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The Benefits of Patient Simulation in COVID

TCS Pro simulators being used for firefighter response training

What was the date your EMS education program changed due to COVID-19? EMS education was significantly impacted when COVID-19 cases surged, and strict rules to inhibit transmission of the virus were enacted. Most of EMS education is rooted in skill competency assessments requiring close contact and physical touch as an essential component to meeting the curriculum requirements.

The COVID standard of social distancing boundaries impacted EMS education dramatically, requiring educators to rethink how to safely offer simulation activities without placing at risk standardized patients/embedded participants, students and faculty. In short, everything went sideways, and we had to do it all differently—almost overnight. Patient simulators have evolved tremendously since their inception. The first-generation manikins were more like a robot, rather than a simulated human. It required sophisticated knowledge to “run” a patient simulator effectively. As technology advanced, the evolution of patient simulators brought reductions in cost while improving realism and increasing functionality. Software platforms became more intuitive, allowing for easier navigation. Age appropriate and gender specific physiology and pathology now allow for enhanced realism and fidelity during a simulation. Clinical skills can be completed on a simulator offering an opportunity for participants to achieve skill completion that would otherwise be harmful to a standardized patient. This promotes a simulation activity with less talking through the steps by participants and more actual “doing” of the steps, hence an actual simulation.

Patient simulators are not new to EMS education and many programs own or have access to a simulator. The Simulation Use in Paramedic Education Research (SUPER): A Descriptive Study, revealed most paramedic education programs have access to a patient simulator but often lack the faculty development necessary to fully integrate its use into the curriculum1.

EMTs and doctors treating a patient

If you have access to a simulator and do not know how to use it for a simulation, or you only know the basic operational characteristics of your simulator, go to the manufacturer website or contact the sales representative. The manufacturer can provide excellent guidance and support. Additionally, you can network in your community with other simulationists who use simulators in their education programs. This is a great way to learn tricks and tips and build a network of support at the same time. By and large, simulationists are passionate about their work and enjoy sharing their expertise. Lastly, familiarize yourself with the best practices for simulation published by the Society for Simulation in Healthcare (SSH), the International Nursing Association for Clinical Simulation and Learning (INACSL) and the Association of Standardized Patient Educators (ASPE). These standards provide important advice approaching simulation design, delivery and debriefing standards.

During COVID, the use of patient simulators offers a mechanism of making simulation activities safer by reducing the exposure and limiting the spread between humans. The use of simulators can provide a separation of humans from each other, decreasing transmission risk. The educators and learners are in different locations, and learners can be kept separate as well.

Manufacturers have published enhanced decontamination guidelines for their devices to support elimination of cross contamination. These are important considerations for an EMS educator who is choosing the appropriate simulation modality. Normally, selection of the modality should be based on the learning objectives identified. However, the rules for engagement in COVID means that this cannot be the only consideration, as mitigating transmission is equally important.


As you are developing and adapting simulation activities, past simulation experiences can overshadow EMS manikin simulation. Many EMS manikin scenarios are unmanageable, especially for initial learners. There are many ways to ensure a positive experience2.

  • A simulation orientation is a key component to success. If a simulator is being used, this offers an opportunity for participants to learn the functionality and limitations of the simulation.
  • Identifying a strong need and objective is the first step to executing a purposeful activity.
  • Simulation is best delivered with the operator and/or evaluator out of the simulation space. This allows participants the freedom to function without the obvious cuing by instructors during the activity.
EMTs using a monitor on a patient
  • Cases must be evidence-based and medically probable, reasonable and progress as a live patient would evolve with the same pathology.
  • A developed case script with progressing physiological signs and symptoms, driven by essential case interventions by the participants, is the best way to standardized simulation assessment outcomes.
  • Simulator manufacturers have vetted simulation scenarios which can serve as an excellent starting point for programs newly adopting simulation or working to expand their manikin-based simulation activities.

It should be noted that concepts from other modalities can be incorporated into simulator use as a standard practice. Embedded participants (often called actors) have long been a staple of EMS education activities3. Having individuals act as a bystander, family member, or even an associate healthcare provider, enhances the experience with the simulator. While simulators cannot replace many of the activities and aspects of other simulation modalities, they can certainly do a tremendous portion. They are a powerful tool for offering a safe education program by reducing the risks during a simulation activity.

This is evidenced by the Honolulu Fire Department’s decision to move to simulator-based training. “COVID changed the whole equation” as it relates to training, said Michael Jones, fire captain for the Honolulu Fire Department Training & Research Bureau. The Honolulu Fire Department is one of the largest fire departments in the country with over 1,000 personnel. Seventy-five percent of the department’s call volume is medical in nature.

Traditional training used personnel to simulate their training scenarios. This was no longer an option with COVID. “We had to find a way to continue to run recruit classes while not exposing them and our trainers to unnecessary risk,” Captain Jones said.

In addition to safety, increased interactivity for training was also a need. In the past, scenarios were limited since personnel simply didn’t have the ability to simulate challenging health situations. It was even harder to keep existing personnel engaged for annual retraining with humans that simply couldn’t present the way scenarios were written.

Operative Experience trauma simulator

The Operative Experience, Inc. (OEI) Trauma Care Simulator has a silicone exterior that simulates real flesh and is one continuous body from head to toe. Medical symptoms were able to be presented that were more real world such as heart or respiration rate. “The OEI simulators were more realistic, more interactive, more entertaining, and more real world,” according to Captain Jones. Honolulu Fire Department’s first class of 22 recruits are finishing up the EMT program. A second class of 24 will follow them. After training, they sit for the EMT National Registry. The Honolulu Fire Department needed realistic tactical simulation solutions necessary to respond to medical incidents while increasing and maintaining the level of safety that is appropriate in the middle of a global pandemic. The use of OEI trauma simulators is helping them meet this goal.

  • Benefits of patient simulation are well researched allowing for low-frequency, high-risk cases as well as more routine medical and trauma cases to be managed by all learners. Allowing crews to practice new protocols or treatment standards prior to live patient care is now achievable. Having participants build new thinking and response mechanisms to situations like COVID requires not only learning but safe practice. Simulators are undoubtedly a safe mechanism. Standardizing the expected actions and the assessment quality is also a benefit. Most importantly though, is the decreased risk to all involved during EMS education by reducing the risks of COVID.


    1. McKenna KD, Carhart E, Bercher D, et al.: Simulation Use in Paramedic Education Research (SUPER): A Descriptive Study. Prehosp Emerg Care. 2015;19(3):432-440. doi: 10.3109/10903127.2014.995845
    1. INACSL Standards of Best Practice: SimulationSM Simulation Design. Clinical Simulation in Nursing. 2016;12(S5-S12. doi: https://doi. org/10.1016/j. ecns.2016.09.005
    1. Lioce L, Lopreiato JO, Anderson M, Diaz D, Robertson J, Chang T, Downing D, Spain A, ed. Healthcare Simulation Dictionary. 2nd ed. 2020; Washington, D.C.: Agency for Healthcare Research and Quality.


    Jennifer McCarthy, MAS, NRP, CHSE, serves as the Director of Simulation and Clinical Associate Professor for the School of Health and Medical Sciences, Seton Hall University where she leads simulation activities for six graduate healthcare programs. She is also the President of 579 Solutions, LLC a consulting company dedicated to improving clinical assessment and the use of simulation for all levels of learners. Jennifer has over 30 years of experience as a paramedic and 20 years as a simulationist. Jennifer has led many simulation workgroups to lead efforts to improve IPE simulation initiatives and advancement of science based medical simulation activities. Jennifer holds many member positions with the Society for Simulation in Healthcare. She has won numerous teaching excellence awards and serves on several state and national committees that address the advance use of evidence-based healthcare simulation. Most notably Jennifer was named one of the Top 17 People to Watch in Healthcare (201 Magazine, January 2015) and has received the EMS Career Lifetime Achievement Award (November 2015) presented by the New Jersey Department of Health Office of Emergency Medical Services.

    Jan Wilson, M.Ed., SHRM-SCP, SPHR, is an organizational development and learning consultant who has provided strategic planning, process alignment, change management, curriculum development and planning, as well as learning solutions to a variety of clients such as pharma, healthcare and state governments. As principal and founder of Wilson and Associates Consulting, she partners with clients to solve learning challenges, develop customer targeted marketing strategies and messaging, and build strong teams. She has also served as adjunct faculty at her alma mater, the Peabody School of Leadership and Organizational Performance at Vanderbilt University in Nashville, Tennessee.

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