The EMS roundtable: Expert insights on medical simulation

As simulation continues to become a greater part of EMS education and training, we sit down with several subject matter experts to discuss some of the issues and predict what the future might hold. In addition, check out our in-depth report on simulation in EMS.

1. In education and training we toss around a variety of phrases to describe some of the manikin-based training that we do to keep EMS providers for job readiness. Terms like “scenarios,” “low-fidelity simulation” and “high-fidelity simulation” are sometimes confusing. From your perspective, just what is “simulation” and how does it differ from traditional, scenario-based training?

David LaCombe:
Scenario-based training and simulation are one in the same. Simulation is part of a learner-centric teaching strategy. It provides an immersive experience where learners may practice without risk of personal failure or harming patients.

When implementing simulation training, one should understand that technology is a supporting cast member, not the star. The star is the health care provider learning how to safely manage complex patient problems.

Scenarios, or simulations, reproduce real-life experiences. The best designed simulations are focused on situations with well-defined goals – Resuscitate a patient with uncontrollable external hemorrhage; Provide effective ventilation and oxygenation for an apneic patient; Perform quality CPR according to current guidelines.

Greg Friese:
I use simulation even more broadly to describe any type of patient assessment and treatment practice. Simulation can use students in the role of patients, as well as other trained and untrained actors pretending to be patients.

Simulation, like many things, exists on a continuum. On the low end of the continuum a student might simply pretend or act to be unresponsive so another student can assess for respirations and signs of circulation. On the high end a computer-programmed, high-fidelity manikin can be the unresponsive student.

Amar Patel:
Simulation is the act of simulating an experience. This can be done using scenarios where providers are role-playing, where we as educators provide information to help facilitate the progression of a skills training experience, or during a developed immersive educational drill. The confusion lies in what the terms actually mean.

Scenarios exist in everything we do. It is a matter of how much fidelity we would like to inject into the experience. The biggest difference between traditional and scenario-based training is the level of complexity and fidelity involved in the implementation of the experience.

Traditional involves case discussions with no role-playing. Simply put, the student and the educator discuss how to treat the patient. Scenario-based training has the student actually performing the skills necessary to manage the simulated patient. The simulated patient can be a low fidelity manikin or a high fidelity human patient simulator. The key is they are actually treating the simulated patient.

2. Sometimes the patient manikins seem to be the show piece of the training module. What’s more important, the sophistication of the simulator or the operator of the equipment?

David:
The degree of technology sophistication and fidelity, or realism, should be determined by the learning objectives of the session. For example, a simulation designed to teach foundational skills supporting vaginal delivery of a newborn can be accomplished with a low-tech task trainer.

Whereas, teaching a team to respond to life-threatening post-partum hemorrhage may require a simulator with additional functionality. Educators should select the tool (simulator, task trainer, e-Learning) based on the learning need – don’t let the technology drive the teaching decisions.

Even the most sophisticated technology cannot help save a life without a skilled operator controlling the application of the tool. We have learned so much in the past 10 to 15 years about what leads to effective learning when using simulation. We know that providing feedback to learners and the repetitive, deliberate practice of skills are most important.

Greg:
The equipment operator is clearly most important. But, the label or title of that person is reflective of their importance. An operator is a technician, someone versed in starting and executing the steps in the program.

Students are expected to respond to a logical set of steps that have been pre-written and the technician is simply delivering. This is the mega-code style. A technician switches the patient into pulseless v-tach, regardless of the student’s progress through the scenario and readiness to provide treatment.

Following a recipe could be appropriate in a competency test, but it is ineffective during practice.

I would rather have simulation be guided by a facilitator, someone who is knowledgeable of the simulation objectives and can manipulate the program to achieve the objectives.

A facilitator can recognize a student struggling to obtain the patient’s history and guide the student through completion of that skill rather than simply sending the manikin into v-fib at the three minute mark.

Facilitation of hands-on learning is a challenging skill to learn and do well. The educator/facilitator needs to be:

• A skilled and patient observer.
• Willing to let students reach a desired end point while not necessarily following the same steps the facilitator would in a similar situation.
• Able to answer questions that help students get to the next steps without giving all of the answers or delivering a mini-lecture.
• At ease so as not to project undue stress or anxiety on the students being facilitated.
• An ally in the student’s success.

A facilitator may also need to be a technician and have responsibility for executing manikin programs, trouble-shooting equipment problems, and capturing video of the student’s performance.

Amar:
It is my belief that the operator is more important than any piece of equipment used in training. The operator is often an educator tasked with conducting the simulation experience and is responsible for how well the training experience goes.

Even with the best simulator, the operator must be involved in setting up the experience, providing the education, and ensuring the training modules learning objectives and outcomes are met. The equipment can fail. It is up to the operator to make sure the students get what they need no matter what happens with the simulator.

3. If you have any words of advice for the instructor who is new to simulation training, what would they be?

David:
My words of advice for new simulation instructors are “think differently.” Think about how you want EMTs and paramedics to perform in the field then design learning sessions that focus on the desired behavior. Be very clear on what you want people to do differently after training.

Also, think about how you will help to maintain the provider’s competence – current research shows that knowledge and skills sharply deteriorate after training. Frequent, small doses of refresher training are much superior to the prevalent bi-annual approach.

Rehearsal, or deliberate practice, is an ongoing activity meant to maintain and improve competence. Providing complex health care could be improved with ongoing training, coaching and feedback.

Greg:
Work towards becoming a facilitator, not a technician. Facilitate simulations that honor a student’s time, knowledge and experience. Deliver scenarios that are reality based rather than once in a lifetime oddballs. Guide students towards success rather than failure. Do a lot of background research on the topic of simulation before moving into this exciting area of training.

Amar:
Be patient! It is important for the educator to know what he/she hopes to accomplish using simulation training. If you are looking to teach task-based skills, buy a task trainer.

If you are looking to grow a current or future EMS provider using high-paced complex scenarios that create lifelike situations, use a simulator. The educator must think through what they are looking to accomplish, how that can be accomplished, and identify gaps that exist in the current training program that will be may be fixed with simulation.

You have to be patient and make the time to develop a great simulation experience. But, with patience comes great rewards!

4. What are some pitfalls of simulation training?

David:
Medical science and advanced education technologies are only effective when locally implemented. We must work cooperatively with EMS to help demystify simulation training.

Currently, the largest simulation-related pitfall may be the small number of EMS instructors trained to design and facilitate simulations. Formal training, beyond how to operate the simulator, is needed and, fortunately, is widely available from a number of sources.

Greg:
The pitfalls of simulation begin before the high-fidelity manikin is acquired. Too many programs simply purchase the manikin without any forethought to where it will be stored, where it will be used during practice sessions, how instructors will be trained to use it, and how the simulation program will be built and maintained.

If your high fidelity manikin is in a space formerly used for janitorial supplies, there was not adequate planning for the simulation program.

Using a high-fidelity simulator for low-fidelity skills, such as practicing chest compressions or auscultating a blood pressure, or delivering lectures to a group of students gathered around a manikin rather than letting them have multiple simulation opportunities are additional pitfalls to avoid.

Amar:
As professionals, we look to purchase the best educational tool money can buy. While we understand the value it can provide, we are not trained or experienced at using the technology and ultimately the methodology.

As educators, we have a hard time saying “I don’t know how to integrate that into my classes.” For years I have seen programs purchase simulation equipment, think about how they may use it, and finally make a plan to expand the use of simulation methods.

The core concepts of simulation need to be integrated early on. You must think and plan well before you decide to buy. Simulation is a powerful tool and often gets blamed for educator and student failures. We need to remember simulation training is just one method of learning.

5. Where do you see simulation training in 10 years?

David:
I envision a much greater emphasis on highly immersive learning. EMS providers will learn about patient problems on smart devices then practice decision-making in interactive game-like environments.

Educators will function more like coaches – helping to improve learning and performance. Continued evolution of technology will enable the simulation of a wider variety of patient presentations. All of these innovations will come from EMS organizations’ increased expectations to improve quality with greater efficiency.

Greg:
In the future, simulation will be less reliant on an actual manikin placed before students on a bed or cot. Instead, simulated patients, with countless complaints, signs, and symptoms, will appear before students on a screen like a smartphone or tablet. Maybe, 3-D projection will be a reality in 10 years.

Simulation will also transition from a focus on emergent conditions, like chest pain, cardiac arrest, and heart failure, to non-emergent conditions that paramedics are increasingly called upon to assess and treat.

Scenarios might be focused towards the care provided by community paramedics, behavioral emergency encounters, or even coaching a patient’s medication compliance.

Amar:
The integration of simulation has exploded in just the last five years. We are beginning to see simulation training take new forms to include video games and 3-D immersive environments.

With current research leaning towards the use of video games to help identify knowledge deficits, we will soon see programs changing how they deliver education.

Over the next 10 years, I see video games playing an integral role in helping us identify areas we need to focus education and then helping us deliver it. I see simulation training growing to include a 3-D immersive environment that will allow us to replicate any situation without having to worry about a provider’s safety. There is so much out there, it is an amazing time to see the industry explode.

6. Do you have anything else you would like to add about simulation training?

Amar:
Simulation is a fantastic methodology to utilize but it has to be accepted, integrated early on, and thought through. I have seen some amazing results using simulation to include improvements in patient safety and patient care. Think about how simulation can benefit your program and take some time to plan it out.

Greg:
When planning a training session, always begin with objectives. Then select training activities, equipment, and staff to meet those objectives. Be clear on your training objectives and select the training method best suited to accomplishing those objectives.

David:
Educators new to simulation should balance their investment in technology with equal, or greater, investments in the implementation of the education strategy. Simulation-based teaching requires skills much different than lecturing – educators need new skills that support facilitation of debriefing and providing feedback.