Simulation is recommended by the National Association of EMS Educators (NAEMSE) as an important part of EMS training.¹ In 2015, NAEMSE released a vision paper concurrently with the Simulation Use in Paramedic Education Research (SUPER) study.² Although the study focused on paramedic programs, many of the same principles apply to EMT training. Simulation in healthcare education overall is a critical component and serves as a compliment to clinical experiences.³ “Simulations are experiential learning opportunities during which participants can learn new information, as well as have the opportunity to apply previous knowledge.”⁴
In this article, we talk about how one EMT program greatly improved the teaching environment by building an ambulance simulator, or a “Simbulance.” We’ll describe how the concept arose, how we accomplished the construction and how the Simbulance helps meet the objectives of the EMT curriculum. We’ll also discuss Bloom’s taxonomy theory and how we can use it to improve the students’ progression through their education.
A Unique Problem
The Vassar College EMT program began in 1983 as a method of training students to serve as first responders on the Vassar College campus.5 Today, the program is a cooperative effort between Vassar College and Dutchess Community College (DCC). DCC supplies the Certified Instructor Coordinator (CIC) and lab instructors. The students receive Vassar College credit, while DCC provides the authority as a New York State Course Sponsor for EMS Programs.
In addition, Vassar College supplies two academic Interns to help teach lab skills, both of whom are certified EMTs. The typical class size is 25 students per year. The class runs both semesters, typically ending in April with the state practical and written exams. Students can take the National Registry of EMTs (NREMT) written test as well, in order to get their NREMT certification.
Vassar College EMS (VCEMS) operates on campus when school is in session. One of the challenges for VCEMS and the EMT program at Vassar College is that VCEMS isn’t a transporting agency. The initial assessments are done by VCEMS, but care is then transferred to either Arlington EMS or Mobile Life Support for transport. The students in the EMT class don’t get experience on an ambulance until their clinical rotations. Once they certify as an EMT, they get no further ambulance experience unless they affiliate with a responding EMS service.
Lifting, moving, extricating and transport play a large role in EMS. Because VCEMS doesn’t transport patients, the students don’t get to practice the entire call process. Patient care within the ambulance has its own challenges, including working in small spaces, background noise and distractions. Many EMTs on VCEMS have expressed the desire for more experience on an ambulance. In addition, safe patient movement often requires specific problem-solving skills, and these skills are difficult to teach in a classroom.
Birth of a Simbulance
The Simbulance project came about from the desire to provide a more realistic simulated experience—one that includes lifting and moving a patient to an ambulance, performing skills in the back of an ambulance, calling in reports to the hospital and, finally, taking the patient out of the ambulance and bringing them to the next point of care in the ED.
Previously, this need was addressed by bringing an ambulance to campus where the students would practice stretcher skills, patient movement and care on board. Unfortunately, this only occurred once during the curricular year, so it did little to ensure proficiency of the students’ skills. In addition, due to the recent decline of volunteers, it’s become difficult to arrange this event due to a lack of available ambulances and personnel.
Last year, the Vassar EMT program acquired a storage space on campus. After supplies and equipment were stored, an idea began to surface … why not build a simulated ambulance?
Omri Bereket, EMT, a Vassar student and set builder with Vassar’s Drama Department, designed the Simbulance and served as our lead builder. His expertise and hard work were instrumental in making this vision come true.
Bereket created the design using a computer-aided design (CAD) program called Vectorworks. The CIC was able to secure an in-kind donation of the inside of a Wheeled Coach van ambulance from EMStar Ambulance in Poughkeepsie, N.Y. Additional wood, paint and other supplies for the platform were donated by the CIC. DCC donated the wall posters depicting the inside wall above the bench seat, which makes it look like a real ambulance wall. The wall graphics for the Vassar project were donated by Hudson Simulation Services (HSS). HSS is the developer of the graphics and trademark holder of the name Simbulance. Labor was contributed by five EMT interns, a few students of the Vassar EMT class and the CIC.
The build began in late January 2018, and was completed and displayed with an open house on April 6, 2018. The main part of the build took about 12 hours. The rest was completed over another weekend and a few evenings. The best part of this was the excitement of the students and interns about what they created.
The result is a near-situ simulation experience for the student.6 The Simbulance has working lights that the instructor can operate. The stretcher is mounted, and the cabinets and bench seat are the exact dimensions of a van ambulance. Emergency lights, oxygen and suction are all operational in the Simbulance. There’s also a Bluetooth speaker for siren and other noises.
Having the students load and unload the stretcher from the Simbulance teaches them important skills, including time management and the practical application of in-class learning that they need to perform as an EMT working on an ambulance.
Two-way radios were added to the Simbulance for practicing communication with dispatch and the receiving hospital/medical control. Two-way communication is often an overlooked aspect of learning to be an EMT. The student uses one radio to call in a report or talk to medical control, while the instructor has the other radio to receive report or give orders.
The EMTs we train should be critical thinkers, able to perform their skills under stress. The goal of our Simbulance is to put our students in a more realistic situation to practice these skills in a stressful environment, so that they’re prepared and competent on their first day volunteering or working on an ambulance.
The Student Learning Outcomes (SLO) from the EMT course at DCC are adopted from the National EMS Education Standards.⁷ The SLO’s that we’re able to address with the Simbulance are:
- “The student will demonstrate lifting and moving patients including correct equipment choices and appropriate operation of each device.”⁸
- “Communicating with other health care professionals using appropriate medical terminology, and communicating a report to the receiving facility.”⁸
- There’s another SLO on components of field operations, which includes operation of ground ambulances, incident management, MCI triage, getting ALS assistance and aeromedical transport criteria.⁸
Using the Simbulance
The students will be timed doing simulated calls from start to finish. The students must make decisions, including whether or not to call for ALS, how to transport the patient with lights and sirens if applicable, scene time management, and hospital destination choices. Having a safe environment in which to load the patient and making some of these critical decisions will provide an invaluable experience for the students.
The SUPER study, which surveyed EMS programs nationwide, found that many EMS programs have the ability to implement simulation, but simulation is only used one-third of the time by instructors.² This problem of reluctance to use available simulation tools has many roots, including instructor training, insufficient time to train, instructor ability to be comfortable with technology, and lack of time to develop scenarios that meet learning objectives and will work well with simulation. Many EMS instructors are working full-time as providers on an ambulance and report to a lab session at the end of a shift, making lack of preparation time a real issue. Creating realistic simulation scenarios that make sense to the student takes time, effort and experience.
Bloom’s taxonomy is a method of conceptualizing the learning experience that has applications for EMS learning. Bloom’s has three domains of learning:
- Affective; and
All three domains reflect different aspects of learning, as well as taking into account the student’s learning style. The domains are further subdivided to five or six different levels.⁵ These levels are helpful when writing lesson plans as the instructor can identify where students are in their learning, set objectives, and then design lessons which progress students to the next level.
The cognitive domain is typically associated with five specific levels of knowledge and the application of this knowledge. The different levels in ascending order are: knowledge, comprehension, application, analysis, synthesis and evaluation.⁴
For example, a student at the knowledge level knows that a bag-valve mask (BVM) is used to ventilate a patient. When a student progresses to the level of evaluation, they can use judgement to evaluate whether a patient needs to be ventilated.
Cognitive information presented in a lecture helps a student when they start practicing a psychomotor skill in the Simbulance.⁵ For example, when the student learns the motor skill of connecting oxygen tubing up to a flowmeter and squeezing a BVM while applying a mask seal, they also need the cognitive knowledge of the conditions under which to apply the BVM.
The affective domain addresses motivation and behavior. It has the ascending levels of receiving, responding, valuing, organization and characterization.⁵ For example, an EMT student performing a trauma assessment identifies that the simulated patient is in shock. If this student is being assessed in a classroom, without the expectation of actually having to move the patient off-scene, the sense of urgency isn’t as apparent as if the student is expected to assess and package the patient and get them into the Simbulance in 10 minutes. The patient is then in the Simbulance with the lights and sirens on, which creates noise and psychological stress for the provider. Starting with this for new EMT students just learning trauma assessment might be overwhelming, therefore, before introducing such a scenario, instructors can scaffold the student’s skills to be successful and build confidence.
Brand new EMT students have less bias and values than returning students, who have learned other habits; therefore, new students accept information more easily. This allows us to teach them the correct ways to perform skills in the back of the Simbulance and during other skill stations. This is especially true for stretcher handling skills and stretcher seatbelt strapping.
The Psychomotor domain levels are Imitation, Manipulation, Precision, Articulation and Naturalization.⁵ The Imitation level happens as students mimic the instructor demonstration, and the students move to the manipulation level as they practice. At the Precision level, the students should be able to perform the skill without mistakes. At the Articulation level, students become proficient in the skill and at the Naturalization level they master the skill.⁵
The Simbulance will be of greatest value when the student reaches skill proficiency (articulation level), and we want them to progress to skill mastery (naturalization level). At this point, the student is at the mastery level of the skill and has muscle memory. This is when we can insert environmental problems or circumstances into scenarios where the student will have to problem solve and still perform the skill.⁵ Once again, timing the introduction of scenarios is important. Inserting complicated problems earlier in the levels of learning, the student may not progress and will become frustrated. Of course, the Psychomotor Domain is affected by the Affective and Cognitive Domains as well. For instance, if a student has not received the cognitive knowledge of when a skill needs to be performed they will not know when to initiate the skill in a scenario. However, they may be able to perform the isolated task if asked.⁵
Bloom’s three domains intersect within a student. What the student is learning cognitively affects the attitudes toward a topic. In addition, these two domains affect and are affected by the psychomotor skill level.⁵
Psychological safety is an important component of simulation and needs to be addressed with the students in the beginning of the course and before each simulation.⁶ Psychological safety is provided when an educator creates an environment of support, curiosity and respect.⁶ This can be part of the pre-briefing where the instructor talks about the goals of the simulation, what the rules are for the simulation (i.e., no picture taking), and how the debriefing will be run. When students feel safe they are more open to learning.⁶
We created a low-resource, ongoing benefit with our Simbulance. The open house was successful for the program in terms of publicity, which led to securing funding from Vassar College to purchase a new stretcher. The publicity also led the EMT program CIC at Marist College to express a desire to come use the Simbulance, since they have the same limitations within their program.
One of our important goals as educators should be to provide our students with the best tools before they go out into a possibly dangerous and hostile environment. The best way to accomplish this is to expose them to as many levels of Bloom’s taxonomy within all three domains during their educational experience.
EMS is complicated. We are one-part people mover, one-part social worker and one-part medical provider. The more we can prepare our students in a realistic environment, the safer and more competent they will be when it really counts.
1. National Association of EMS Educators. (Nov. 18, 2015.) Simulation in EMS Education: Charting the Future. Retrieved Aug. 14, 2018, from https://c.ymcdn.com/sites/naemse.site-ym.com/resource/resmgr/Docs/SimPressRelease15.pdf.
2. 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.
3. Motola I, Devine LA, Chung HS, et al. Simulation in healthcare education: A best evidence practical guide. AMEE Guide No. 82. Med Teach. 2013;35(10):e1511–e1530.
4. Picher, J, Goodhall, H, Jensen C, et al. Special focus on simulation: Educational strategies in the NICU: Simulation–based learning: It’s not just for NRP. Neonatal Netw. 2012;31(5):281–287.
5. Gabriel G. Fast maneuvering: Emergency medical service. Vassar Newspaper. 1986;71(4):3. Retrieved Aug. 14, 2018, at https://newspaperarchives.vassar.edu/cgi-bin/vassar?a=d&d=miscellany19860926-01.2.8&srpos=6&e=——-en-20–1–txt-txIN-emt——-.
6. National Association of EMS Educators. Foundations of education: An EMS approach (2nd edition). Cengage Learning: Pittsburgh, 2013.
7. National Highway Traffic Safety Administration. (January 2009.) National EMS Education Standards. Retrieved Aug. 14, 2018, from www.ems.gov/pdf/National-EMS-Education-Standards-FINAL-Jan-2009.pdf.
8. Palaganas JC, Maxworthy JC, Epps CA, et al. (editors): Defining excellence in simulation programs. Wolters Kluwer: Philadelphia, 2015.
9. Cekuta B. Extended Course Syllabus. Fall 2017. EMT-B 105 910-911. Located at: Dutchess Community College. Wappingers Falls, N.Y.