A 10-member expert advisory group was formed to identify training priorities for which 3D-SC1 could be appropriately used. All these experts held local or national roles in organization and training of SC programs. Experienced physicians and soldiers in operational units, with significant experience of deployment in combat zones, also participated. A scenario was created to illustrate a real-life–based experience, the explosion of an IED during a reconnaissance mission. The same panel of experts promoted the scientific validation of the scenario according to the SC French guidelines.

In the 3D-SC1 scenario, the explosion of an IED creates 3 casualties: one is dying, one is slightly stunned; and the last one presents with a traumatic amputation of the limb, difficult breathing, and another hemorrhagic injury under the arm. At the beginning of the experience, the care under fire stage is illustrated by hostile fire after the IED explosion, in a stressful, hostile, and noisy ambience (explosion, firearms shooting, shouts of pain), and an austere setting (desert; Figure 1). The trainee has to choose between several tactical options: return fire, determine which casualty is dead or alive, determine which casualty can return fire, or pick up the casualties and run to cover (Figure 2). When no longer under direct enemy fire, the trainee has to deal with different forward combat life-saving procedures from SC programs (Figure 3): tourniquet application, casualty survival positioning, hemostatic dressing, and morphine auto-injector use. In addition, the trainee has to deal with weapons security, management of personal protective equipment, call for a 9-line medical evacuation (MEDEVAC) and a MIST request (which includes mechanism of injury, type of injury, signs, and treatment given).

The development of 3D-SC1 was performed in a 3D studio (Figure 4). Particular attention was paid to essential movements and postures, such as tactical tourniquet application, recorded in a motion capture mode to provide to the trainee a high-quality reproduction of the movement in the 3D-SC1 experience. Development included a gamification process where players are challenged to keep on playing to reach the game’s objective. Two levels were defined: beginner and advanced modes.

In case of failure in applying the right procedure at the right time and in the right order, an automatic virtual instructor takes control of the experience and simulates the right procedure. In the advanced difficulty level, the trainee has to face a more restrictive time limit, combined with more challenging procedures: an inefficient first tactical tourniquet and delayed MEDEVAC arrival or frequent changes in tactical context.

Most importantly, at the end of the 3D-SC1 simulation, a personalized debriefing is proposed (Figure 5), highlighting good performance achieved in the experience, the procedures for which the trainee has to improve, and the missed procedures for which the automatic virtual instructor had to take the control of the experience to perform the procedure [16-17].

Finally, on the basis of a scoring process, the trainee graduates with either a gold, silver, or bronze medal. In case of fatal outcome in the virtual experience due to an inappropriate response of the trainee, an automatic virtual instructor saves the combat casualties, and the trainee obtains nothing but a training certificate. They are invited to participate in the 3D-SC1 experience once again to improve their knowledge in the application of SC procedures.

Because SC programs are now completely incorporated into the predeployment training course of all combatants, the diffusion of 3D-SC1 is planned to reach at least all combatants before their deployment in a theater of operations. Successful deployment of 3D-SC1 was conducted in only 3 months and has already reached 84 of 96 (88%) French Army regiments. Solutions for massive implementation of 3D-SC1 include, for now, personal computers and laptops in a basic classroom, with a total of 818 hours of connection in the first 3 months (in hours, for each training center, mean 19.9, [standard deviation 35.2]). However, 3D-SC1 is also scheduled to be deployed on tablets or smartphones. Such an individual deployment of the SG could let the trainees have their own 3D-SC1 experiences anywhere and anytime. The personalized debriefings are planned to be collected in an extensive databank, allowing global statistical analysis, in order to improve the SC training programs according to the results obtained in different groups of trainees.

A major limitation of this study is that no objective data regarding the pedagogic value of the SG were assessed. In fact, we have not measured most benefits of simulation, such as that with 3D-SC1, described in this section. However, a randomized observational comparative study is ongoing. How these SGs could be assessed, as new tools for learning and training, is not clear. When applying the concept of 4 levels in evaluating training programs, as described by Kirkpatrick, we believe that studying preventable deaths as an outcome (the fourth level in the Kirkpatrick model, ie, did the change in behavior positively affect the patient) could be really challenging, especially in a combat setting [18]. We could probably only reach level 3 in the Kirkpatrick model by placing the soldier in a physical simulated environment to assess whether learning is transferred from cognition to skills and attitudes. Other points of discussion include that 3D-SC1 concerns a single-center production. However, as highlighted in the description of the process of creation and production, the development of 3D-SC1 involved a collaborative platform with interdisciplinary actors.

Actually, realization of an SG for SC training is based on the concept that an SG has the potential to increase observance and engagement with training programs in military institutions. There is an increasing interest for medical virtual simulation in numerous settings, including trauma, surgery, anesthesia, emergency medicine, women’s health care, and even patients’ education [19-27].

The benefits of complete virtual training include the ability to create unlimited training scenarios and to repeatedly try and fail in a consequence-free environment. In addition, when training is conducted in a virtual environment, each performed step is considered as essential data. The computer reproduces each movement a trainee makes, and thus, can track and record each and every one of these. Using these data, performance can be automatically quantified to a level that was not achievable ever before [28]. Furthermore, through the processes of scoring and gamification applied in 3D-SC1, the trainee is motivated to improve his personal experience. He also shares his scores with his peers in a competitive and engaging challenge [29-31].

Different virtual simulations have been developed in TCCC programs and several military medical settings, with a very strict adherence to TCCC guidelines depending on the nations’ specific policies [8,28,32-38]. Indeed, 3D-SC1 is following the SC guidelines created by the French Military Health Service Academy (École du Val-de-Grâce) in an official 2007 publication, which has been updated every year by the COESC (the Operational Committee for SC teaching) [13].

Besides SGs, live simulation exercises are the accepted “gold standard” for military preparedness before deployment in a combat zone. However, they are costly and time consuming to organize and may be disrupt local services [39,40]. In contrast, 3D-SC1 , used on a standalone computer with a suitable connection for data collection, enables multiple trainees to learn in a real-time, immersive environment, regardless of physical location. Finally, SGs are gradually taking an important place beside physical simulation (high-fidelity manikin simulation combined with casualty simulation moulaged actors), although the incomplete application of strong artificial intelligence, which would allow full mixed-initiative dialogue, can limit their applicability. However, growth in the use of SGs is likely to continue because of their ability to scale inexpensively to large numbers of physically dispersed learners, adapt quickly to prior knowledge and other individual characteristics of learners, and be available anytime and anywhere via a global information infrastructure [41].

A common criticism about SGs is that the dynamic colorful world of a computer game will distract the trainee’s attention from the learning process. However, current soldiers grew up with digital media and have developed a much better aptitude to relate a virtual world to reality. However, this criticism must be addressed for 3D-SC1 to become well accepted. It is also necessary to demonstrate its educational value and its clinical effectiveness in real combat casualty situations.

Virtual environments are not a substitute for hands-on training; they can neither simulate the physical elements of tactical response nor provide training in the dexterity of performing procedures on a casualty. To potentiate existing training, 3D-SC1 can be used as an. For example, it can improve knowledge of adequate procedures before participating in complete military exercises or local SC stages, conducted in lifelike conditions, such as MedicHos Médicalisation en milieu Hostile (Medicalization in a Hostile environment) or ExOSAN Exercice Opération Sanitaire (Exercise for Operation Sanitary) exercises [13,23].

Multiplication of 3D-SC1 scenarios and the next production of SC2 and SC3 could lead to the building of a virtual simulation platform for SC training, incorporated as part of a large military medical simulation-training program combining both SGs and physical simulation. Multiplayer large-scale virtual exercises could be included in predeployment training [42,43]. Finally, upcoming technologies such as augmented reality or haptic simulation could add to the definite 3D-SC program development [34,43,44].

3D-SC1 is a new SG module, dedicated to the cognitive training of soldiers for forward combat casualty care, during the care under fire stage. The development of 3D-SC1 involved a collaborative platform with interdisciplinary actors, including forward combat casualty care experts (the French SC), programmers, and game designers. The creation and production of 3D-SC1 outlines the applicability and acceptability of using virtual environments for training in SC procedures in dedicated scenarios. This type of simulation could easily be adapted to address different training needs of SC1 (such as urban combat or convoy attacks), SC2, and SC3 (such as combat casualty management during the tactical field care phase and preparation for casualty evacuation). 3D-SC1, actually designed for the French Army, could also find many applications to train people involved in the management of trauma casualties in other settings such as tactical emergency care, disaster and crisis management, or mass casualty events. Further possibilities related to the application of 3D-SC1 are unlimited. The observational comparative trial addressing its educational value is ongoing, and its integration in a mandatory official military degree validation is the next step [23,45-51].