knew what I was doing on that day in a medical sense, so I’ve used that as a stepping stone to do a lot of extra medical training to ensure that when those incidents happen, I can make a difference and save a life.

Once I left the military, I went into private security industry.  Throughout that period, I spent a lot of time in hostile environments and continued with medical training including voluntary time in US military hospitals. All of this  helped me with subsequent incidents. I just wanted to learn more and do more, because I knew it had a massive impact.

From there, I returned to the UK and started my paramedic training in 2012 which involved studying for a DipHE at university. Once qualified, I began working for North West Ambulance Service (NWAS). After a period also working as a security consultant for England Rugby, I saw that NWAS HART was recruiting for positions in Manchester and Liverpool. I decided to apply due to HART working in a small specialist team which would suit my background and experience.

I have been a HART paramedic ever since. We specialise in working in hazardous environments, which includes responding to Marauding Terrorist attacks (MTA); safe working at height; confined space; urban search and rescue (USAR) water rescue; chemical, biological, radiological, nuclear and explosive (CBRNE) incidents; and providing support to security operations.

The beginnings of the project

As part of HART, you get offered lots of opportunities to train and up-skill. I decided to do a MSc which I self-funded. I decided that the Queen Mary University three-year Emergency Medicine and Resuscitation course which covers all aspects of emergency medicine including trauma and CRBNE would help with my role in HART.

For my final year project, I thought about the training paramedics receive and where I think it needs to be improved. That’s mass casualty triage, in my view – at present you have a sand mannequin with a piece of paper and a set of observations written on it, and you have to read it and react to it. It’s not intuitive. And triage is a big part of the work. It can look like a simple algorithm, but it can be difficult, especially when you are stressed.

Alongside that, I read some articles on virtual reality. I’m not the most technical person myself, but I started to look into it.

I ended up pitching the idea for a virtual reality package that could be used to help train responders for mass casualty incidents. My main message was that they would help get academic research for a product that I helped co-create; they would be making a difference and improving vital training.

They agreed to help me. It took six months to go from nothing to actually having the product there for me to trial, which was a lot of work in a short space of time. But we did it – Andrew Connell and his team have been so helpful.

The overall result is a package consisting of software and a platform behind it which will capture the data from the training.

How does the product work?

I’m in Manchester, so at present the virtual reality scenarios focus on this area. We’ve mocked up Exchange Square in virtual reality and we’ll be creating scenarios within that area. You can run these scenarios through the virtual reality headset so that first responders will be able to train within environments which they’ll actually be facing.

The scenarios could be things like vehicle accidents, stabbings, shootings, a bomb incident – you can change that scenario you want your trainees to face. It immerses users into the sights and sounds of a real-life incident.

For my training, I used the scenario of a Marauding Terrorist attack (MTA) at a football stadium. Inside the VR, users stand outside the stadium. You are briefed on the incident, and then you go inside.

Participants find themselves looking at a room full of casualties. You can see injuries on the body right there in front of you rather than just trying to imagine them and you can touch them too, using hand controls with inbuilt haptics so that you can do things like checking for massive bleeding, opening airways feeling breathing rates, checking pulses, putting the person in recovery position.

At present, users need to show that they have the skills to identify what is needed – for example, choosing an option within the VR to indicate that the person needs a tourniquet or wound packing. A future development will allow users to actually administer that tourniquet there and then.

One of the learnings from the Manchester Arena attack in 2017 was around responders’ confidence in handling a situation if a person has passed away. The deceased individual needs a triage card to identify their time and date of death – it’s a key legal document which also includes the time, date and your pin number with signature. The VR also allows staff to have practice doing this.

Different options

There are different training options available as part of the software. Mass casualty triage will be one option, so trainees will be able to follow the triage process in their virtual reality setting. This includes the new Ten Second Triage (TST) and NHS Major Incident Triage Tools which are coming into the emergency service later in 2023.

Commander training for the ambulance, police and fire service will be another – you can combine this with the triage training, if you want to, so that they can get the benefits from both.

Another option which we are currently developing will focus on CBRNE, and there will be different sets of training focusing on that. For example, if a situation includes chemical or biological contamination, staff need to be trained in decontamination procedures. That’s really hard to do with standard training procedures which are nothing like the real situation they’ll be facing – and the virtual reality means that unlimited numbers of people can go through the same training without having to gather large groups of people together at the same time which can be difficult and costly.

Data capture

The platform sitting behind the software consistently collects data from the training that has been undertaken, including stats such as time spent on task, accuracy of actions taken, the speed of interventions and so on. Through that, not only can we improve staff training in the present, we can also see where the training is lacking for the future and adjust it to match the data.

Looking at longer term plans, I’m wanting to work with the National Ambulance Resilience Unit (NARU) to cover iconic sites in different cities. Touching on the data point again, this will also mean that we can compare data between different regions and share learnings and best practice.

Ultimately, I hope that the ambulances services will take it up to enhance their training offer for frontline staff who could respond to a major incident.

The study

For the purposes of my study I developed a pre-survey which went through participants’ experience and demographics, exploring things like how many years they had worked for HART, how many major incidents they had been involved in, and whether they had ever had to use the triage tool in a real-life situation.

Following a training session on how to use the VR headset, the training scenario was trialled with 36 paramedics from my trust, NWAS HART Manchester. One of the main things in development was keeping it simple – I didn’t want to overwhelm the people who would be using it, especially as a lot of them had never touched this kind of technology before.

For the primary outcome of the study, I wanted to understand whether virtual reality offered better training overall than the existing training. As I mentioned, at present the training includes a sand mannequin and a piece of paper asking for observations such as whether they are walking, talking, breathing, whether they have a pulse and what injuries they have.

In my study, 100 percent of participants said that the virtual reality enhanced the training, and 83 percent said that it provided better training than the sand mannequin.

For my secondary outcome, I wanted to understand staff confidence, not only in terms of attending a mass casualty incident but also in applying the triage tool. The study found an 86 percent increase in confidence in both.

Since the study, around 20 more paramedics have gone through it and tried it out. Some of them were really sceptical at first but they really saw the worth when they’d actually been inside the VR world and seen what is possible.


Finding a tech company to support my idea by letting me use their product for the study was obviously a challenge because I wasn’t paying them, I was just telling them about my background and idea and hoping that they help. This is why I had to find a company a build everything from scratch.

I think the main challenge for me was around permissions. I originally wanted HART paramedics from Manchester and Liverpool to be involved in the study, but getting permissions for that proved to be a long and complicated process. I stuck with my own Manchester HART base in the end and the university really helped me through the process of getting the necessary permissions. My HART team was also so supportive to me, both my colleagues and my management team which I’m really grateful for.


If I was giving advice to someone about to start a project like this, I would say: don’t give up, and use your team effectively. I bounced ideas off people all the time and involved them as much as I could, and they’ve all been incredibly supportive.

I had particular help from Dr Stephanie Hayes, a consultant midwife at my trust – she completed a PhD in virtual reality focusing on its use in maternity settings. I learnt a lot from her and she was a brilliant mentor to me.

Relationships are important in making it work. I’ve built up a good rapport with the Chief Technical Officer Andrew Connell. We’re from very different backgrounds – he’s very techy, I’m not! But I think we work well in that sense because we’re both looking at it from different angles.

Looking to the future

In five years’ time I’d love to see our VR simulations used nationally, by all emergency services, to support different types of training. Furthermore, I’ve had a lot of interest from international organisations.

Virtual reality doesn’t replace the other forms of training; it enhances it. The thing with VR is that you can pick it up and go into that world and keep practising, so you can better your skills until you feel confident.

I’ve been in that position before, when something goes wrong, and you aren’t sure what to do – it’s a very vulnerable feeling. It’s why I’m a HART paramedic now. So, if our VR simulations can help people to build their confidence in those situations, then that means a lot to me.

I want to focus on trying to help the wider ambulance services, police forces and fire services in the UK, but this will need help at a national level for funding either from government or from large corporate companies that want to help ensure the emergency services can use tech to improve their training.

Many thanks to Steven for taking the time to share his story with us.

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