EMS simulations: A primer
Keeping it real and providing feedback are essential to success
By Art Hsieh
High fidelity simulations (HFS) have entered the medical education mainstream in EMS. Various studies in medicine and allied health have demonstrated the value of training personnel to "real world" conditions, which can result in more accurate and efficient processes in the field.1 Done properly, HFS can improve decision-making processes, technical skills and leadership ability in a controlled educational environment.2
On the other hand, developing and executing high fidelity simulations can be extremely time-consuming and costly. Providing meaningful feedback can also be a challenge.
Nevertheless, with some planning and creativity, you can create realistic training sessions that your participants will find interesting, educational, and most of all, fun! Let's walk through the process of putting one together, from beginning to end.
Step 1: Begin with the end in mind
What is it that you are trying to accomplish? Don't create a simulation out of thin air – make it meaningful. In a primary training program, consider skill sets that can be hard to teach otherwise, like scene control, task delegation and critical thinking.
You can begin by focusing on clinical areas that are, on one hand, fairly straightforward to train a new student to a skill sheet but becomes challenging when conducted under realistic conditions.
For example, performing a medical examination of a patient with a complaint of shortness of breath can become messy when the simulated patient can't speak more than three word sentences, is in a tripod position, looks cyanotic and is diaphoretic.
Perhaps your students have mastered this condition, and you want to take them to the next step. Add in the conditions that the patient is located on the second floor, requires extrication and is found in a cluttered bedroom where the medication bottles are strewn about. Now there are plenty of distractions to keep the student off the task of assessment and incorporate the skills that are best learned through experience.
Simulation ideas for continuing education often come from quality assurance/ quality improvement processes. For example, you might determine that nitroglycerin administration in presumed cardiac ischemia is not being done in a timely manner. Further investigation reveals that the chief complaint is often not classic chest discomfort, but of an atypical etiology. You could create a simulation based around these complaints and see how crews perform.
Another example is a new employee who appears to be struggling with scene management issues. Evaluating that employee with HFS can reveal specific weaknesses in prior training that can be remediated or retaught, improving performance and avoiding the costly loss of an otherwise valuable employee.
In summary, building a simulation takes some investigation and consideration on your part. Write down what you plan to do, and how it will get done.
Step 2: Build your resources
The cost of simulations range from virtually zero to tens of thousands of dollars. I suspect that many of us tend to have fewer resources than more. The good news is, you don't need a lot to get started.
The goal is to make whatever you are trying to achieve in step 1, happen in as realistic an environment as you can. Examples of achieving a level of realism can include:
- Use real equipment in a realistic manner.
If you are within an operational agency, using bandages, monitors, oxygen tanks, and cots can be straightforward. You can have an on-duty crew come by with their unit, perform the simulation using their bags and equipment, and then restock them directly, allowing them to go back in service as soon as they are done.
If you are within a training institution, consider partnering with the local service provider to borrow the hard-to-get items.
- Make patients look and act like patients.
The idea is to have students pick up key clues about the patient's condition without having to ask an instructor for them.
Build a closet of used clothing of all different sizes. Putting a request out to students and surround agencies can result in a quick cache of clothes.
A little makeup helps. You don't need to be a moulage specialist – providing a little white base to the cheeks and forehead, and a tiny amount of blue color under the eyes and around the mouth can provide the cues to the student that the patient is under stress.
Rehearse scenarios with patients – a lot. Don't assume that they will automatically know how to act the part. Having some medical knowledge is helpful, but the key attribute for simulation is acting.
Providing a written script prior to the simulation will give the actor time to prepare. Just prior to the simulation, have the actor show you the "act". If necessary, mimic the behavior or actions you want him to perform. Explain any cues he should be watching or listening for, so he can make changes as prescribed in the script.
Finally, consider building a "stable" of actors. It's difficult for the student to believe that a twenty year old person is really 65 (even with really good makeup and acting!) Putting a word out to your community can often result in volunteers of all ages and sizes wanting to help out their local EMS service or training institution.
- Make the environment as realistic as possible.
Classrooms and the apparatus floor poorly replicate bedrooms, office spaces and other environments. Look for other sites within your facility to conduct simulations, such as bathrooms, kitchens, or bedrooms. Again, the idea is to put the students in as realistic situations as possible.
If alternative locations are not available, consider building a "set" within the training area. You might be able to collect donations of household furnishings – bed frames, mattresses, night stands, lights, and so forth. Medical appliances such as walkers, canes, splints are often collecting dust in people's homes. Collect empty medication bottles before people throw them away.
With a little planning, businesses might "lend" their space, especially in the evenings or weekends. It's a low cost way to promote their business and can lead to better relations (and maybe even donations.) Make sure that your institution or agency's liability insurance covers training that physically occurs outside of the organization.
Step 3: Execute the simulation in a realistic manner
All of your planning will be for nothing if the simulation is not performed in "real time" and under realistic expectations. Recall that the idea is to have the student emotionally believe that it is a real patient in a real environment. This means that:
- All procedures happen in real time. Blood pressures are taken, 12 lead patient cables are applied, and oxygen administered. If you are not able to perform invasive procedures with live patients, have manikin limbs and heads available for intravenous access or advanced airway procedures.
If those are not available, have the student walk their way through the process as much as possible, then place a marker of some sort (i.e., tape down the angiocatheter to the arm, or have the patient use his teeth to clench an ET tube that has been cut down so only the proximal piece remains).
- There is little to no interaction between participants and instructors during the simulation. This is crucial. If your preplanning and preparations went well, the student will have no need to turn to you and ask for any information. This allows the simulation to run without any distractions, and really place the student "in the moment".
If you have not done simulations before, the temptation to step in will be very strong. Don't! Trust your preparation and your actor(s) to really set the stage for the student.
Be a distance from the scene. If you can, don't even be there – using a remote camera or a one way mirror will allow you to observe the interactions.
- Maintain safety. Consider points during the simulation where harm could occur. Examples might include lifting and moving the patient, removing heavier items during extrication, or excessive manipulation of the patient during splinting or spinal restrictions.
Have a word or phrase that anyone could use to freeze the simulation if they spot a potential problem.
Step 4: Debrief
Talking through the simulation after it is done is critical to learning. It allows the student to review her actions and behaviors after the fact.
There are various ways to conduct debriefings.3 A common trait is that they take time – don't make them brief or cut them off prematurely.
Key points to keep in mind when debriefing:
- Don't be the lecturer. Instead, facilitate discussion with the student or team. Ask questions like, "What went well?" and "What would you do differently?" If the student isn't responding appropriately, use more questions to lead him to the correct response. It takes longer but is more effective than just telling the "right" and "wrong" answers.
- Focus on what you were trying to achieve. Students will only hear the first few points; it's hard to maintain attention if your droning goes on. You might acknowledge that there were some other issues that came up, but focus the debriefing on what you were setting out to accomplish.
- Check in with the student's emotional responses. You might be surprised how stressed students become in a well run simulation. Debriefing them on the emotional content can help them recognize the signs of excessive stress and develop coping mechanisms to overcome it.
- Summarize at the end. After the discussion, make sure you let the students know they met the objectives (or not) by summarizing key learning points related to your original objectives.
Simulations are a highly effective form of training. It can produce real life reactions, behaviors and emotions when conducted appropriately. With proper planning on your part they can also be fun for everyone involved.
1. Issenberg SB, McGaghie WC, Petrusa ER, Lee Gordon D, Scalese RJ. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach. 2005 Jan;27(1):10-28.
2. Okuda Y, Bryson EO, et al. The Utility of Simulation in Medical Education: What Is the Evidence? Mount Sinai J Med. 2009; 76:330-343.
3. Fanning RM, Gaba DM. The Role of Debriefing in Simulation-Based Learning. Society for Simulation in Healthcare. 2007; retrieved 5 June 2013: Found here