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July 1, 2013

The importance of simulation in EMS education

Since the introduction of the NHTSA 2010 National EMS Education Standards, EMS educators have been working hard to incorporate the use of medical simulation into their classrooms. The reason is obvious: while textbooks, publisher instructional resources, lectures and skill labs have been the pillars of prehospital education, they fall short in teaching EMS providers how to think critically and make rapid decisions accurately.

Medical simulation creates the environment that allows these skills to be taught, acquired and practiced. Moreover, a well-run simulation can help EMS providers to practice the "soft skills" essential to EMS practice.

Critical thinking - what is that?
In 1987, the National Council for Excellence in Critical Thinking defined the term as a "intellectually disciplined process of actively...conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication...."1 Note that the terms conceptualizing, applying, analyzing, synthesizing, and evaluating are active verbs - they represent an action, an activity.

Simulation helps with these actions by creating the conditions that promote this level of learning. An "ideal" simulation would situate students into the real world conditions in which they would be expected to perform. Actors would mimic realistic patient conditions and respond to questions and physical examinations appropriately. A scene would be built to look like a bedroom, an office, a busy urban street. Students would use real equipment, performing tasks in real time, and be expected to make decisions in a realistic way.

Sounds like a tall order - and it is. But not all simulations have to be this thorough. And, students have to be ready to undertake this level of learning. It's not reasonable to just throw them into the simulation pool and expect them to swim. Without preparation, it's very likely that they will sink!

From classroom to lab
If you are a trained educator, you probably realized that the same action verbs used in the critical thinking definition are part of Bloom's Taxonomy of learning.2 In fact these verbs occupy the highest cognitive levels of Bloom, synthesis and evaluation.

On the other end of the spectrum are the baseline levels of knowledge and comprehension. The combination of textbook reading and instructor-led learning (lectures, discussions, skills lab and homework) have served generations of EMS students in building these levels of understanding.

These two groups of learning levels are highly inter-related. The reality is that EMS students must have a foundation-level of knowledge under their belt before they can apply it. This means the EMS educator has to ensure that the student can demonstrate basic comprehension of the material before a simulation lab.

Simulations from low to high fidelity
"Fidelity" is a word often used to describe to level of complexity and realism of a simulation. A "high fidelity" simulation is one that was described - very realistic, and difficult for the student to differentiate from the real thing. A "low fidelity" simulation is fairly unrealistic, using simple equipment scenarios to create training situations and little else.

This is not to say that low fidelity simulations have little value. Because they are simple to devise and implement, they can be very effective in creating highly repeatable training events where students can practice critical thinking easily.

An example of low fidelity simulation is the use of an airway management trainer in developing an EMS student's ability to determine when to apply which airway device, given a set of "findings". In the opening scenario, an unconscious, apneic patient with an unobstructed airway may be easily managed by the student. The instructor might then state the patient is vomiting, in which the student responds by suctioning the airway prior to bag mask ventilation (BVM).  A follow up presentation might be a morbidly obese patient with a heavy beard, preventing the adequate seal of a BVM.

Each of these simulations are easy to implement, are brief and the performance is easy to evaluate using a checklist. The students can quiz each other with prewritten simulations at this level.

A higher fidelity airway management simulation would incorporate an airway simulator that could physically create more difficult airways to manage. Fake emesis could be introduced into the posterior pharynx that the student would have to actually suction using a suction device.

Using such a simulator removes the instructor from the scenario, allowing the student to focus on the "patient". The student would have to pick up the cues from the simulator, just like they would have to do in real life. This allows the student to make the correct decisions in a more realistic manner.

A high fidelity airway management simulation would place the manikin slumped over on a kitchen table, with a bowl of food next to it. Other environmental cues might include dim lighting conditions, concerned bystanders, or a possible unsafe situation. Now the student has to make decisions related to airway management while trying not to be distracted or otherwise taken off task by other factors competing for her attention.

Evaluating learning outcomes in simulation education
In the last example, there is much more to evaluate that the task of simply managing the airway - just like it is in real life. Looking at it more deeply, it becomes apparent that the student has to have learned tasks such as patient assessment and scene size up. That's the key - and why it can be more complex to rate the performance.

Keep the KISS principle in mind will help the educator determine what behavior to evaluate. If the goal is to see if the student can perform airway management under realistic conditions, develop the evaluation tool around that. Comment on the other distractors but don't make them the focus of the review.

If the goal is to evaluate the performance of overall scene management where airway management is but one component, then don't focus too closely on the latter. Point out if there were issues, but don't make it the most critical piece.

Simulation - part of the education practice
Solid education practice is rooted in the use of appropriate learning tools and achieving student learning outcomes. Simulation is a highly effective tool that is highly effective in helping students develop the higher learning levels of analysis, synthesis and evaluation. This will help EMS students be better prepared to handle the decisions they will face in the real world of EMS.


1. The Critical Thinking Community. Defining Critical Thinking. retrieved 20 June 2013.

2. Bloom BS. Taxonomy of Educational Objectives, Handbook I: The Cognitive Domain. 1956; New York: David McKay Co Inc.

About the Author

Art Hsieh, MA, NRP teaches in Northern California at the Public Safety Training Center, Santa Rosa Junior College in the Emergency Care Program. An EMS provider since 1982, Art has served as a line medic, supervisor and chief officer in the private, third service and fire-based EMS. He has directed both primary and EMS continuing education programs. Art is a textbook writer, author of "EMT Exam for Dummies," has presented at conferences nationwide and continues to provide direct patient care regularly. Art is a member of the EMS1 Editorial Advisory Board. Contact Art at and connect with him on Facebook or Twitter.