Selecting Appropriate Simulation Modalities for EMS Training Activities

“Experience is a hard teacher because it gives the test first, the lesson afterwards.”-Vern Law

When using simulation as an educational methodology, it’s paramount to choose the correct simulation modality so that the desired objectives of the activity can be met. In February’s column, we discussed the importance of the proper foundations for effective simulation activities. This month we build on that theme by describing how different types of simulation modalities can enhance and improve simulation activity effectiveness.

As educators, we often rely on using high-fidelity manikins or other advanced technology to meet our programmatic objectives, but often our objectives can be met by using a less costly asset.

Learning new skills requires instruction on some or all of the cognitive, psychomotor and affective domains of learning. There are proficiency standards within each of the domains that learners must demonstrate to be successful.

Simulation Modalities

Teaching trauma care offers a great canvas to highlight the application of different types of simulation modalities, which should be purposefully selected to match the activities and build in various levels of difficulty (i.e., scaffolding), following the idea that learners should crawl, walk, and then run.

Let’s look at preparing novice learners for a summative trauma care assessment involving bleeding control management and identification of internal organ injuries that require rapid transport to the trauma center. To be successful, learners must acquire and become proficient in the individual skills required for the summative assessment-otherwise the summative assessment is giving the test before the instruction.

Crawl: There are many components of trauma care and assessment that can be described as falling in the “crawl” category, such as bleeding control, chest decompression, injury identification and simple assessment techniques. There are several simulation modalities that help in learning to crawl:

>> Task trainers are a great choice to practice and show competence on isolated skills;

>> Standardized patients can help with learning how to perform history taking; and

>> Desktop activities with drawings or even model cars can help acquire skills in scene safety and management as well as decision-making.

For these activities, make sure the learner has access to practice time with both faculty and peer evaluation. This stage of learning allows the learner to show novice-level competence in an individual skill.

Walk: As learner move into the walking phase of preparation, they build more expertise and are combining individual skill elements together. Trauma assessment and management skills can be linked together as learners now walk. Note that as the complexity increases, so do the simulation modalities.

>> Standardized patients may have skills components attached, such as ability to start an IV (called a hybrid);

>> Lower fidelity manikins are often useful for these types of activities where different skills can be easily combined as trauma care is expanded;

>> Computer-based options for scene management skills and decision-making offer improved challenges.

Meaningful practice allows the learners to solidify the skill steps so that they can move on toward higher application of the skill, such as multitasking while accurately performing the skill, not being distracted by environmental sounds or by seeing through the emotions that can often come with distracting injuries. This practice prepares the learners for the next phase of higher learning while increasing their speed of accurate completion for the individual skill(s).

Run: The learners move on to running when they are engaged in completing the steps of the multiple skills in a more complete and complex setting. The complete management of trauma patients from start to finish are the primary activities of learners, often found in multiple patient scenarios or in the more unusual setting for the advanced learners. The complexity of the activities requires more high level simulation modalities.

>> A high-fidelity manikin is the modality most often used in this phase for single patient activities.

>> Standardized patients-especially in a hybrid scenario-can be equally successful in simulating many different injury patterns.

>> Multiple-modality is also an option, where there are a variety of different modalities within one activity (e.g., a combination of different fidelity manikins and standardized patients could be used, along with even adding in environmental components through a computer-generated, projected environment with ambient sounds.)

>> Realism factors such as environmental sounds, smells and moulage of wounds also serve to better engage students and support their learning.

During this last phase, skill accuracy or skill time completion may decline. This will be resolved with continued exposure to scenarios allowing adjustment of the student’s stress response, and you’ll see pseudo-instinctive skills come forward.

After these complex, time-sensitive activities, learners often report not remembering what they did during the simulation. Viewing video recordings can help students evaluate their own critical thinking and obtain a purposeful debriefing of the activity.


We must do everything possible to help our students build the cognitive, psychomotor, and affective domain skills required to be successful. This requires systematic movement through each of these three phases while using the appropriate simulation modality or combination of modalities that both supports the student’s level and meets learning objective(s).

Be sure to carefully select the modality or modalities that support the designed activity, balancing the strengths of the modality with appropriateness and cost-effectiveness. Only after the learners have moved through each phase will they be fully prepared for the summative assessment. jems


1. Lopreiato JO, editor: Healthcare simulation dictionary. Society for Simulation in Healthcare. Retrieved March 8, 2017, from

2. National Association of EMS Educators: Foundations of education: An EMS approach, 2nd edition. Delmar, Cengage Learning: Clifton Park, N.Y., 2013.

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