HIGH FIDELITY, LOW COST
appropriate responses to correct or inappropriate treatments or interventions. Obviously, these details should be tied directly to
the learning objectives of the scenario. Using
standardized patients who the students don’t
already know can also greatly increase realism.
WOUNDS & BLOOD
There are an amazing variety of resources
available for creating moulage, including elaborate kits with fabricated wounds
and bleeding systems that deliver
an impressive level of realism. There
are also countless online videos that
demonstrate low-cost ways to create various wounds and other medical makeup.
Regardless of the materials you
use, the most expensive aspect of
moulage is usually the time required
to create it. Nicholas Miller, the
paramedic program director at Lin-denwood University in St. Louis,
Miss., uses simulation extensively
in his courses. Miller’s advice for moulage is,
“Keep it simple; we’re not making a Hollywood movie. Rather than detailed wounds
that must be repaired or refreshed after every
scenario, we create wounds on Coban that can
be quickly applied and easily used multiple
times.” These wounds may not be as realistic
in appearance, but students still need to find
them, manage them and move on.
For simulated active bleeding, there are
impressive systems like the HydraSim that
can be used on multiple manikins or stan-
dardized patients, produce arterial or venous
bleeding, and is remote controlled. But there
are also a number of lower-budget options that
involve bags, tubing and squeeze bulbs. There
are several fake blood products available as well
and some even simulate clotting characteristics.
Some of these products are quite expensive,
and require some additional preparation and
cleanup as they can stain manikins, clothing,
carpets, and skin.
An inexpensive alternative is beet powder.
It’s biodegradable, easily cleaned, doesn’t stain,
and a 1/4 cup will make about 5 gallons of
fake blood. It costs about $8 a pound through
wholesale food suppliers online.
Miller describes a simple and inexpensive
way to reinforce the importance of body substance isolation in bleeding patients. He fills
a spray bottle with fake blood and when a
student manages a bleeding wound without
appropriate personal protection, he simply
directs a well-aimed shot to illustrate the point!
Early in his paramedic internship and after a
particularly challenging call, one of my stu-
dents asked his preceptor how he did. The
reply was, “You suck at patient assessment.”
When the student asked what he needed to
do differently he was told, “Suck less!”
Although some may view this as a concise
description of the problem and the solution,
most students need and deserve an opportunity
to clearly understand where they’re lacking,
and more importantly a clear idea of specific
things they can do to improve. This is why
many simulation experts consider debriefing
to be the most important component of effec-
tive simulation training.
Debriefing should be a learner-centered
process designed to assist learners
in thinking about what they did,
how they did it, and how they can
improve. One significant challenge
for instructors is to decide what type
or types of debriefing to use. The
choices are similar to those available in field training and internship processes.
A traditional EMS approach, and
one often used by new educators, is
for the instructor to do most of the
talking, pointing out in detail where
mistakes were made and identifying
areas for improvement. Although this direct
approach can sometimes be effective, it’s often
less productive than other methods.
Simulation training has been in use in medical training for many years, especially in nursing, and a number of established models have
been described. Details of those processes are
beyond the scope of this article, but instructors should learn about the various options
such as Plus/Delta (which asks two questions:
“What worked well?” and “What would you
change?”), Advocacy/Inquiry, Non-judgmental,
Facilitated, and others. 2
It’s important to note that research on the
effectiveness of specific debriefing styles hasn’t
established that any one approach is better
Figure 1: Basic, intermediate and advanced debriefing techniques5
Students can help recruit
volunteer patients, & they
often have friends or
family members willing
& eager to participate.