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Sink or Sim

Many EMS services embrace and push for additional training. Personally I think EMS does a pretty good job at focusing on training and sees the value in it. Quite frankly EMS has no other option but to continually train due to the nature and variety of our work.

Training is a bridge that allows the educator to facilitate the learners journey from their current knowledge to a different area of knowledge that influences the learner’s ability to think and perform. But EMS training is a wooden bridge, it gets you from one side to the other, but it’s bumpy, and if poorly designed the training can be pretty miserable. Sometimes you’ll come across a pretty nice bridge, but only travel on it to get from one side to the other.

Simulation is just another bridge that can facilitate knowledge transfer. We can choose to build another bumpy, wooden bridge or build a more modern, structurally sound bridge. Or better yet, we can facilitate the learner’s ability to self-reflect and have an awareness and understanding of their own thinking and thought process so they can build their own bridges. As educators we need to create a safe environment for learning that fosters self-reflection and challenges the learners to challenge their own thinking and thought process. Failure to create a safe place in simulation will sink your bridge faster than a patient vomiting after saying “I think I’m going to be sick.” This will lead to moans, groans, and just a general bad taste toward simulation and training.


Our careers as EMS professionals were built in simulation. EMS utilizes the term scenarios, but they are simulations that utilize standardized patients (live people that have been taught how to act congruent to a specific condition), which really just meant other students. Many programs now utilize high fidelity manikins to conduct their simulations including task trainers such as IV arms and intubation manikins. We’re taught to stick to this sheet and do it exactly this way… until you get to the streets and then forget it.

One of the things that I didn’t hear about until I began working full time in simulation was maintaining psychological safety.

Simulations or any training outside of a didactic form requires participant engagement. This means that participants are going to perform in front of peers and receive feedback on their performance. Performing before an audience of one's peers can produce unpleasant feelings called psychological distress which can be forms of anxiety, hostility, and in severe cases depression. All of these are signs of stress that people can feel during calls and depending on the type of training you’re doing the point may be to increase the stress. But educators can’t just stress people out to be realistic. Educators must create an environment for students to practice coping skills to better their performance during calls.

This stress comes from stepping outside the comfort zone and into the uncomfortable zone. The uncomfortable zone is the place for learning and growth. As educators we need to create a safe environment that allows learners to step into the uncomfortable zone to try new things, make mistakes, and self-reflect on knowledge gaps without crossing the boundary into the panic zone.

Educators must prevent learners from entering the panic zone. The panic zone can cause psychological damage to learners causing real, potentially long term problems for the learner and completely turn them away from EMS and learning. If you’re familiar with Lt. Dave Grossman’s illustration of the Colored Stress Conditions then we need to prevent learners from getting into a condition, red or black, where their performance and ability to cope with the stress and noise significantly declines. See EMCrit’s review on On Combat about stress and how performance changes. Stress can have cumulative effects that result in paralysis for the learner. While not necessarily getting into the 'panic zone,' but continually visitng the 'uncomfortable zone,' the repeated and cumulative stress can cause learner apathy and ultimately lead to psychological distress. The end result being a greatly reduced or failed learning experience.

During simulation, dismissal of learners feelings of stress (i.e. Well, that's realistic), and failure to provide tools to deal with said stress, can send learners into the panic zone. The educator will likely crush their motivation to train and miss an opportunity to optimize their performance.


To establish psychological safety the educator must be skilled in providing a pre-brief, monitoring, and debrief. The pre-brief is the foundation which allows learners to enter a place where safe simulation can occur. Educators will not be able to get full participation and self-reflection without establishing safety from the beginning. The pre-brief should involve some form of "The Basic Assumption" from Harvard:

“We believe that everyone participating in activities at the Center for Medical Simulation is intelligent, capable, cares about doing their best and wants to improve.”

As educators we have to believe and act in a way that is congruent with "The Basic Assumption" to build the bridges with our students and inspire them to self-reflect and begin building their own bridge.

The pre-brief that I utilize is “The Sim Center is a learning environment and during the learning process we will try new things and make mistakes. I want to encourage you to learn. We are not here to judge, assess, or grade you.* I am not here to go back and tell your boss or other students about your performance here today. The session will be recorded to ensure accuracy of the feedback/debrief, but the recording will be destroyed at the completion of this program. I also want to encourage you to become fully immersed in the simulation because we think everyone is capable of doing their best to learn and grow as a provider.”

*Some simulations are used as a summative assessment and the learner will receive a grade on their performance. If this is the case I change the verbiage to be clear on that.

This statement is followed by other logistical things like restrooms, where to store items, how the flow of the session will go, and what kind of debrief we’ll be conducting, as well as the objectives for the simulation. We’re conducting a simulation for learners to meet the objective and need to be as clear as we can with them. With the pre-brief you’ve built a modern bridge that learners feel safe to cross. As the educator you’ve created the platform to transport their current knowledge that is built upon the sturdy pylons of your objectives and simulation design.

During the simulation you may need to down or upregulate the stimulus to allow the learners to meet the objective. This ability to adjust the scenario should be based on the learner’s performance and the amount of distress experienced during the simulation. Make sure to apply enough stress that allows the learners to get into the growth zone without entering the panic zone. If you notice that learners are entering into the panic zone then stop the simulation. Reestablish safety and reevaluate whether to continue the simulation.

The pre-brief is your word and your promise. The debrief is your action and follow through with keeping your word of creating a safe environment for learning.


The learner’s educational and behavioral backgrounds are the basis for which they draw upon to be able to think and make clinical decisions. These backgrounds can be extremely complex and come with a variety of baggage. As educators we need learners to reflect on their previous experiences, and on how and why they came to the decisions they made during the simulation. We’ve taken the first step and created a psychological safe environment. Now we need to apply rigorous self-reflection during the debrief that inspires learners to reflect and understand their thinking. This creates a metacognitive experience that will catapult their ability to learn and perform. The educator’s ability to get learners across this bridge could have a limitless ability to improve patient outcomes for years to come. To do this, educators must challenge and inspire their learner’s development.

To support rigorous self-reflection educators can utilize the advocacy-inquiry method for delivering feedback. The advocacy-inquiry method works like this: you made a factual observation (I noticed) you told yourself a story based on that fact (I think) and then inquire about their perception (what story did they tell themselves). You are disclosing your view on their performance (advocating) and asking for their view of their performance (inquiring). Before utilizing this I will quickly recap the scenario with the facts allow learners to contribute or correct anything so we can all agree on the facts before getting into the feedback. This allows everyone to utilize the same operating picture of what happened.

An example of this would be a code scenario. You (the learner) came into the room, noticed he was unresponsive, you checked for a pulse, found no pulse, pressed a code button, and started compressions. Did I miss a step?

From there I will utilize the advocacy-inquiry method. I noticed that your compression rate was over 130 without complete recoil. I think you weren’t paying attention to your rate because you were concerned with coordinating the other parts of the resuscitation. What are your thoughts?

I’ve expressed my concern for the compression rate and allowed them to reflect on why they were (or weren’t) performing the appropriate action. This maintains safety while also challenging our learners to become the best provider through a stimulating and supportive learning environment.

Utilizing the advocacy-inquiry method avoids the mindreading “pimping” sessions that has often been used in medicine where the learner must guess what the educator is thinking rather than the educator diving into the mindset of the learner to challenge and inspire them.

Without safety your bridge will implode and sink your participants from learning and self-reflecting on their performance. Your simulations don’t have to be sexy, they need to be safe. This means simulations that are designed with enough details and realism to meet the objectives to allow participants to learn. Inspire the next generation of EMS educators by keeping them safe.

-Adam LaChappelle

The master of disaster looking to practice good medicine in austere environments


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Rudolph, Jenny W., Robert Simon, et al. “Debriefing with Good Judgment: Combining Rigorous Feedback with Genuine Inquiry.” Anesthesiology Clinics, vol. 25, no. 2, June 2007, pp. 361–76. PubMed, doi:10.1016/j.anclin.2007.03.007.

Rudolph, Jenny W., Daniel B. Raemer, et al. “Establishing a Safe Container for Learning in Simulation: The Role of the Presimulation Briefing.” Simulation in Healthcare, vol. 9, no. 6, Dec. 2014, p. 339., doi:10.1097/SIH.0000000000000047.

“The Basic Assumption.” Center for Medical Simulation, Harvard, Accessed 2 July 2019.


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