"And we would give Ketamine..." - Paramedic trainee/student who is being run through a scenario

In EMS, we rely on simulation for a lot of our experience. It isn't everyday that we perform RSI/DSI, assist in childbirth, see De Winter's, etc. So, it is only logical that we rely on simulation. Ideally, the first time we see or perform things like what I just listed, it would be in clinicals. However, that is the topic of another debate (see my Reform Paramedic Education blog). For now, simulation and proper debriefing is probably the best way to test our skills and knowledge. With that being said, I've been through a lot of scenarios that totally sucked. Not because they were hard, but just because they were unrealistic and didn't have clear learning points outlined. This raises the question: How can we avoid putting out students and trainees through useless misery???? I've got 3 points to help us all out. And by the way.... None of them cost a thing.

1. Plan Out Your Scenarios

Nothing is worse than a scenario that doesn't make sense. It frustrates the learner to no end. Whenever you're planning to run scenarios as part of training, make sure you have these things down:

- Where will it take place?

- What equipment/people will I need to make it realistic?

- What will be the patient's chief complaint?

- What is the patient's story?

- What will the patient's labs and vitals be?

- How will the patient respond to interventions?

- What is the main point I want my students/trainees to take home?

If you fail to plan, plan to fail! Trust me, everyone can tell when you come up with scenarios on the fly. You're cheating everyone involved out of an experience that could be much better. If you're planning a scenario, don't discount it as second class learning. Prepare for it just like you for for a lecture.

2. Use The Real Stuff!

During training/simulation, we often let people verbalize treatments, we aren't in an ambulance, and we even let them verbalize assessment! This has to stop if your simulation is going to be effective for teaching. Wherever the simulation is meant to take place, have it take place there. Here is a picture from a simulation I was running with a trainee:

Darth Vader might look funny, but he's actually a difficult airway manikin that vomits. We do not currently have iSimulate, but I do think it is a great tool for making the crew look at their monitor rather than their proctor for information. iSimulate soon to come. That being said, this was a simple DSI/RSI scenario that I think had a lot of good points to it. Check it out!

- We are in the actual ambulance where this should take place in real life.

- We really turned on the oxygen and section (real noises and muscle memory).

- We used medication vials that were refilled with saline for the med pushes (they really had to draw them up and push them into an IV at an appropriate rate)

- The preoxygenation and denitrogenation was timed on an iPhone to ensure it wasn't rushed.

- Conversations were had about airway positioning and strategy by the crew.

- After the intubation, the IV pump was actually used to set up a post intubation ketamine infusion.

- If questions came up, we paused the scenario, talked about them, and then continued where we left off.

- A good time was had by all!

At my workplace, our training and education supervisor Tyler Christifulli ( @christifulli88 ) was able to construct training bags and equipment that are just like what the crews use on the ambulance. I really believe this has brought our simulation game up to a new level. It has also resulted in a better learning experience by the crews (they can focus on the call instead of the equipment). I have done something similar for critical care trainings!

For critical care trainings, I not will often use a real person placed on a non-invasive mask to simulate an intubated person. That way, the person acting as the patient can breathe over the vent, make high peak pressures, respond to 'sedation' and 'paralysis,' etc. I will hook up a fake IV to the actor so that IV infusions can be connected to them. The crew will also use a real monitor to get full vitals and ECG on the actor. Having to transfer a real person from a bed to the cot, worrying about IV lines, sedation, etc, has really brought a new level of realism to training.

3. Have Clear Learning Objectives - AND DON'T LET THEM FAIL!

Just like a lecture can only have so many 'take home' points, a simulation is the same way. If your simulation is convoluted with unnecessary details, your student/trainee might get distracted and miss the point of the simulation. While it might be fun to give the diabetic emergency patient a positive Sgarbossa Criteria, it isn't going to help your student learn to manage a diabetic in real life. What would be a good example of quality, straightforward objectives to complete?

- Able to immediately delegate responsibilities to crew members.

- Performs appropriate assessment in an acceptable amount of time. For example: Complete assessment of airway, breathing, and circulation within 3 minutes of patient contact. Check BGL within 4 minutes. Full set of V/S / ECG in 5 minutes . IV established in 7 minutes. Etc. Decide what timeframes are acceptable to you. times may differ based on the student/trainee experience level, knowledge base, and nature of the simulated patient.

- Treatments were appropriate per what you designated the patient needed before starting the scenario.

Above all, do not let the student/trainee fail. This rule applies only to practice simulation. During a testing scenario, it is of course understandable that some people fail to perform. Now, back to practice simulation for the purpose of learning. It is important to identify when the individual is having trouble. Don't let them drown if they are stuck. Pause the scenario in a non-rude fashion and redirect their thinking pattern. This will give them confidence to run the next scenario with less help. If they fail in simulation, they will believe that they are bound to fail in real life. In training, NEVER let them fail! People should not walk away from the scenario feeling like they cannot succeed. What then?

Afterwards, always do a quality debrief. I've found that people respond best to the following training format:

- Rounding in (light discussion about calls, good things, bad things, operations, etc). Rounding in gets everyone comfortable in the room, and used to talking. They also will feel like they got everything they wanted to say off their chest before training starts. This will allow them to focus on the subject they're learning about.

- Brief lecture. A short lecture about the training topic will prepare the students to run the scenarios. You will give them valuable information that they can apply shortly afterwards. Encourage them to take notes that they can reference during the scenarios.

- Break for 5-10 minutes

- Scenario 1. Run the scenario for however long it takes. Pause the scenario however many times it takes to get the crew through it successfully. Afterwards, do a thorough debrief and invite the rest of the class to participate. Reference your material from the lecture and briefly expound upon it if necessary.

- Scenario 2. Repeat the same sequence as scenario 1.

- Round out. "Was this helpful?" "do you all feel like you learned something about the topic that you can apply?" "What questions do you have?"

- Closing remarks. Never close with questions. The classroom just tends to fizzle out in a very anticlimactic way. Try to close with some kind of statement that reaffirms the usefulness of what was covered, even if it is something simple. 'Thanks everyone for coming and supporting the training today! I had that really difficult to deal with vent patient the other day and afterwards I thought that you guys would really benefit from going through the same things I did. These patients are often really sick and we have to be on top of our game to deal with them. Good job today!'


#EMS #Simulation #CriticalCare #Paramedic #Education