Category Archives: Education

Brighter Lights for Darker Nights (or How and Why to Set up Trauma Workshops for Your Local Volunteers)

Greg Brown, the person with the job of coordinating education at CareFlight on things anyone with a bit of background can do to help make the wide, brown land feel a little less remote. 

It is a dark and stormy night. It had been a long day at work and you are now driving home from a nearby town where you have been holding fort at what is loosely termed a “hospital”. Your mind drifts to all that is warm, dry and welcoming – family, a comfortable lounge, re-runs of your favourite show (obviously it’s Helicopter Heroes…) – only 40km to go…

These were your last conscious thoughts before you hit a kangaroo, lost control of your Tesla (okay, maybe a Camry) and crash into a tree.

A passer-by calls emergency services. They are on their way – but it’s a dark and stormy night and you don’t live in NSW (that’s Newcastle, Sydney or Wollongong) and the response will be made up of volunteer emergency services.

Meanwhile, a page goes out back in your hometown. Members from various volunteer agencies drop their food and head to their respective depots, don their respective protective uniforms (usually coloured yellow, orange or white), jump in their respective response vehicles and head to the scene where you are now cold, wet and sore.

You are still in your car – you cannot get out because the dashboard has collapsed into your lap. The passer-by tells you that the first response vehicle has arrived. You twist your head to see who it is – Police, Fire or Ambulance? It’s none of those – you don’t live in NSW (again, that’s Newcastle, Sydney or Wollongong) and the response is made up of volunteer emergency services: State (or Territory) Emergency Service, the volunteer bush fire brigade and some others that you didn’t even know existed.

“Where’s the ambulance?” you ask – but the nearest ambulance is at least another half an hour away – maybe more! They tried calling the local doctor but it turns out that was you.

Damn those “dark and stormy nights” you sigh……

Reds Mando Gomez
The other kangaroo probably looks even less impressed.

The Problem

If this scenario sounds far fetched then I encourage you to head out of the big smoke and go bush for a while. Situations such as this are not only real – they are an almost daily occurrence in Australia and many other parts of the world. Conservative estimates reveal that volunteer emergency services personnel outnumber their paid (professional) compatriots by a ratio of 20:1 in Australia with similar comparisons reported abroad.

But all is far from lost. The reality is that the vast majority of emergency services volunteers in Australia are highly capable, appropriately resourced and widely respected for the unpaid yet vital roles that they perform in serving their communities in times of need.

But (yes, there is always a but) those roles rarely include the provision of medical first response unless they are trained community first responders or volunteer ambulance officers. As such, it is also a reality that in non-metropolitan Australia the victim of trauma (vehicle, industrial or other) is likely to be treated initially by a volunteer with nothing but a generic first aid kit and some non-specific training – good if you need a splint or sling, not so good if you are seriously injured. What’s more, many of these volunteers lack the confidence to engage in the provision of medical first response.

The Challenge

Whilst it would be nice if an expertly trained and equipped pre-hospital care team was available in every postcode every hour of the day, we all recognise that this is simply not possible. But (yes, another but) we can do something to help the volunteers that are out there in regional and remote areas. It’s called training.

In the mid 2000’s a small group of “greybeards” at CareFlight were discussing the ways of the world over a few decaf-soy-mochaccinos (probably more likely double macchiatos…) and collectively voiced that if only those volunteers in regional and rural Australia felt appropriately trained and empowered to do a few extra small things for their casualties then they could make even more of a difference to the survivability of the people that they treat. Thus, the concept of the Trauma Care Workshop (formerly termed the Volunteer Trauma Course) was born. With this concept came a list of expectations. These included:

  • The training was to augment the participants’ current training content and systems, not replace them;
  • It needed to bridge the gap between high quality first aid and the care provided by professional medical responders;
  • The educators providing the training needed to be expert clinicians that were clinically current – credibility was going to be important;
  • The training needed to occur in the locations where the responders live – not in Sydney; and
  • Since the participants were likely to comprise mainly volunteers, the training had to be for free (or at least at no charge to the individuals).

Nothing like a good challenge to get the neurons firing…

The Role of AeroMed in Regional Trauma Training

There is little doubt that the sound of an aeromedical flight (helicopter or fixed wing) provides reassurance to both the injured patient and their carers, especially in regional and remote areas. The very sound of an inbound flight conjures up images of advanced medical care, expert clinical decision makers and the opportunity to whisk the patient away to a shiny hospital filled with white lab coats and machines that go “ping”.

The reality is that most trauma patients do not get better at the place their injury happens; they get better in hospitals. So the presence of an aeromedical retrieval team on scene does not in and of itself guarantee survival for the patient – but it can help. So too can that group of volunteer emergency services personnel – if they are trained and empowered to do so.

Herein lies the opportunity. Aeromedical providers owe it to the volunteers that they support to build local capacity and resilience within the regional and remote areas that they service. After all, at some point we all must recognise that we all exist for the same purpose – that is to save lives, speed recovery and serve the community. It is not about the colour of your uniform, nor is it about the company that pays you – it’s about people.

The same is true for clinicians working in regional and remote areas but not associated with an aeromedical provider. Clinic staff are often the second line of defence in the battle against trauma related morbidity and mortality. Supporting the local emergency response team in many ways makes your job easier, and who doesn’t want that?

So what can we offer? To me, we can offer three things: time, knowledge and support.

1. Time

Never underestimate the power of offering your time. I know you are busy – heck, we are all busy. But finding the time to head bush and conduct clinical teaching for those who are rarely exposed to it is one of the most powerful gifts that you can offer.

Emergency services personnel, particularly those of the volunteer varieties, want to know what you are thinking when you are presented with a casualty – any casualty. For you it may be a simple, run of the mill, seen it a thousand times before type of patient; but for the local volunteer emergency services personnel it will likely be new, difficult, unexpected, or perhaps all three! What are YOU thinking when you fly overhead? What goes through YOUR mind when you step onto the pre-hospital scene? How does YOUR clinical assessment process differ from that of a first aider? They can never learn from you if you don’t ever find the time to visit their locations and teach them. Your time is important – to both you and them.

2. Knowledge

Most readers of this article will have at some point in their careers been subjected to a training session delivered by an individual who knows their content but nothing more. This is all-too-often the case in first aid. The reality is that the process for teaching accredited first aid in Australia is highly regulated within the AQTF (that’s the Australian Quality Training Framework – if you’re having trouble sleeping you could look right about here). To pretend you can change or ignore this is perilous.

So aeromedical providers need to embrace the fact that the emergency services personnel that they work with already hold first aid skills and therefore seek to deliver complimentary training. In other words, fill the gaps but eliminate duplication.

What are the elements of casualty care that are easy to perform by a non-clinician yet not covered by the majority of first aid courses? Consider topics such as arterial tourniquets, the difference between crush injury and release syndrome, and the elements of aeromedical evacuation that they need to know (e.g. like not using flares when you’re flying on night vision goggles).

3. Support

The need to build resilience amongst emergency services personnel in Australia is well publicised (if you don’t believe me check out this or this or this).

Building this resilience is a long and involved process, but simple things can and do make a difference in the lives of emergency services personnel. It can be as simple as: acknowledging effort; involving them in decisions; asking them their opinions; and explaining what you are doing / thinking. But you can build resilience during training by offering your time to answer questions or “fill in the blanks”.

For example, in 2015 I taught a bunch of volunteer and professional emergency response personnel at a resort in an extremely remote part of Australia (note: details kept purposely vague). Whilst there we heard of a horrendous job that the local team attended which involved the death of a tourist. In 2016 our team taught a different bunch of response personnel in a different part of Australia and had the opportunity to informally debrief an individual who was effected particularly badly by the aforementioned incident – essentially, this individual volunteered to accompany and protect the deceased tourist overnight in the bottom of a canyon until a repatriation team could fly from the nearest urban centre.

This is an extreme example, but every time I teach I am afforded the privilege of hearing these personal stories. I like to think that every time an individual vents their job related emotions to me that “black dog” is pushed ever so slightly out of the picture.

CareFlight’s Trauma Care Workshop

As previously mentioned, the Trauma Care Workshop (TCW) concept was born out of numerous conversations had by the “greybeards” of CareFlight. It took a few years to secure the funding, purchase the equipment and, of course, write the content, but between January 2011 and June 2016 a total of 174 TCW’s were delivered to a total of 2711 emergency services and first response personnel across Australia – at no cost to the individual attendees.

Everywhere copy
Trauma Care Workshop Locations 2011-2016

The TCW is an eight hour interactive workshop that is delivered either as a single day session or over two consecutive nights. Utilising the principles of adult learning (look up andragogy or Knowles’ principles of adult learning – or just go here) the content is delivered by professional pre-hospital care providers, many of whom also hold post-graduate or vocational qualifications in clinical education, training or assessment.

Any contemporary medical training that is worth the paper it is written on is interdisciplinary in nature. Therefore, the TCW works best when members from different services (e.g. state emergency services, bush fire brigades, rescue agencies, police, park rangers etc) all attend. After all, when was the last time you attended a pre-hospital scene and saw only one colour uniform?

KI copy
Park Rangers and Volunteer Ambulance Officers training together on Kangaroo Island, South Australia

The reality is that pre-hospital scenes are like an open bag of Skittles – every colour under the rainbow all mixed in together. But this goes for the Educators too. Where possible, the three Educators on any given TCW will come from diverse clinical backgrounds – critical care doctors, specialist flight / emergency nurses and professional paramedics.

Importantly, all content is evidence based and research centred. The content itself is delivered through a combination of pre-readings, didactic lessons, interactive skill sessions and immersive scenarios which cover the essentials of pre-hospital trauma care:

  • Patient assessment techniques;
  • Haemorrhage control;
  • Basic airway management;
  • Mass casualty triage;
  • Extrication;
  • Burns management;
  • Teamwork and communication strategies (including the need for a shared mental model); and,
  • The essentials of aeromedical evacuation.

But what the TCW does NOT do is change anybody’s scope of practice; the TCW is designed to augment previous training, not replace it. We are not there to take over the world or supersede anyone’s service – it’s about the patient, not the uniform.

If individuals who complete a TCW wish to see their scope of practice altered in light of their newfound knowledge and skills then the responsibility for achieving these changes rests with them (although we are always happy to provide the evidence to back up their case).

Kalgoorlie copy
Police and local mine rescue staff often form the frontline in emergency response in outback areas (photo from a course in Kalgoorlie, Western Australia).

But what about you?

Whilst at CareFlight we love delivering high quality evidence based training in locations that are off the beaten track the reality is that we cannot be everywhere. But if you are living and working as a clinician in regional areas then you can help.

Head down to the depot of your local volunteer emergency services agency and introduce yourself. Whilst there, ask them how you can help. They will most likely be looking for more volunteers but the purpose of this article is not to recruit those (although that would be a welcome side effect); instead ask them what medical-based training they’ve been looking for and seek to fill the gaps.

You may find this to be a challenge, especially if pre-hospital care is not your forte. However, the benefits for the community – you, the volunteers and the constituents alike – will be huge. You will need to conduct research, refresh some long forgotten knowledge and perhaps step outside of your comfort zone – all great professional development benefits.

NT copy
Park rangers, resort staff, volunteer emergency services and local cattle station workers all training together at a Trauma Care Workshop in the Northern Territory

The volunteers will benefit from the networking and the opportunity to expand their base of knowledge via education delivered by a local healthcare professional.  This will lead to increased confidence within the volunteer group and therefore positively affect their willingness to commence appropriate clinical treatment (even when their primary role is not a medical one). The community will benefit by having local emergency responders who are better trained, more empowered and have increased resilience.

In the words of Mr Dylan Campher (from Queensland Health’s Clinical Skills Development Service), “Economy of scale is produced by having a single agreed model and adapting that to the local needs”. In other words, training and working together makes sense. There are some caveats though:

  1. Don’t expect to change the world overnight – believe me when I say that the wheels of change turn slowly in highly regulated environments.
  2. Don’t attempt to teach something that you have no credibility in – differentiate between what you know (based on experience, training and research) versus what you think.
  3. And perhaps most importantly, don’t ever discredit their previous training. Is it perfect? Probably not. But has it helped serve the community prior to your arrival? Absolutely!

Remember: fill the gaps, eliminate duplication.

That dark and stormy night …

All is not lost. It turns out that the volunteers in their various coloured suits have trained for this very incident – in fact, judging by their shared mental model, it appears that they have trained together!

They rapidly assess the scene and make it safe then apply a “zero survey” to you. This “zero survey” has allowed them to sort any oxygenation issues and expedite your extrication from the car using appropriate spinal precautions. They then applied all the relevant clinical interventions within their scopes of practice including binding your pelvis and protecting you from the elements; all you need now is for the volunteer ambulance crew to arrive on scene so that you can be taken back to work (no re-runs of Helicopter Heroes for you tonight).

You gaze up at the volunteer in the yellow / orange / white uniform and ask “Who are you people, and where did you learn to do all of that?” Her response? “We are just the local volunteers – and your predecessor taught us.”


The Post Script:

If you want to know more about the CareFlight Trauma Care Workshop then go here.

If you would like to know about the other clinical education delivered by CareFlight then check out this spot.

If you would like to keep up with where we are and what we are doing then consider following us on Twitter where we travel under @MyCareFlight_Ed

The image of the kangaroos was posted by Mando Gomez under Creative Commons and is unchanged from the original post. All those appearing in the other photos have given previous permission.


Reports from the Top End – The TriClinicians Cup

Recently the Aeromedical Society of Australia had their annual conference up in Darwin. This is the first of a few posts arising from people who got there – Dr Sam Bendall with a report from sim land. 

I love the way simulation brings people together. All aeromedical services use simulation as a training tool and that familiarity allows fun to be had and challenges to be set in the form of the 3rd annual ASA & FNA Simulation Cup.

The Getting Ready

It’s quite tricky putting together scenarios that will work for different team configurations and will be fun but enough of a challenge. We also had to be super careful to keep everything under wraps to keep it fair, so only 4 of us from NSW knew anything about it. I have enormous respect for my predecessor in organizing the Simulation Cup – Ben Meadley from Ambulance Victoria. He was unfortunately unable to make it this year but he was always on hand to provide guidance and advice in putting together this challenge. Thanks a million Ben! Kate Smith, the conference organiser, and her team were incredibly flexible and happy to work around the simulation craziness…. you want to what…. where ….. and with THAT??? allllrrriiight 🙂

Our logistics team was once again truly awesome – they are completely unflappable. Despite doing 3 training events in 2 weeks in different states, they not only transported several tonnes of gear to and from Darwin, but also helped in the scenarios and sorted out transporting it all back! Legends (and a double 🙂 for that).

We do a great deal of simulation at CareFlight and we are lucky enough to have some pretty cool toys, dreamed up and provided by our amazing Logistic and Events team. The newest addition to the stable is the NT crash car simulator. We have had version 1 and 2 in NSW for some time, but this one is new to the NT team so it had to have an outing.

It's cool and all but the engine could use some work.
It’s cool and all but the engine could use some work.

The Teams

Three teams competed in the heats – Cheah and his team from Malaysia (who did their scenario in English AND their native tongue), MedSTAR and CareFlight NT. The CareFlight NT and MedSTAR teams went through to the finals that were held at the end of the conference on Friday. Spectators grabbed a cold beverage and most of the delegates came down to support the two teams – a fantastic audience turnout.

Four members of the Northern Territory Emergency Service came to help out and add fidelity to the final scenarios. Gary and his team were happy to help out and be the rescue service in both scenarios. Many of the NTES folks have done the CareFlight Trauma Care Workshops so it was great to have another opportunity to train together.

Game Time

The first scenario saw the CareFlight NT team managing two patients in a Motor Vehicle crash. Their CRM was awesome and they were so calm it was amazing. They even found Chelsea, the puppy!

The second scenario saw the MedSTAR team managing a patient who was impaled on a construction site and bleeding heavily, and another injured construction worker. They too had great communication skills and did a good job of managing their patients. At the end of the day, the scores were close but the MedSTAR team was the winner on the day – NICE WORK TEAM 🙂

It takes an enormous amount of courage to get up in front of your peers and compete in a simulation challenge. It tests your CRM skills, your ability to function under pressure and your ability to treat patients as a team. Thank you to all three teams to stepped up to the plate. You are all incredible and it was a privilege to see you all in action.

Till next time …… bring on Queenstown (which btw, is my FAVOURITE place on earth!)…

QT copy

It Takes a Team

This entry could not pass without a big thanks to the following people who helped us out enormously with the Simulation Cup:

  • Kate Smith and her team – for everything!
  • Ben Meadley – for all his support and advice
  • Melinda Riall from Limbs and Things – provided the Suture Tutor prize for the Simulation Cup Final
  • Anthony Lewis – for providing an iSimulate unit for use in the scenarios
  • Stacey Williams from Zoll – for providing a defibrillator for use in the scenarios
  • NTES – Mark Fishlock, Gary and their team
  • The judges (some of whom were co-opted at very short notice – thank you J:
    • Mary Morgan – Hunter & New England Retrieval Service
    • Anthony De Wit – Ambulance Victoria
    • Paul Gallagher – NET
    • Andrew Pearce – MedSTAR
    • Emmeline Finn – CareFlight QLD
    • Andrew Duma – RFDS Sydney
    • Lachlan Beattie – NSW Ambulance
    • Lindsay Court – NSW Ambulance
  • Martin Dal Santo – CareFlight Logistics Team – he made EVERYTHING work!
  • Don Kemble – Manager Facilities and Logistics CareFlight – Enormously helpful with planning and logistics.
  • Ken Harrison – outstanding confederate performances – thank you
  • Richard Potts – AV guru from Kate’s team
  • Kellie Robertson, Danny Hickey and the AV team from the Darwin Convention Centre
  • Sarah and Ursula – fabulous coordinators from the DCC
  • Justin Treble, Elwyn Poynter and the rest of our fabulous education team – for all your help at the last minute making technology work and packing up!

Fidelity – can you have too much of a good thing?

Finally Dr Sam Bendall returns with another post on things educational. This time around it’s about how to focus on fidelity. You can read Sam’s earlier post right about here

The human mind is a complex machine. I am constantly amazed at its ability to “fill in the gaps” or create a reality. Like …. I was SURE I saw my keys on the bench this morning.

This is not a post about drug-altered states. (By Rob Gonsalves.)
This is not a post about drug-altered states. (By Rob Gonsalves.)

Fortunately for those of us who love simulation as a teaching tool, this amazing ability can be exploited to create realism in our scenarios.

So this then begs the question, if the most powerful simulator in the world is on top of your neck, capable of filling in many environmental deficits, how much external fidelity do we really need? I love Dr. Cliff Reid’s line: “Run resuscitation scenarios in the highest fidelity simulator in the known universe.. your human brain.” (you can check out the related talk here). So how do you get other people’s brains working for you in your simulation?

Searching High and Low

In doing a little research for this post, I was curious to see what others felt constituted high fidelity vs low fidelity simulation. In many sources it was simply to do with how technologically fabulous the manikin was. No mention of recreating key environmental stimuli. No mention of inserting the human factors elements that play out repeatedly in any microcosm. No mention of recreating other sensory or physical cues that affect the way we behave in any given situation and affect our decision making.

The über end of the spectrum is virtual reality – full recreation of the all the visual stimuli you would ever encounter in any situation, sometimes involving goggles. Maybe something like this Virtual reality “cave” simulator.

Now some folks may thing that is amazing, and in my humble opinion the graphics are amazing. But how often do you treat patients with goggles on and by waving a wand thing at a wall? If you do…. well there is olanzapine for that. Last time I looked we also don’t work in a three-sided 3m x 3m box.

Actually these are just this guy's sunglasses. [via]
Actually these are just this guy’s sunglasses. [via]
The Experiences Where You Gain Experience

So lets take a step back. Think about your most memorable experiences – positive or negative. What are the details of those experiences that caused them to be so strongly imprinted in your mind? Was it the smell? The fact that you were freezing cold? Was it to do with touch? Chances are, it was not just the view in front of you.

Now think back on the medical cases you remember. What is now stuck in your mind about them? Was it the sound of the pulse oximeter descending into the basement where hypoxia hides? Was it the conflict going on in the resus bay? Was it the difficulty you had getting a piece of equipment to work?

I put it to you that THIS is the stuff we remember. If we are using simulation as a teaching tool, we want our participants to remember what they learnt so that they can apply it when it counts. So we have to make it memorable. Perhaps we need to rethink exactly what fidelity means in simulation…

I am fortunate to work with someone I consider to be a master of simulation, Dr Ken Harrison. By making the smallest tweaks, he can add a whole new aspect to the scenario and increase the fidelity for the participants that little bit more. Usually the cost involved in making the scenarios highly memorable is about $0.

I did his scenarios many years ago as a participant in the CareFlight Pre-Hospital Trauma Course, the first of which ran as a trial in 2001 (not with me attending) after years before that of employing simulation in education.

I can still remember being cold. I can still remember making a cluster of our environment. I have never forgotten the lessons I learned from those as the necessary fidelity was there, even though the manikin was a Resusci Annie simulator, the monitor was a billion year old defibrillator and the Thomas packs we were using were generic. No lights, no camera, no creepy goggles. Just the cold of the ground reminding me to wear warm stuff on jobs, the difficulty in getting unfamiliar equipment to work (know your equipment) and the difficulty in getting to the head of the patient because of the tree we had centred quite nicely in our workspace.

These are lessons I have not forgotten and things I will not repeat. All this by simply setting up a scenario on the side of a moderate embankment that our minds turned into  a 100 ft cliff, on a chilly July day. Job done I reckon!

The Bits You Need to Stick

So in considering where to invest your money, time and energy in creating fidelity in your simulation ask yourself this:

What is it about this scenario that I want my trainees to remember vividly in six months time when they will really need it?

For example I want my trainees first and foremost to stay safe on the job. There are a variety of hazards in the pre-hospital environment, some of which will kill you. Like this one.

This is not a recommended way to remember where your car is. [via Springfield New Sun]
This is not a recommended way to remember where your car is. [via Springfield New Sun]
Do I need to connect the car simulator to a 12V battery to teach them to look out for power lines? No. I can bring that same learning point out with a much more subtle long fat piece of electrical wire across the simulation field (car/ building site etc.).

This means if they notice it – great! The didactic part around scene safety worked. If they didn’t, one of our confederates will draw attention to it and ask for it to be isolated. The realisation that they have all potentially been electrocuted because they didn’t look is pretty powerful. Fidelity for $9 from Bunnings. Awesome!

Similarly if they are working outside in the elements, train outside. There is no point doing a scenario in an air-conditioned classroom if you work in an aircraft that is usually around 40 degrees Celsius. Once you get used to working with sweat dripping in your eyes yours, your patient’s and your teammates temperature you are able to concentrate on the task at hand.

Alarms are another easy one. We are so accustomed to hearing that pulse oximeter beep. Most critical care practitioners have an operant response when that tone starts to decrease or the rate goes up. It makes us look around. It can also be really distracting if the volume is turned up too high and the general anxiety level goes up. Easy way to create a bit of stress in the environment.

Then of course there’s broken things. Not everything goes well on every retrieval job. Equipment malfunctions, patients crash, the aircraft become unserviceable. We need to train our training audience to think laterally and deal with these problems quickly when they come up.

Most retrieval equipment sets have redundancy. Bringing this in is a different example of  fidelity. Give them a scenario and make some key equipment stop working or not work at all and watch their response. If they have a methodical approach to using the “other” equipment then they are more mission ready.

Weapon of Choice

So in essence, choose your weapons wisely. I LOVE cool toys more than most. Give me gadgets any day. BUT if you want me to remember what you taught me 6 or 12 months later or even 7 years later in the aforementioned example, make it real. Make me own it, smell it, feel it, touch it, troubleshoot it, be anxious in it, be hot/cold in it and THAT I will remember. And building that type of fidelity into your simulation usually takes neurons but not too many dollars.



Why? How? What? Big Questions for Prehospital Simulation

At CareFlight another round of training many people is about to come up so it seemed like a good chance to ask Dr Sam Bendall for her first contribution. 

Sam is an Emergency Physician who is passionate about education, particularly all things simulation. She works half-time at Royal Prince Alfred Hospital in Sydney in the Emergency Department where she helped develop and teaches the RPA Trauma Team Training program, teaches on the CIN nurses programs and helped develop the ED Essentials program. 

At CareFlight she is a retrieval doc (the other half-time) and the Deputy Director of Education. The CareFlight Education Team are always up to interesting things – from training the Australian Defence Force medical on how to look after all things ballistic, medical, surgical and paediatric, to running the Pre-Hospital Trauma Course both in Sydney and other locations (Malaysia, anyone?), to running Trauma Care Workshops all over the country. Oh, and of course all those working with CareFlight too. 

Anyway, here’s Sam …


As a passionate advocate for simulation I look around and see this amazing tool appear in many guises, all under the same blanket term. It certainly seems to mean many things to many people depending on their previous experiences. In some ways it is the SWISS ARMY KNIFE   of kinesthetic education. The coolest knife has pliers and scissors. However, just like a Swiss army knife, it can be a harmful weapon (hence the name!), just plain useless (like when you want the one with pliers but you only have the single blade), or a bit uninspiring and encourage automatic behaviours – e.g. all Swiss army knives are red and you should have one.

This clearly rubbish version doesn't even have the magnifying glass.
This clearly rubbish version doesn’t even have the magnifying glass.

Simulation has almost become the learning apparatus du jour – everyone has to do it but some are not sure why or how to really make it work. A bit like having a Swiss army knife so you can be part of the Swiss army, but it lives in the drawer.

I will put a disclaimer in at this point. The following are my own opinions – the musings of a dedicated simulation-phile after several years of training in simulation and doing simulation exercises for anywhere from 2 – 150 people.

So what’s the point?

WHW copy                                            

I’m going to put a slightly different spin on it, with an emphasis on simulation for the pre-hospital environment. Simon Sinek, in his TED talk in 2009 titled “Start with Why” made a very powerful case for asking yourself WHY you want to do something… in this case, simulation, at the outset. The HOW and the WHAT will follow if you drill down onto the why and firmly establish WHY you want your participants to do simulation.

Simulation is a journey, for both the instructors and participants. Hopefully a journey towards some constructive learning, but one that will have many interesting twists and turns along the way. Being sure of WHY you are undertaking this part of the journey, gives you the freedom to explore the twists and turns of the journey without losing sight of the original intent. So my step 1 in building a simulation, is to ask yourself why? WHY are you doing this?

In our organisation, our WHY? is to create a mission-ready workforce.

Pre-hospital medicine throws out so many variables – communication, teamwork, environmental, situational awareness, medical challenges, geographical challenges and the list goes on.

In order to make our workforce mission ready, we need them to be critical thinkers, able to choose the right skill, equipment and approach for the right case at the right time.

Though if we had one of those shapeshifting Terminator ones could we program it to be friendlier?
Though if we had one of those shapeshifting Terminator ones could we program it to be friendlier?

We also need them to be aware of the variables they will need to deal with on real jobs so that they can manage them consciously. In order to do this we need to replicate as many of these variables as possible so they can address them in a training environment. We aim to send our participants out on jobs that feel just like the scenarios they have done in training. No pressure!

HOW? – choose your weapon

Weapon copy

The simulation menu is fairly extensive and limited only by your creativity and ability to structure it in a way that is true to the learning objectives and easy to follow for your participants. The key elements of creating a scenario, whether it be for 2 or 50 participants, is that they need to know the rules, boundaries, and premises for the scenario….. hmm sounds like parenthood!

So first decide on your structure. Is it an audience that is learning a concept for the first time and you need to do it for real, but slow it down? Well “pause and discuss” is your man. Do you need to see where your participants’ critical decision making is at and where the deficits lie? Immersive, relatively high fidelity simulation, with key variables built in, is the tool of choice.

Do you need to occupy 30 participants in a large scale simulation? – Create foci so the participants will need to form their own teams within the simulation. This will bring out all of the teamwork, communication and leadership points from the start.

Whatever weapon you choose, it needs to be appropriate to the audience, their experience and what you are trying to teach by doing the simulation exercise.

WHAT …the final frontier

Well this depends on what you are trying to deliver in your simulation. If, for example, your aim is to test and consolidate a new protocol, then the scale of your simulation can be quite limited. You may not need to bring in as many variables, or much fidelity. As long as the key prompts are there for the participants and they have the knowledge, skills and equipment to fulfill the protocol, then a limited scenario is fine.

BUT…. and there is a BIG but in this one. Be realistic in developing your scenario. If you are testing an ALS protocol, doing a bog standard ALS protocol with a patient in a bed may tick your box. BUT ….. in 20 years of medicine I think I have been to less than 10 arrests in ward beds and way more than 30 in other places – the toilet, the CT scanner, theatre, the foyer of the hospital, the waiting room, the beach etc. etc. You get the picture. So I would argue here that a bog standard ALS type scripted scenario has its place, but should be followed up by the application of the protocol where it is likely to happen and bring in the teamwork and communication aspects that we know actually make ALS protocols work in real life.

At CareFlight we educate using a “crawl, walk, run” paradigm.

  • First you crawl – i.e. you learn the skill or concept in isolation.
  • Then you walk – using relatively low fidelity simulation with limited learning outcomes, you learn to apply that skill appropriately.
  • Then you RUN. In our “RUN” scenarios, we introduce many more variables that replicate the environment they will have to operate in. We increase the fidelity and prompt the participants to evaluate the situation, decide whether that skill or concept is appropriate, apply it if it is or find an alternative if it is not. This layering approach helps to consolidate skills and knowledge and develops critical decision-making processes in a way that is directly applicable to the job we do.

When you get to the RUN scenario you are trying to bring out multiple learning points across many categories, for example:

  • Teamwork and communication (CRM)
  • Leadership skills (CRM)
  • Graded assertiveness and conflict resolution (CRM)
  • Scene safety and situational awareness (CRM, environmental and logistics)
  • Management of a multitrauma patient in an isolated environment (medical)
  • Packaging and preparation for transport (logistics, medical)
  • How to carry a patient out of the bush safely (logistics, medical)
  • Planning for contingencies e.g. weather etc. (logistics)

Then the scenario has to be much higher fidelity and be crafted in a way that replicates those key learning objectives – CRM, medical, environmental and logistic. You need to recreate the key environmental elements that will impact on the participants’ decision-making, bring in the key teamwork elements, replicate the equipment or types of equipment they will use and think about the team structures they will be given. Even simple tweaks to the scenario such as limiting access to the patient’s head, can improve the problem solving and CRM elements of the scenario so the devil is very much in the detail here. AND SO IS THE FUN …

Why yes that is a mobile rollover simulator that some clever people built ...
Why yes that is a mobile rollover simulator that some clever people built …