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Simulation Brain Wash

Simulation allows EMS clinicians to train for scenarios they may encounter in the field. Depending on the EMS providers, these scenarios may be ones that they have already encountered or those that they have yet to see in real life. The concept is simple: put providers in a simulated environment where they can form mental models and safely learn from mistakes, and they will perform better in real life. The simulation model is so important that it is often viewed as a quality metric in clinical excellence. While this form of training is salient, if done wrong, it can potentially form a real  “house of cards” mental model.

Parents typically will exaggerate stories to prevent their kids from doing something they deem unsafe. When my brother and I first got bikes, we could not leave the driveway. This was a real issue because all our friends lived down and across the street. My mom would tell us that she knew a kid who was riding his bike in the neighborhood and got either hit by a car or kidnapped. Either way, it was a story made up to program fear in our brains and prevent us from doing something she thought could be dangerous. However, I always thought to myself, “This poor boy my mom knew was extremely unfortunate!” This kid had sticks go through his cheek from running with a lollipop, hit by a car, almost kidnapped, attacked by a dog, and almost burnt his house down by throwing a 9-volt battery in the trash.  As a parent, I totally get this concept and believe it comes from a good place, but I wonder how much we do this regarding EMS training & simulation.

Fear Conditioning

The person sitting behind the controls of the simulation device has more power than one may imagine. Not only are vitals, trends, and pathology entered into the computer, but they are also programmed into the clinician’s mind during and after the simulation. A great example of this can be seen in the too-familiar example of nitro and the inferior wall MI. In one of my classes, I ask everyone what happens if you give nitro in a paramedic school scenario without obtaining a 12 lead first.? Every single time, the audience says, “the patient crashes.”  You may remember this FOAMfrat meme from a few years back.

Obviously, the fear is that if a patient has RV involvement and pre-load dependency (aren't we all?), they will have a precipitous drop in blood pressure. The truth is, there is a lack of evidence for this fear (see this paper), and we have been programming it for years. While one may argue that nitro really has no mortality benefit in ACS, I have seen patients with CHF present with hypertension and inferior S-T elevation, in which the providers were scared to even look at the bottle of nitro. The clinical impressions that we leave on clinicians (especially in school) have real-life downstream sequelae that can either make or break the way they view reality.

Time Compression

Educators often refer to something called a "sim-izm" when referring to things we do during a sim that is not very true to real life. This may be something like arranging chairs to pretend you are now in a helicopter or ambulance or even expediting specific time intervals to speed up the simulation. Most of the time, I do not see any issues with this, and it is warranted to avoid long periods of staring at the monitor and saying, "ok, we will keep monitoring on the way to the hospital." However, I feel like one of the areas in which I believe time intervals truly matter is with medication onset. Life Link III is the only place I have participated in a sim that truly makes you wait 90 seconds-ish for the rocuronium to kick in when simulating an RSI. If you push the "stop breathing and go flaccid" button 10 seconds after they push the medication, you are building a false mental expectation for real life.

When building out a simulation, I believe it is worth building out instructions on how long the meds should take to kick in and how hemodynamics may alter the onset. For example, if a crew attempts to RSI a hypotensive patient, the paralytic will take a while to circulate in a low-flow environment. This means the onset will be even longer than if the hemodynamics allowed for normal distribution rates.


Recently, I interviewed Josh Kimbrell, Judah Kreinbrook, and Tom Bouthillet about the prevalence of false capture with transcutaneous pacing (TCP). Their recent paper identified that 19 of the 23 (82.6%) patients who underwent TCP had false electrical capture despite all 23 having documented mechanical capture by palpated pulse. While this is a single-service case study, some of the clinicians I respect most in emergency and critical care medicine have reported similar findings. I can remember TCP simulations in paramedic school where you would turn the mA up until you get a complex after every pacer spike and then palpate the femoral artery to make sure you have mechanical capture. Unfortunately, feeling for a femoral pulse is unreliable, and there is quite a bit more we should be teaching to ensure we have true electrical and mechanical capture. Such as:

  1. The presence of a visible wide QRS and T wave after each pacer spike.

  2. Corresponding Pleth Wave

  3. Cardiac ultrasound, if available

Pacing is just one example of an intervention/procedure where we can create a false sense of security if we don't keep our ears to the ground regarding the efficacy and nuances in the literature.

Addressing these potential areas of false expectations requires educators to balance the benefits of simulation training with recognizing its limitations in replicating real-world clinical scenarios. The power of simulation can be extremely helpful or harmful to recognition-primed decision-making and mental models. By providing context and thorough research, educators can help learners understand the transferability of simulation experiences to actual practice.


Kimbrell J, Kreinbrook J, Poke D, Kalosza B, Geldner J, Shekhar AC, Miele A, Bouthillet T, Vega J. False Electrical Capture in Prehospital Transcutaneous Pacing by Paramedics: A Case Series. Prehosp Emerg Care. 2024 Mar 15:1-9. doi: 10.1080/10903127.2024.2321287. Epub ahead of print. PMID: 38407212.

Robichaud L, Ross D, Proulx MH, Légaré S, Vacon C, Xue X, Segal E. Prehospital Nitroglycerin Safety in Inferior ST Elevation Myocardial Infarction. Prehosp Emerg Care. 2016;20(1):76-81. doi: 10.3109/10903127.2015.1037480. Epub 2015 May 29. PMID: 26024432.


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