During a recent National Registry of EMTs (NREMT) scenario workshop with about 40 other EMS educators in Roseville, Calif., participants were asked to raise their hand if they currently use “simulation” in their training programs. Only about a third of those in the room raised their hands. But most, if not all of us in EMS education have actually been using simulation training for years.
The term “simulation” is often used to refer to incorporating the use of high-fidelity, technologically advanced EMS training manikins in an education program-but it’s really not about the manikin. Most EMS educators use simulation on a regular basis, and should be aware of the key factors that contribute to using it successfully.
The Society for Simulation in Healthcare (SSIH) defines simulation as “a technique that creates a situation or environment to allow persons to experience a representation of a real event for the purpose of practice, learning, evaluation, testing, or to gain understanding of systems or human actions.”1 We’re using simulation every time we have one student lie on the floor and pretend they’re injured while another student performs an assessment and makes treatment decisions.
Technology can certainly augment and improve our training options, but you don’t need a million-dollar simulation lab or a $100,000 manikin to create realistic and effective scenarios.
In January, the NREMT implemented the new scenario-based paramedic psychomotor exam which includes an integrated out-of-hospital (IOOH) scenario. Robert Victorino, a pioneer in EMS simulation in Oregon observes, “With the integration of the IOOH, the NREMT is unequivocally showing that high stakes, summative simulation is a valid tool.”
Simulations can be very simple or highly complex. At any level, there are a number of key components that will increase the chances that your simulations will promote learning and improve performance. Although there are costs associated with all of these components, this article will highlight some of the key elements needed to make simulation training effective and outline some ways you can spend your limited training dollars wisely.
Think beyond the classroom or training center-locations to stage great simulations are all
around you, from restrooms and offices to the drainage ditch behind your station.
What’s the Point?
Time is often our most expensive resource, so we need to make sure that our training is designed for maximum efficiency. Each scenario and training opportunity should be created with specific learning objectives in mind, and that design should include some thought about how much time is needed to hit the objectives.
EMS training scenarios are too often simply a reenactment of a really cool or interesting call the instructor was recently on, run from start to finish. Although reenactments can provide students with an excellent example of real-world EMS, if it’s not well matched to the student’s current level and training needs, it’s unlikely to produce great results.
Effective scenarios can be short and focused and may only represent a small portion of a typical EMS call. For example, a simulated call for a critical pediatric emergency might start with distraught and disruptive parents that must be dealt with effectively. The scenario is stopped as soon as the parents have been managed, or when the student has failed to do so.
Although the student may be anxious to move on to patient treatment, this scenario may not address the patient’s needs at all, but simply focus on the importance of managing the scene in order to obtain a history and control the event.
The same scenario can be used again in the future, but continued further to include patient assessment and care. The objective of this “repeat” scenario might be specific to something like a differential diagnosis for an altered mental status in an infant. If the students have already become comfortable managing the parents, they’ll be better prepared to handle that component quickly the next time they encounter the situation, allowing students to focus on meeting the new objectives.
Highly complex EMS calls with numerous things to identify and manage can be very appropriate and effective towards the end of an EMT or paramedic training program, or when working with experienced providers, but they are a setup for student failure if done too early.
Simulated monitor systems can be integrated into scenarios to keep the
process of gathering assessment data realistic and can be used with
standardized patients and both low- and high-tech manikins.
Playing Make Believe
“High fidelity” is a term that’s widely used in healthcare education today, but the term can be interpreted many ways. Training manikin manufacturers use it to imply high-end and high-cost technology. The SSIH defines it as “simulation experiences that are extremely realistic and provide a high level of interactivity and realism for the learner; can apply to any mode or method of simulation; for example: human, manikin, task trainer, or virtual reality.”1
In other words, high fidelity is about making it real, regardless of the tools you use. True high-fidelity simulation doesn’t come from a manikin, but results from careful planning, creative use of resources and a commitment to creating scenarios that are as realistic
One critical component of effective simulation that’s often overlooked is the importance of getting the students, role-players and instructors to “suspend disbelief.” This simply means getting everyone to treat every aspect of the scenario as if it were real. It’s critical to explain early in your training why students should approach each exercise like it’s a real call and resist the urge to perform differently just because the patient is plastic or a classmate playing a part. Role-players should be discouraged from joking around or breaking from the character they’re portraying, and interruptions from instructors should be minimal.
If using advanced manikins or other technology, ensure students and instructors are familiar with how they work and what they can and can’t do before starting the scenario. This pre-briefing will help learners fully engage in the scenario and give them a clear idea of what to expect. Without pre-briefing, manikins may become a very expensive distraction from the learning process, rather than a valuable addition.
The military mantra of “train like you will fight because you will fight like you train” applies very well in EMS. We’re preparing our students to perform in high-stress, high-stakes environments and we know that it’s likely their performance in those situations will mirror whatever was practiced in their training.
Making it Real
Time and budget constraints can pose a challenge to putting students into realistic scenarios. Packaging a trauma patient in a muddy ditch is very different than the carpeted floor of a well-lit, temperature-controlled classroom, but with a little effort we can replicate those field situations.
If we expect students to be ready to perform effectively in the field, it’s imperative to use real gurneys, stair chairs, and ambulances. A dedicated simulation house or simulation rooms are great resources, but even without those spaces, most training areas (e.g., schools, EMS operations centers, or fire stations) have offices, bathrooms, closets, and other spaces that can be used effectively. To minimize confusion from people not involved in the training, I suggest strategically placing large signboards to indicate “EMS Training in Progress.”
Cutting corners or leaving key details out of scenarios also fails to prepare students for what they will actually do in the field. For example, assessing lung sounds requires the steps of finding a stethoscope, placing it in your ears, placing it on the chest in appropriate locations and listening to each breath.
Too often in our training, this assessment is accomplished by turning to the instructor and asking, “what are the lung sounds?” and being given an answer. If you do similar shortcuts with blood pressure, pulse checks and respiratory rate-let alone not performing an actual physical exam-the problem is greatly magnified. Running a simulated 40-minute EMS call in 10 minutes changes the timing and the flow and doesn’t prepare students for real-world performance.
Manikins that produce pulses, blood pressures, lung sounds and more can be effectively used to keep these components realistic, but if you don’t have those tools, students should still be required to complete each step, report their findings and then have the instructor provide the details appropriate for the scenario.
Simulated monitor systems such as the solutions from iSimulate are less expensive than high-fidelity manikins or actual monitor/defibrillators and can be integrated into scenarios to keep the process of gathering assessment data realistic and appropriately timed. They not only allow simulation of pulse, ECG, and blood pressure, but also oxygen saturation, capnography waveforms, images, and more. They can be used for scenarios with standardized patients, as well as with low- and high-tech manikins, allowing for great flexibility in a variety of settings.
Realism can be greatly increased with inexpensive props such as clothes that can be cut or destroyed (e.g., disposable scrubs), pill bottles with printed labels to fit various scenarios, walkers, canes, wheelchairs, bicycle and motorcycle helmets, plastic simulated weapons, and more. Many of these items can be purchased for low cost at garage sales, thrift stores or the Goodwill. Students and other instructors can also be a great source of donated items if given a list of things needed.
There are often other simple, low-cost ways to increase realism if you tap into the creativity of students and instructors. Instead of purchasing $30-$50K ambulance simulators that mimic the sounds and movement of an ambulance ride, you can use old, used, or donated rigs from local agencies. They don’t have to be fully functional to be realistic. In one recent scenario, one of our instructors stood on the back bumper and bounced up and down to simulate the transport phase of a simulated call. This creative, low-tech solution was probably just as realistic as an expensive simulator.
The term “standardized patients” refers to the use of actual people to realistically portray patients in training scenarios. Using a standardized patient is especially effective when teaching and evaluating the affective domain, including interpersonal communication, patient interviews, demonstration of compassionate care, and patient assessment skills. These skills are difficult to teach and evaluate with a manikin, no matter how technologically advanced it is.
In programs with the budget to support it, standardized patients may be paid actors with significant time and training. In smaller programs, these can be volunteers, students or instructors. Students can help recruit volunteer patients, and they often have friends or family members willing and eager to participate just to be a part of the training and see what EMS providers do.
Other possible sources of volunteer patients are retirement facilities and school drama departments. Residents of retirement facilities have real medical histories they can share and a vested interest in knowing the emergency providers in their community are well prepared. Drama students often want and need the experience of playing new and different roles, and some drama departments will even offer students extra credit for participation.
To be most effective, the patient should be provided with a detailed script, preferably with enough time in advance to memorize most of the details. These details should include things such as the history of the event, chief complaint, medical history, answers to anticipated questions and instructions for appropriate responses to correct or inappropriate treatments or interventions. Obviously, these details should be tied directly to the learning objectives of the scenario. Using standardized patients who the students don’t already know can also greatly increase realism.
Wounds & Blood
There are an amazing variety of resources available for creating moulage, including elaborate kits with fabricated wounds and bleeding systems that deliver an impressive level of realism. There are also countless online videos that demonstrate low-cost ways to create various wounds and other medical makeup.
Regardless of the materials you use, the most expensive aspect of moulage is usually the time required to create it. Nicholas Miller, the paramedic program director at Lindenwood University in St. Louis, Miss., uses simulation extensively in his courses. Miller’s advice for moulage is, “Keep it simple; we’re not making a Hollywood movie. Rather than detailed wounds that must be repaired or refreshed after every scenario, we create wounds on Coban that can be quickly applied and easily used multiple times.” These wounds may not be as realistic in appearance, but students still need to find them, manage them and move on.
For simulated active bleeding, there are impressive systems like the HydraSim that can be used on multiple manikins or standardized patients, produce arterial or venous bleeding, and is remote controlled. But there are also a number of lower-budget options that involve bags, tubing and squeeze bulbs. There are several fake blood products available as well and some even simulate clotting characteristics. Some of these products are quite expensive, and require some additional preparation and cleanup as they can stain manikins, clothing, carpets, and skin.
An inexpensive alternative is beet powder. It’s biodegradable, easily cleaned, doesn’t stain, and a 1/4 cup will make about 5 gallons of fake blood. It costs about $8 a pound through wholesale food suppliers online.
Miller describes a simple and inexpensive way to reinforce the importance of body substance isolation in bleeding patients. He fills a spray bottle with fake blood and when a student manages a bleeding wound without appropriate personal protection, he simply directs a well-aimed shot to illustrate the point!
Early in his paramedic internship and after a particularly challenging call, one of my students asked his preceptor how he did. The reply was, “You suck at patient assessment.” When the student asked what he needed to do differently he was told, “Suck less!”
Although some may view this as a concise description of the problem and the solution, most students need and deserve an opportunity to clearly understand where they’re lacking, and more importantly a clear idea of specific things they can do to improve. This is why many simulation experts consider debriefing to be the most important component of effective simulation training.
Debriefing should be a learner-centered process designed to assist learners in thinking about what they did, how they did it, and how they can improve. One significant challenge for instructors is to decide what type or types of debriefing to use. The choices are similar to those available in field training and internship processes.
A traditional EMS approach, and one often used by new educators, is for the instructor to do most of the talking, pointing out in detail where mistakes were made and identifying areas for improvement. Although this direct approach can sometimes be effective, it’s often less productive than other methods.
Simulation training has been in use in medical training for many years, especially in nursing, and a number of established models have been described. Details of those processes are beyond the scope of this article, but instructors should learn about the various options such as Plus/Delta (which asks two questions: “What worked well?” and “What would you change?”), Advocacy/Inquiry, Non-judgmental,
Facilitated, and others.2
It’s important to note that research on the effectiveness of specific debriefing styles hasn’t established that any one approach is better overall.3 What is consistent, however, is the observation that when students are allowed adequate time to reflect on and evaluate their own performance, they will often learn in ways that are more meaningful and information and skills are more likely to be retained.
Scenario training and the debriefing method used to review it can be viewed on a continuum from basic to advanced. The knowledge and preparedness of the student should be appropriately matched to the level of scenario complexity, the debriefing techniques used, and the level of learning that takes place as a result. (See Figure 1, p. 28.)
Instructors may use a variety of debriefing approaches in their training and each may work well for a specific situation or individual, but it’s also beneficial to students if all instructors within a program or organization utilize a similar approach. This gives students a clear expectation of how “the game will be played.”
Video capture can provide a very helpful perspective during debriefing. To review an entire scenario on video can take longer than the original scenario, which makes this process impractical in some settings. Students are often very appreciative of opportunities to watch their own performance; however, some studies have suggested video debriefing doesn’t result in any greater improvement in performance than oral debriefing alone.3
Simulation and video review software systems provide additional tools for the instructor and students. Events and assessment findings can be time-stamped within the video, reviewers can pause and annotate during review, instructors can control how and with whom videos are shared, and more. This is another area where it’s possible to spend a lot of money, but also possible to gain some of the benefits with very little cost. Most students have smartphones with decent video capability and other recording devices such as tablets or even small digital cameras are relatively inexpensive. Assigning one student in each group the responsibility of videotaping the scenario is a quick and easy way to start capturing this element.
So, where should you spend your money? In 2015, the SUPER study looked at data from 389 paramedic programs in the United States to determine what simulation resources each program had and how they were being utilized. More than 90% reported having access to simulation trainers and manikins, but 31% of programs indicated their simulation equipment sits idle and unused. The study concluded, “To ensure simulation is used effectively, programs must have the appropriate equipment, faculty training, and resources. If any of these elements are missing … programs are less likely to use simulation.”4
Many schools and organizations have purchased manikins and other simulation tools through grants and other sources, and then forget to set aside funds dedicated to the initial training and the ongoing instructor hours needed to use them effectively. Before investing in expensive equipment, make sure that you have also budgeted for the resources to use it!
Miller’s advice is simple: “Invest in instructors, not manikins! I’d rather have five $10,000 manikins than one $50,000 manikin. Expensive manikins [often] gather dust. They are complicated to learn, expensive to repair and often tethered.”
Victorino adds, “An investment in staff development in the form of a robust inter-rater reliability program and frequent norming sessions will significantly reduce variance.” The norming sessions he refers to are opportunities where instructors meet to watch and evaluate the same student performance and compare their scores to minimize variations and increase consistency.
These experienced educators have learned that effective EMS education is not about an expensive manikin or other high-tech tools. By establishing clear objectives for what educators want to teach, investing the time and having the creativity needed to develop realistic scenarios, and providing students with productive debriefing, we can get the most bang for our training bucks. jems
1. Lopreiato JO, editor: Healthcare simulation dictionary. Society for Simulation in Healthcare. Retrieved April 29, 2017, from www.ssih.org/dictionary.
2. Fanning RM, Gaba DM, The role of debriefing in simulation-based learning. Simul Healthc. 2007;2(2):115-125.
3. Raemer D, Anderson M, Cheng A, et al. Research regarding debriefing as part of the learning process. Simul Healthc. 2011;6(7 Suppl):S52-S57.
4. McKenna KD, Carhart E, Bercher D, et al. Simulation use in paramedic education research (SUPER): A descriptive study. Prehosp Emerg Care. 2015;19(3):432-440.
5. Olson S. (n.d.) Developing effective simulations. University of Wisconsin Health Clinical Simulation Program. Retrieved June 15, 2017, from www.med.wisc.edu/files/smph/docs/clinical_simulation_program/developing-effective-
• Phrampus P, O’Donnel J. (2007.) Debriefing in simulation education: Using a structured and supported model. Peter M. Winter Institute for Simulation, Education & Research. Retrieved June 15, 2017, from www.wiser.pitt.edu/sites/wiser/ns08/day1_PP_JOD_DebriefingInSimEdu.pdf.