Airway & Respiratory, JEMS Games, Training

Simulation Furthers Learning in the EMS Classroom

Issue 6 and Volume 37.

EMS has used simulation for decades in the form of CPR manikins, task trainers and standardized patients (i.e., real “victims” moulaged and simulating illnesses and injuries).

However, with the advancement of high-fidelity (HF) manikins and the use of standardized patients in critical-thinking exercises, we’re now capable of offering scenarios that immerse students and providers in real-world exercises. And it’s had great results in improving the educational process and changing a lot of the traditional behaviors.

Case in point: the 2012 JEMS Games. The use of HF manikins proved essential in providing a scenario that simulated a deteriorating patient and provided the participating teams a platform to perform all necessary treatments in a realistic environment. The Laerdal/JEMS folks strategically designed and implemented an integrated educational approach by creating an article about asthma and announcing that asthma would be seen in the competition.

In conjunction with this new educational approach, Laerdal provided its comprehensive Discover Simulation Toolkit to each JEMS Games attendee. The teams obviously paid attention, which emphasizes a key point of simulation: It’s designed to be constructive, not critical. Simulation is a safe place to learn, make mistakes and take away positive reinforcement. 

The Theory

Simulation in healthcare is used for education, evaluation, research and system integration. The goal of this article is to assist the instructor in building a relevant scenario and providing a positive learning experience for the student. We can divide the simulation experience into the four “Ps:”
>> Prepare;
>> Practice;
>> Present; and
>> Post-review.

Learn your simulator’s capabilities: Many institutes and departments have purchased HF manikins to augment their training program. Their use ranges from critical-thinking exercises to using the simulator as an advanced “task trainer.”

Although all positively enforced training is good, it’s recommended that the instructor participate in training sessions offered by the manufacturer, and simulation-based training offered by such recognized organizations as the Society for Simulation in Healthcare (, to understand the components of a successful simulation program.

Skilled educators and technical consultants are also available to assist with planning and developing simulation learning. EMS conferences now regularly have simulation as a topic, so this can help the operator keep current on trends.

High-stakes risk assessment: Every training institute and department has its own unique risks and encounters. A primary goal of your simulations should be how to address the high-stakes situations that your students/EMS providers encounter. Is there a trend your students are struggling to grasp? Is there a new method or protocol you want them to learn? Has a problem been encountered that affects crew or patient safety?

You can gather the information from classroom and exercise performance, patient charting/documentation, crew reports, hospital/command feedback and any stakeholder resource. Once the risk is identified, you can begin to plan your strategy for a simulation exercise.

Critical-thinking points: No matter the exercise, critical-thinking points should be limited to the main point of the exercise.

Let’s take the subject of identifying an ST-elevation myocardial infarction (STEMI) patient and transporting the patient to an appropriate facility. The provider should be able to do the following:
1. Identify STEMI;
2. Know of and be capable of directing appropriate care;
3. Communicate with command physician and recommend STEMI alert; and
4. Communicate well with receiving facility staff.
This example stays within the parameters of care, treatment and transport of a STEMI patient. It doesn’t add complications or “gotcha” points.

The Practice

Skills: Simulators are also valuable because they can be used effectively to develop, maintain or augment various lifesaving skills. This can include the administration of drugs, advanced airway care, medication and most BLS and ALS skills.

Simulators have the ability for instructors to log skills in real time as they occur, and some skills are automatically logged by the program. The instructor can also log in during the scenario run and make comments that may aid in instruction after the scenario is complete.

Pre-programmed scenarios: Many simulator manufacturers have common, frequently seen (and seldom seen) simulations for clinical (medical and traumatic) cases, to get you started.

They also offer programs you can purchase that are designed to meet the needs of specific healthcare practices. For example, you can purchase programs that meet advanced cardiac life support and pediatric ALS and standards.

This saves you from having to build these programs from scratch. However, you should ask yourself whether the program meets the needs of your simulation education because if it doesn’t, you’ll have to build or modify your program to suit your specific needs.

Scenario building/environment: We emphasize that instructors need to be able to program and operate their simulator efficiently. Sketch out your scenario into a logical flow. Using a template or flow chart is an ideal way to lay out the scenario on paper. Check all sections for accuracy and have your key instructors check and agree that all points are included in the template.

Building scenarios in your simulator’s program: This will vary by each manufacturer and even between models from any manufacturer. Consider your critical-thinking points as key trigger points in your simulation. Other triggers can be skills and procedures that normally would be encountered in the given scenario. Simulator manufacturers provide a good number of skills and procedures, but you may want to add more to meet your specific needs.

Running a program “on the fly:” This type of program is completely manual. It depends on the simulation operator to make all necessary parameter changes and record all critical-thinking and skills assessments. Obviously, the operator needs to be familiar with the simulator and its systems to be able to run an “on the fly” program successfully. This type of program can also be used for situations in which a preprogrammed or built scenario fails to advance and critical parameters need to be changed.

Now that your simulation is operational and loaded with key simulation scenarios, you should do run-throughs with key instructors and personnel to be sure that all key critical-thinking points have been met, correct procedures are implemented and all teaching points are included. Running the program will alert the instructor to possible conflicts or errors in the program as well. 

A checklist of critical-thinking points and skills should be provided to each instructor to ensure all training criteria have been met. Use this “shake-down run” to ensure you work out any bugs and eliminate surprises.

Presenting to the Masses
You’re now prepared to present your simulation to the learners. Make sure that everything they need to learn is presented in advance and that all required equipment is in place before you start.
The learner should be made aware of the type of simulation they’ll be participating in and given an outline of what’s expected of them before they start.

Allow sufficient time for learners to check equipment and environment for their comfort. It’s recommended to advise the students to check their environment and ask any questions they may have before starting.

Start the simulation and allow the students to immerse themselves into the care of the patient. You should only interrupt if there’s a safety concern or if the student(s) prompt you. If possible, it’s best for the instructor to be in a separate room or other remote location where you can view the entire process.

Let the scenario flow. You should have an on-screen checklist of the points and skills you want covered. This will help you in the debriefing process. The instructor running the simulation usually acts as the voice of the patient via microphone and headset.

Video recording is another tool commonly used in the simulation process. Students should be made aware they’re being recorded for educational purposes only and that the video won’t be stored or used to embarrass or show negative outcomes.

Post-Simulation Review
Student debriefing (review) should be accomplished immediately after the scenario is concluded or as soon as feasible. Debriefing is the process by which students interactively review their performance after completing a simulation exercise. The procedure should be guided by session objectives, course material and student comments and questions. Instructors should serve as a resource and interject goals and outcomes of the scenario in a positive manner, not act as a lead voice in the debriefing process.

Instructors should debrief and review participants to reflect on the presentation and its benefits in the learning process as soon as possible after the simulation presentation. The instructor can have debriefing files generated during the simulation. Some simulators have the capability of recording video that synchronizes with the debriefing file. Key points that occur can be marked in the file for fast retrieval and playback during the debriefing.

In your review, consider the following:
>> Were the main critical thinking points covered in the simulation?
>> Were all skills addressed and completed?
>> Did the participants respond appropriately to the presented scenario?
>> Were crew and patient safety appropriate?
>> Was there anything else that should have been covered to meet the goals of the scenario?
>> What’s the feedback from the participants?

Healthcare HF simulation is advancing and has joined the ranks of aviation, space flight, military and other high-stakes roles. With the continual advancement of computer science and simulation design, we can provide a safe learning environment for EMS providers and produce a more effective and efficient EMS system. JEMS


This article originally appeared in June 2012 JEMS as “Sim for Students: Master using simulation in your classroom.”