Cardiac & Resuscitation, JEMS Games, Training

2012 JEMS Games Use Simulation & Integrated Training

Issue 8 and Volume 37.

For the seventh straight year, EMS teams from around the country demonstrated their clinical expertise and ability to overcome scenario challenges during the 2012 JEMS Games clinical competition at the EMS Today Conference and Exposition. Teams registered for the competition received a packet that included important details about the competition, including the preliminary event and the finals. Earning one of the top three slots in the preliminary competition is the only gateway to the finals.

New Aspects

For the 2012 JEMS Games, JEMS and Laerdal teamed up to create an innovative, integrated training and simulation program for the JEMS Games competition. In December 2011, a clinical article and clinical education program about acute asthma (“Fighting for Air,” December 2011 JEMS) informed all competing teams and the JEMS/EMS Today audience that an acute asthma patient would be among the patients managed during the 2012 competition. 

The intent was to assist participating teams in preparing for this patient type in advance of the games and to allow those attending the competition at the conference to read the article in advance of the games. This would allow attendees to see how each team performed in accordance with the latest recommendations for treatment of the acute asthma patient.  

Teams and attendees were also told that JEMS Games founding sponsor, Laerdal Medical, prepared a blend of instructional resources to support EMS training on the assessment and care of asthma patients. The complimentary tool kit, known as Discover Simulation, was provided to the competition participants and spectators. 

The Discover Simulation Tool Kit provides a comprehensive approach to teaching clinical skills. Its components include resources to support knowledge acquisition, skills practice and simulation in teams. The knowledge component includes an article on asthma, test items and an item analysis tool. The Tool Kit also provides a comprehensive list of suggested skills related to prehospital asthma care. The simulation resources include a programmed scenario compatible with all Laerdal simulators and standardized patients. The simulation file is the actual asthma scenario used in the 2012 JEMS Games. Each of the Tool Kit components includes checklists and suggestions for implementation. 

The preliminary course was also redesigned to keep pace with current clinical trends and include new care components, emphasizing the 2010 American Heart Association (AHA) recommendations for continuous and consistent cardiac compressions. The course also emphasized use of capnography, continuous positive airway pressure, therapeutic hypothermia and rapid assessment and treatment of the deteriorating asthma patient. 

New wireless Laerdal Medical simulator technology was also added to allow the competing teams to assess, manage and move the same manikin throughout most of the eight stations on the preliminary course.

Team Orientations
The day prior to the preliminary event, competing teams check in their response bags and equipment. To aid them in their final preparation, competitors are provided an overview of the expectations during a competitor briefing the evening before the preliminary competition, which is followed by a walk-through of the entire course. 

Each team could then finalize their specific strategy about how they would manage the clinical course challenges, interact with the competition coordinators and practice with the Laerdal simulators used throughout the competition.

Preliminary Competition
On preliminary competition day, the teams are sequestered in preparation for their individual rounds. When it’s time for a team to compete, the lead judge calls them into the competition floor. They start the event by loading all their equipment and medical bags into a mini-rescue ambulance. Their official time starts when the lead judge blows the whistle. At that time, the team must bring the stretcher, equipment and bags near the first station. 

The first task for the competitors is to open a locked window, look through it with binoculars and identify the UN/NA number on a placard 40 yards away. Using the identified North American Emergency Response Guide number, the team must correctly identify the product, determine the initial isolation distance and establish the protective action distance from the table in the green section of the book. After the team completes this task by writing the correct information on a large flip chart adjacent to the window, they’re allowed to enter the course by transferring all their team members and equipment through the window. 

In the next station, the teams were required to perform an “emergency move” to bring the patient, exposed to a toxic environment and in subsequent respiratory distress (early asthma symptoms), to a safer, pre-designated location. 

As referenced earlier, a significant enhancement to this year’s competition involved use of the new Laerdal wireless patient simulation, SimMan Essential. The SimMan Essential added a more realistic feel to the competition because teams could treat and move this enhanced simulator through every clinical station without being tethered to a computer. 

The team members brought their equipment and bags to the patient’s side, and two team members had to carry the “patient” (already secured in and placed on a backboard) to the safe area to begin assessment and treatment. Once the patient was safely relocated, the team members were faced with a patient suffering from a severe asthma attack. They had to quickly identify the patient’s condition and begin treatment. 

This station involved interpretation of a capnography waveform, which displayed the classic “shark fin” pattern associated with an asthma attack. Competitors were allowed to progress in the competition once the upper and lower airways were appropriately managed. 

At this stage, the patient lapsed into cardiac arrest, irrespective of the treatment provided. Thus, each team was required to demonstrate two minutes of effective CPR before being able to move the backboarded patient (simulator) and all their equipment through a 4′ x 4′ x 12′ tunnel (built to simulate a difficult patient removal pathway). 

On the other side of the tunnel, the teams were required to perform two additional minutes of CPR because of the interruption involved in moving the patient through a tight, obstacle-filled environment.
They were then allowed to progress up a flight of stairs, across a platform/landing and down an opposing set of stairs to the cardiac arrest management station. Teams were expected to perform excellent CPR, provide appropriate medications based on current AHA guidelines and provide post-resuscitation care as indicated by the clinical progress of the patient.

CPR Quality & Endurance
This year’s competition produced some interesting and predictable results. Several teams were unable to maintain consistent quality compressions and maintain the rate of compressions recommended by the AHA guidelines. Use of feedback devices and metronomes definitely helped, but many teams couldn’t maintain consistent depths and rates of compressions as evidenced on reports generated from the Laerdal simulators software. 

In addition, a few team members became so exhausted trying to perform consistent CPR compressions that it slowed their teams down and hampered their ability to properly treat and resuscitate their “patient” in a timely and successful manner. The physical condition of several team members and their inability to perform properly during an extended time period was further evidence of the need for crews to rotate compression rescuers frequently and be physically fit. 

Once a team successfully completed the cardiac arrest resuscitation station, they were allowed to load the patient, equipment and medical bags back into the mini-rescue ambulance to complete the course.
All competitors must be in their seats with their seatbelts fastened before the lead medic is allowed to signal that the team is finished. The official time for their team is then stopped. The team’s scoring sheets are then collected from each judge, and extra time is added to their course completion time for areas not successfully completed. 

All team scores are then reviewed and ranked, with the top three performing teams announced and advancing to the Friday evening JEMS Games Final Competition—conducted on a stage in a large ballroom with more than 500 spectators present.

The ‘Finals’
The winning teams from the preliminary event were presented with a challenging final scenario in 2012 that involved caring for 12 patients with varying levels of acuity. Prior to entering the competition area, team members viewed a video that depicted a Joplin-type tornado tearing through a town.
When the teams were allowed to enter the competition area (a realistic emergency shelter area established soon after the tornado), they were surprised to find a quiet area with crickets chirping. When they reached the shelter facility, the team members found nothing inside but cots, stretchers, medical supplies and equipment, a few chairs and American Red Cross volunteers serving as a check-in facilitators. 

This interesting psychological twist lasted for two full minutes that seemed like an hour to the teams—taking them from a heart-pumping, chaotic video to a quiet room with an audience of passive spectators. 

The silence quickly ended when the first person arrived as a walk-in, dyspneic patient. Tying into the acute asthma article, the first clinical component involved a patient with a severe asthma attack. The three competitors on the stage then had just one minute to get as much assessment and treatment rendered as possible prior to the arrival of four additional patients brought in by community emergency response team members. 

Patient No. 2 presented with a significant (through-and-through) abdomen impalement caused by a wind-swept tree branch. The third patient was suffering from anxiety related to the psychological impact of seeing the destruction from the tornado. Patient No. 4 (simulator) involved an electrocution injury that resulted in acute renal failure. If teams didn’t immediately treat this patient in an aggressive manner, he fell into irreversible cardiac arrest. Thus, this was an opportunity for aggressive, well organized, independent acting teams to shine. 

The fifth patient had a flail chest and was developing tension pneumothorax as a result of a wall that fell on him at his home. There was no longer any silence on the stage/treatment shelter area.
At the five-minute mark, the teams were faced with five new arrivals at the shelter. Unlike the first five patients, these new arrivals were simply people who had been displaced from their homes because of the storm. As would be expected in an actual event, they wandered around the shelter asking what was happening and watched in wonder as the paramedics cared for the wide variety of injured and ill patients. The most effective teams quickly realized the need to gain control of the scene immediately.
The last two patients arrived at the 10-minute mark. One had an isolated humerus fracture while the other had multiple abrasions and lacerations after being hit with flying debris. Ten minutes after the arrival of these last two patients, “time” was called. That marked the end of the competitors’ 20-minute journey through the complex, challenging and intense final competition scenario—all enhanced, monitored and recorded by high-fidelity Laerdal simulators.

Competition to Real-Life Care
Although the JEMS Games clinical competition is designed to challenge the competitor’s knowledge and skills, it’s also an educational event with the end goal of helping teams (and the audience) improve patient care. 

Following a major shift in focus, this year’s competition was markedly improved by directly linking the educational article on acute asthma to the competition. This concept was further enhanced by the development and dissemination of the innovative, cutting-edge Discover Simulation Tool Kit that linked all elements into one complete educational training and simulation package. 

For the first time in the history of the JEMS Games, the competing teams were advised to read and thoroughly understand the patient assessment and treatment aspects outlined in an article about asthma. They were forewarned that one of their patients would be an asthma patient and they’d be expected to apply what they’d learned from the article. This concept of cognitive “pre-loading” led to a competition in which all teams competing in the final rendered outstanding care to the asthma patient. Although this was part of the desired outcome, it wasn’t the end of the story. 

To further enhance the educational experience for both competitors and attendees at the EMS Today Conference, Laerdal distributed the Tool Kit—prepared to correspond with the acute asthma scenarios designed into the 2012 JEMS Games—to hundreds of conference attendees and all JEMS Games attendees at no cost. As mentioned, each Tool Kit included the asthma article, a pre-test, a post-test and the algorithm programming for use with either a patient simulator or standardized patient. Attendees were thus able to return to their respective agencies and use the resources of the Tool Kit to train their staff. 

The pre-test was intended to be distributed amongst the learners within a given agency and scored for later comparison against the post-test. The educators could thereafter provide the article to their learners and allow them ample time to read and understand the material. The next logical step would be to assess the caregivers’ ability to care for a simulated asthma patient using the algorithm provided in the Tool Kit

Immersing clinical providers in a simulation allows for assessment of cognitive, psychomotor and affective behavior. After providers complete their assessment and treatment of the asthma patient, instructors can provide constructive feedback on the positive and negative aspects of a person’s scenario performance, and complete the remedial and learning aspects of the educational process.
Providing the post results to all involved in the asthma simulation then enables the participants to recognize the results of the educational process. Participants and instructors can then compare pre- and post-education results with the pre-test.

The conceptual framework designed to enhance this year’s JEMS Games and its educational impact launched a new era in clinical education, simulation and EMS competitions. This integrated approach demonstrated to participants, educators, medical directors and observers that it brings about positive change in assessment and the clinical approach to specific patients. 

Introducing the methodology of the Discover Simulation Tool Kit to this year’s JEMS Games competition demonstrated to EMS educators how to approach blended learning, how they can use competition as part of their strategy, how integrating classroom learning and simulation can enhance education and how to ensure education continues and is expanded throughout an entire workforce after the competition. 

Laerdal and JEMS will be continuing and expanding the use of this integrated approach to training and simulation in articles produced and presented in October and December 2012 JEMS, January 2013 JEMS and at the 2013 EMS Today Conference and Exhibition in Washington, D.C., March 5–9. Look for these valuable educational tools in JEMS and at the Discover Simulation website: For information and applications to participate in the 2013 JEMS Games, go to JEMS