Many EMS education programs do an excellent job teaching clinical skills but struggle to prepare students for the realities of the field, as patients typically don’t collapse in quiet classrooms. They become critically ill in crowded restaurants, noisy stadiums, dark hallways and cramped bathrooms, often surrounded by distractions that make assessment and communication far more difficult.
The Charlotte (N.C.) Fire Department set out to close that gap by creating an immersive EMS training program that places recruits into realistic, distraction-filled environments long before they respond to their first 911 call. Using mid-fidelity manikins, live role-playing, themed training environments and progressively more complex scenarios, the department developed an approach that better prepares firefighters for to communicate effectively, think critically and manage a real emergency scene.
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The program didn’t require a multi-million-dollar simulation center. Instead, it grew over several years through creativity, collaboration and a willingness to rethink how EMS education is delivered.
Identifying the problem
The program began with a gap instructors were seeing in new EMT recruits. Many could complete the technical steps of patient care, but struggled to communicate clearly, think through changing conditions and manage the uncertainty of a real scene.
“Roughly 65-70% of what we do in Charlotte is medical, so you have to buy in to it,” Battalion Chief Robert Fitzgerald said. “You may not like it, but you at least need to be good at it. You may be the best firefighter, the best person at extrication incidents, but if you can’t take care of a patient and that’s 70% of your job, you suck at your job.”
Traditional training methods were part of the issue. Screen-based instruction could deliver information, but it did not force recruits to practice face-to-face communication under pressure. Old-school manikin training also created shortcuts, leading students to ask instructors for vital signs instead of assessing the patient directly.
For the new generation of recruits who are native to learning and communicating through screens, CFD wanted training that pushed them beyond passive instruction. The goal was to force recruits to talk to patients, read the room, recognize hazards and make decisions while still performing core EMS skills.
“We’re testing them and we don’t want them to fail or struggle because of the distraction,” Fitzgerald said. “But we do want them to be in a chaotic environment because that’s how they’re going to function going forward.”
Moving beyond traditional manikin training
The department’s first major innovation came when CFD’s Senior Training Officer J.D. Thomas introduced mid-fidelity manikins into recruit training. Unlike traditional manikins, these models allow students to physically assess pulses, blood pressure and other findings while communicating with a live voice portraying the patient.
Rather than relying on the manikin’s built-in speaker, Charlotte equips recruits and instructors with wireless headsets. One instructor serves as the patient’s voice, answering questions in real time and requiring recruits to conduct realistic patient interviews.
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“[The training] forces the recruit to speak to the patient, so to speak,” Fitzgerald said. “Then they have to assess and get all the vitals from the patient instead of the instructor.”
Instructors are coached to stay in character and act as if they are actually experiencing the scenario’s symptoms when interacting with recruits during training, he said: “If the patient in the scenarios is having trouble breathing, sound like you’re having trouble breathing. Speak in two- or three-word sentences, then stop to ‘catch’ your breath.”
That realism forces recruits to adapt their assessments instead of relying on textbook answers.
“They have to tailor their assessment,” Fitzgerald said. “The acting plays into that and helps lead them to the next questions to ask,” he said.
Creating immersive environments
Once the communication model was established, Fitzgerald and other CFD instructors began transforming ordinary classrooms into realistic emergency scenes using borrowed or donated items.
Recruits may find themselves treating patients in an airport terminal complete with luggage, gate announcements and passenger noise. Another scenario recreates a Japanese hibachi restaurant, complete with tables, food, bottles behind a bar and cooking videos projected on screens. The department also creates nightclub scenes with loud music and strobe lights, as well as collapsed buildings filled with debris, dark apartment hallways and fire victim rescues.
Each scenario builds on the previous one by adding more obstacles while reinforcing the same assessment principles.
The most challenging simulation places recruits inside an NFL Carolina Panthers game control room, where crowd noise is pumped in as a loud football game plays out on a big screen, while instructors act as oblivious bystanders and an uncooperative patient competes for the student’s attention.
“There’s instructors that bump into the recruit who is trying to talk to the manikin,” Fitzgerald said. “And the manikin is not wanting to be treated, even though he needs it. It puts them in a real situation.”
Impact training for the real world
The department intentionally increases the cognitive demands placed on recruits throughout the course.
Early scenarios feature relatively quiet environments with limited distractions. As students gain confidence, instructors introduce noise, movement, environmental hazards and emotionally challenging situations that require recruits to prioritize information while maintaining patient care.
The philosophy extends beyond recruit school. CFD has steadily expanded its annual EMS in-service training from small classroom exercises into large-scale, multi-agency mass casualty incidents involving Medic, Charlotte-Mecklenburg Police Department and specialized transport resources.
Recent exercises have included active shooter responses, vehicle-into-crowd incidents modeled after real-world attacks, high-rise rescues and complex triage operations. Upcoming drills will incorporate mass-casualty transport buses, so firefighters gain experience caring for patients during transport as well as initial treatment.
Rather than inventing fictional emergencies, Fitzgerald prefers building scenarios around incidents that have recently occurred elsewhere.
“Learn from what’s happening in the real world and then create scenarios that are like that,” he said.
Measuring success
Charlotte evaluates the immersive EMS training program through both recruit feedback and observations from firefighters working in the field.
Recruits consistently rate the immersive scenarios among the most valuable portions of the course, particularly those who have attended previous EMT programs elsewhere, Fitzgerald said. More importantly, field personnel report that new firefighters arrive better prepared to communicate with patients and operate more effectively in dynamic environments.
“From the street, we get feedback that we’re providing a better product to the guys out there,” he said. “When these recruits come out, they’re better trained than they used to be,” Fitzgerald said.
The department has also refined its instructional approach based on recruit feedback. One important lesson involved how and when instructors should intervene during scenarios. Rather than stopping students every time they make a mistake, instructors increasingly allow scenarios to run their course before conducting a comprehensive debrief. Interruptions are now generally reserved for unsafe actions or situations where recruits have completely gone off track.
Lessons for other departments
Fitzgerald believes almost any department can build an immersive EMS training program regardless of budget.
“Start small. Dumpster dive, because you can get a lot of stuff free,” he said.
Many props can be pulled from existing training grounds, surplus materials or community donations, he said. Pallets, old furniture, scrap building materials and inexpensive lighting can all become part of realistic scenarios.
“We started off with just turning over tables and saying, ‘This is a wall,’” Fitzgerald recalls. “For my first built-out scenario, we have a USAR training course here and there’s all kinds of junk available to use. I brought it in and made it look like the room had collapsed, so they were having to go through debris.”
Even he was shocked by the realism: “You wouldn’t even recognize the room from the way it was set up.”
As the program grows, departments can gradually add permanent props and themed environments without making significant upfront investments.
More important than money, Fitzgerald says, is finding people who enjoy being creative when developing the training.
“The only limit is your imagination,” he said. “I’m always trying to come up with the next best thing.”
He encourages departments to pair creative visionaries with instructors who have complementary technical skills to turn ideas into reality: “If you’re a visionary, find someone on your team that can help make your vision happen.”
More than medical training
For Fitzgerald, the program is about more than creating engaging classes. It’s about ensuring firefighters are prepared for the work they actually perform.
That philosophy continues to drive the department’s approach to innovation. By blending realistic communication, immersive environments and lessons learned from actual emergencies, Charlotte Fire Department created a training program that better reflects the demands of modern EMS — and offers a practical blueprint that departments of any size can begin adapting one scenario at a time.
