In the process of medical education, simulations are one of the most important and often overlooked tools available to instructors. There are many considerations that must be taken into account when leading a simulation. The process of converting theoretical knowledge into practical actions is not a simple one, especially when critical decision-making is involved. A firm guiding hand, when applied correctly, can have immense benefits in the execution of a sim. Let us begin at the beginning.

Each and every simulation is grounded in theory. Students must have an adequate understanding of the material before attempting their hand at treating a mock patient, this much is evident. However, instructors tend to take the pre-brief for granted. A simulation must have a clear goal for the students to strive for. Just telling them to “treat the patient” is often not enough. Ideally, a scene is described and then the job of the rescuers defined. “Work through the triangles, take full sets of vitals, identify (do not treat) 3rd triangle problems, and finally call into command.” Guidance such as this can instill assurance in students, all the while converting protocol into habit. Different expectations are appropriate at different times during the HEART class. The less the students know, the less complex a simulation should be. The first few simulations should be basic and deal with mastering the patient assessment system, for which something like the aforementioned pre-brief could be ideal. Sims later-on should involve treatment, creating plans for long-term management, and considering evacuation options. Such sims necessitate more involve pre-briefs that give students a sense of where they are, what environmental considerations they will face, and all of the resources available to them. The role of each rescuer is also important. Since there are at least two leaders on each trip, there will almost always be a primary and a secondary rescuer in any situation. It is important to practice this dynamic in simulations so that it feels natural and no conflict develops during the treatment of a real patient. Defining the roles of primary and secondary caregivers and allowing students to practice both roles is incredibly important. An effective simulations begins with a detailed pre-brief that puts everyone on the same page as far as knowledge, expectations and goals are concerned.

Now that the pre-brief has been completed, it is time to launch into the simulation itself. At this point, patients have been prepped and coached in how to act, while rescuers have been briefed on the situation and given a goal. The role of the instructor in this stage becomes that of a guiding hand. In any simulation, there are two major roles the rescuers play – completing the assessment and administering any interventions. First comes the assessment. Rescuers should practice how they are going to play. It is easy to become sidetracked and complacent in the comfort and safety of the classroom. Handling a real injury, especially in the wilderness, requires that simulations be taken seriously. You will fall back on your training in a time of crisis. Therefore, assessments should always be thorough and the rescuer-patient dynamic as accurately modeled as possible. An example of complacency that I have both witnessed and been guilty of myself is not taking a full set of vitals. Yes, it does take time, and yes it’s always going to around 60-100 BPM and 12-20 RR in the classroom, but that doesn’t mean students can’t become highly proficient and locating a pulse and counting it. If then they run into a patient with a weak and thready heartbeat at 180 BPM, at least they will be confident in their ability to locate the pulse. That allows the first responder to establish a trend of vitals. Because, for better or worse, there is always time in the wilderness context, there is no excuse for not having a vitals trend when handing a patient off to higher care. All too often I have seen students who are still not entirely comfortable finding a pulse at the end of a HEART class – that means both the radial and carotid pulses. The same idea goes for collecting a thorough SAMPLE history. Asking the same cookie-cutter questions every sim is not going to force the student to think or come up with any new ideas. The simulations need to be designed in a way that forces students to become creative in their line of questioning, which begins with the instructor presenting SAMPLE in a way that conveys the full extent of the tool. Between vitals, SAMPLE, and the physical exam, instructors need to drill into their students’ heads one important question, “what else could it be?”. Tunnel vision is a trap that many new healthcare providers fall into. It is easy to find a problem and start fixing it, becoming blind to everything else that is developing. A good first aid practitioner is always on the lookout for alternate causes and developing problems. There is no such thing as a diagnosis in first aid, only a differential diagnosis – a list of possibilities. What else could it be? After the assessment, treatment can begin. Often, treatment is neglected in simulations – not necessarily because it is time-consuming, but because it requires resources that we do not always have at our disposal. However, there are still many details which can easily be simulated. An intervention can be as simple as putting a Therm-a-rest under a patient. Indeed, the Therm-a-rest is one of the most versatile tools in wilderness medicine and can be used to great effect to keep the patient warm and dry, immobilize limbs, and create a modicum of comfort in a difficult time. A close second is the blanket or sleeping bag. These are tools that students should be thinking about in their treatment plans. “What else can I do?”, that is the question that any medical practitioner should ask of themselves in the course of managing a patient. Place yourself in the patient’s shoes and think about what you would want for yourself. As the instructor, it is your job to push students when they become stuck on a problem, all the while offering encouragement and reinforcing aspects of their assessment and treatment that have gone well. The simulation itself should be a platform for critical thinking and the application of problem solving skills to alleviate the plight of a real person. Asking “what else could it be?” and “what else could you do?” of your students will go a long way in fostering critical thinking and improving the educational value of the simulation.

After the simulation has ended, the most critical part of the process begins – the debrief. It is easy to gloss over and not spend time on, but let me convince you that it is worthwhile. HEART is a unique teaching experience in that an instructor has almost exclusively Princeton students as trainees. Princeton students tend to be eager for engagement and challenge. The flip side is that they can easily be bored, but given a difficult problem, their creativity flourishes. The simulation should, adjusted to the students’ level of knowledge, present the difficult problem. Debriefing a medical simulation is like going over a difficult problem in precept – everyone has maybe given it a go on their own and then a collective effort is thrown at understanding the nuances of the issue at hand. As an instructor, you have the resources of every mind in the room at your disposal; you should make the most of these resources. The debrief should be more collaborative than the simulation itself. It should be more than just a conversation between the instructor and the rescuer/patient pair or group. The entire class should be involved in identifying mistakes, suggesting areas of improvement and identifying the quality provision of healthcare when it takes place. Here is where the fact that all of your students are Princeton students comes into play. With some effort, it is easy to create a classroom atmosphere that encourages mistakes. The first aid class is the place to make mistakes! Mistakes are a good thing. We learn far more from our mistakes than we do our successes. Emphasizing creativity and some boldness in assessing and treating a patient creates confidence, which will end up serving any first responder well in the field. By creating an environment where it is OK to make mistakes, individual students will feel more comfortable talking about their thought processes in assessing and treating the patient. That will elucidate why they chose the treatment plan that they did, which in turn allows for a thorough discussion of the pros and cons of the particular approach. Reflecting on the assessment and treatment plan is one strength of the debrief. Reviewing relevant material and emphasizing important particulars that may have seemed trivial earlier on, perhaps during the lecture, is imperative for learning. To do so, the instructor must direct attention to signs and symptoms or treatments that were overlooked or not fully understood. In reviewing the material again, directly after the simulation, students will feel more comfortable with it and should grasp it more firmly than before. I hope you can agree with me that the debrief is the most important part of the simulation – it allows everyone to learn from individual mistakes and instills confidence in your students.

Finally, let us take a step back and briefly consider the bigger picture. HEART is a course that is designed to create competence in administering first aid in a wilderness context. Ultimately, caring for a patient comes down to knowledge, competence and confidence. Theory is a great tool, but without practice, it becomes worthless. Especially in high-stress situations, people either panic or fall back on their training – there isn’t much in-between. The sims that we do in HEART are the practical training that our leaders will fall back on in the case of emergency. It is worth the effort of creating simulations of great educational value in order to train the best leaders that we can. Hands down, the simulation is the most powerful tool in our educational toolbox. Lecture merely plants the seed of an idea which practice germinates.

My inspiration for writing this article was another article that popped up on my EMS1 newsfeed, written by Rafi Uddin. I encourage you to read the article HERE.