Major Incidents, Training

Bridge the Clinical Experience Gap with Simulation

Issue 40 and Volume 41.

Although it’s difficult to put a precise count on the number of EMTs and paramedics who are currently serving in the United States, according to 2008 estimates reported by the National Highway and Traffics Safety Association (NHTSA), there are approximately 69,278 licensed EMS providers in 48 states and 4 territories.1 The U.S. Department of Labor rated the potential annual growth rate for EMS jobs at 23%, which is “much faster” than the national average of 11%.2 Clearly, the demand for EMTs and paramedics is very high, and shows no signs of abating in the foreseeable future.

“Probably not much in medicine is sillier than an 18-year-old kid getting out of high school, then graduating an EMT class with a 120-hour certificate, and being expected to ‘act like a professional,’” said Thom Dick , the greatly respected paragon of the EMS profession (and former JEMS columnist).Since Thom wrote those words over 10 years ago, the length of most EMT programs have significantly increased—for example, the EMT program for which I’m a lead instructor, Front Range Community College in Longmont, Colo., runs for 245 hours.

Given the increased amount of time spent training the current generation of EMS providers, one would be tempted to think that as educators, we’re preparing our newest charges for their chosen profession in the best manner possible. But is that really the case?

“Many of the applicants—especially the EMTs, but a surprising number of paramedic applicants too—for EMS positions today have no experience working in the field at all,” says Jennifer Roderick, clinical chief at Rural/Metro-Pridemark of Colorado. “While they’re very enthusiastic and have been well-trained in many of the specific procedural skills and didactic knowledge base that was necessary in order to pass the National Registry exam, we have increasingly found that they lack the training to perform under pressure in the field.”

Her comments have been echoed by many other field instructors, not just within my own agency but also several others, both Fire-based and ambulance-based in nature. Almost all of them make the same point: students are typically primed for success in the classroom environment, less so for the stresses and rigors of responding to 9-1-1 calls and working the streets.

I’d argue there are inherent limitations in the way entry-level EMS providers are trained. This is by no means a criticism of the thousands of EMS instructors who labor to turn their charges into well-prepared field providers during their initial certification classes. But the classroom is a clean, sterile, brightly lit and above all completely safe environment in which to learn—which is exactly what it should be. However, EMTs and paramedics don’t generally work in such a place; the field is a fluid and dynamic environment, constantly evolving and changing as new variables come into play on scene.

The pressures of the classroom—“Will I fail the next test? Did I remember to say ‘scene safe’?”—are very different from those of real emergency medicine calls, where the rookie practitioner is assaulted by a wide variety of stressors and no small degree of information overload. Compare the locations in which a paramedic student learns to intubate: the calmness of the classroom at first, followed by rotations with an anesthesiologist in the controlled environment of the operating room. In the field, a provider is likely to have to employ that skill in the dark, at the side of the road, with the chaos of a motor vehicle collision scene going on all around them. The contrast is startling, and may set the novice paramedic up for failure.

Although EMT students are exposed to real patients during the clinical internship phase of class, the relatively short span of contact time (two 12-hour ambulance rides and two eight-hour ED clinicals) can equate to a small volume of low-acuity patients. If the ambulance rides take place during a slow set, and the ED clinical rotations are scheduled on quiet nights, the eager EMT student may not see a single patient who is in extremis.

Simply being able to score maximum points on a classroom trauma scenario doesn’t necessarily mean that the student will handle a true emergency call well. And quite frankly, do we even have the right to expect them to? Virtually every pre-hospital medical care agency puts new employees through a period of field instruction, which must be completed to the satisfaction of a preceptor before the new hire is cleared for independent duty on the streets. It’s fair to say some field instruction programs are stronger than others; systems do exist in which brand new EMTs and paramedics are rushed through the process in order to fill a personnel void within the organization, and are ultimately cleared for service in a mere one or two days, sometimes without having run a single truly acute emergency call.

“There is an implicit expectation that no matter how inexperienced the new employee is, we’ll be able to get them completely up to speed during the field instruction process,” a frustrated preceptor once told me candidly. “But in reality, we trainers are only as good as the trainees that are sent our way. If there isn’t a strong foundation for us to build upon, the end result is going to be weak.”


Simulation-based training for trauma scenarios

Simulation-based training allows educators to place students under pressure in a variety of ways in a completely safe learning environment.

A clinical experience gap exists; it’s a significant grey area between the time in which a student graduates from their primary education program and the time in which they enter the field internship phase once hired by an employer. It may be that some agencies have unrealistically high expectations of those entry-level personnel who walk through their front door with an employment application in hand. It’s equally possible that we, as educators, could do more to prepare the fledgling student for the challenges of their chosen vocation. In reality, I suspect that a little of both elements is true. This begs the question: How are we to bridge that gap?

We put a great deal of thought into answering that question at Rural/Metro-Pridemark. One of my personal passions has always been the subject of history, particularly military history. I recalled reading of the manner in which the U.S. Air Force (USAF) dealt with a similar problem in the 1970s. During the Korean War, American fighter pilots had shot down enemy planes with a 10:1 kill ratio. But by the time the Vietnam War took place, the kill ratio had plummeted to a shocking 2:1. Throwing some of their finest analytical minds at the problem led the USAF to an inescapable conclusion: the inexperience of the Vietnam-era pilots was getting them killed. What’s more important, however, was that the vast majority of them were dying during their first 10 combat missions.4

The numbers spoke clearly. Those pilots who survived their first 10 missions in enemy skies were significantly more likely to survive their entire tour of duty. Making a critical mistake in the hostile skies over North Vietnam tended to be an unforgiving, often fatal experience, but with 10 missions under their belt, the fighter pilot had generally escaped from the trap of “I don’t know what I don’t know,” and gained a fundamental understanding of the air combat arena.

EMT and paramedic heart rates during simulation training

Major Richard “Moody” Suter and his colleagues hit upon an ingenious idea: What if they could give American fighter pilots those first combat missions before they ever had to go to war? By putting them in a high-stress, but above all safe learning environment, those crucial lessons could be learned in the Nevada skies surrounding Nellis Air Force Base, where missiles and cannon shells were simulated. More importantly, those lifesaving lessons wouldn’t have to be paid for in blood.

In this idea lay the genesis of Exercise Red Flag, which first came to life in 1975, pitting students against a hostile aggressor force in a variety of complex simulated combat missions in the skies of the Nevada desert. The exercise was deemed so popular and beneficial that it continues to this day, 40 years later. American pilots, joined by their comrades from 28 allied nations around the world, all strive to meet a common goal: the creation of the best fighter pilots conceivable.

It occurred to our clinical department that this may be the solution to at least partially bridging the clinical experience gap. We needed our own Red Flag, a way of giving those inexperienced EMTs and paramedics the opportunity to run high-acuity, potentially dangerous calls, with no consequences other than the occasional bruised ego. Simulation-based training would allow us to place our students under pressure in a variety of ways, but more crucially, do so in a completely safe learning environment.


Almost every EMT and paramedic can remember the fear and anxiety that accompanied our first, truly severe 9-1-1 emergency call. Overtaken with the adrenalin-fueled sympathetic nervous system response, with rapidly-climbing heart rates, blood pressures and respiratory rates, our brains may have vapor-locked due the stress. I can still vividly recall an inner voice yelling, “I’m not prepared for this!” as I reached for a blood pressure cuff with a trembling hand. But the truth was that my EMT instructors had prepared me for it, and worked hard to instill the skills and thought processes needed to get me through the call—if I could just remember how to use them under pressure.

With the primary goal of teaching the students to function effectively and safely while under duress, our cadre of EMS instructors wanted to define more specific sub-goals. “We needed measurable criteria by which to gauge our level of success,” explained Keith Hogan, clinical captain. “That meant taking multiple sets of vital signs on the students each day, establishing a baseline for them before and immediately after running a simulation.”

EMT and paramedic respiratory rates during simulation training

Simulations begin on a relatively small scale, and are taught in conjunction with relevant didactic subjects. Lecture and simulation dovetail to emphasize specific learning points. For example, instruction on the appropriate way to treat the newly bereaved parents of a deceased child gains new relevance when the students are dispatched to care for a field delivery with complications.

Depending upon the efficacy of the treatment and transport for which they’re responsible, the EMTs and paramedics will find themselves breaking the news of a child and his mother dying to an actor portraying the role of a horrified spouse and parent. Scenarios aren’t scripted—they change dynamically, based upon decisions made by the students.

At the end of a 40-hour week, training culminates in a graduation exercise based around a mass casualty incident. This is an opportunity for the command and administrative staff to participate, fostering a bond between current staff members and those who are joining the family. We currently implement an active shooter scenario, which has allowed us to bring in members of local law enforcement agencies to train cooperatively.

Responding in real ambulances to a commercial building, the students arrive to find up to 20 moulaged patients with an assortment of gunshot and blast-induced wounds, along with a variety of complicating medical conditions. Their baseline vital signs have already been recorded. Whichever paramedic happens to be first on scene is expected to assume command and run the incident to the best of his or her capability.

Some of the measurable criteria by which we gauge success are:

  • Was command established promptly, and were the appropriate roles assigned?
  • Was the scene sized up appropriately? Were booby-traps found or triggered inadvertently?
  • Were the appropriate resources requested promptly?
  • Were patients triaged accurately under the START and JumpSTART criteria?
  • Were patients transported in the appropriate order and to the appropriate destinations?
  • Were the appropriate medical interventions performed?

Such decisions are easily made when conducting a tabletop exercise, but take on a new dimension of difficulty when made in the middle of a smoke-filled building, with fire alarms and screaming trauma patients providing the soundtrack.


EMT and paramedic vital signs during simulation training

Each employee who completed the simulation was designated with an alphabetic character. (See Table 1.) In the case of subject C, a 23-year-old female, we witness a heart rate that almost doubles during the exercise, indicative of the stress she was experiencing. If this EMT was assigned the role of incident commander, her proctor would determine whether she successfully assumed command, delegated roles and requested the appropriate resources promptly.


Simulation training for trauma scenarios in EMS

Simply being able to score maximum points on a classroom trauma scenario doesn’t necessarily mean that the student will handle a true emergency call well.

It’s incumbent upon every organization to assess the size and severity of its own clinical experience gap, and to devise methods of narrowing and ultimately closing that gap. Although requiring significant creativity on the part of the training officers, the employment of stressful simulation-based training provides a cost-effective method to address this area of growing concern. This type of training can be implemented by departments large and small, and can be scaled and tailored to meet their resources.


1. Chapman SA, Lindler V, Kaiser JA, et al. (2008.) EMS workforce for the 21st Century: A national assessment. NHTSA EMS. Retrieved Feb. 1, 2016, from

2. Bureau of Labor Statistics. Occupational outlook handbook. (2015.) Retrieved June 19, 2015, from

3. Dick T, Berry S, Forster J, et al. People care: Career-friendly practices for professional caregivers. Cygnus Business Media: Fort Atkinson, Wis., p. 27, 2005.

4. Kleinholz J. (Jan. 23, 2015.) 40 years of Red Flag at Nellis. Air Combat Command. Retrieved June 19, 2015, from