Simulation: Making Real Out of Pretend

Arthur Hsieh // June 1, 2012

If you are an EMS provider, chances are that you have already participated in some type of reality-based training. Educators often use scenarios during initial EMS training, casting a fellow student as a "patient" and having other students act the role of care providers or bystanders.

You probably have also placed an oropharyngeal airway into a manikin head, and ventilated it with a bag-valve-mask. These training techniques are important; however, medical simulation is much more than just acting or using task training devices. It's all about making real out of pretend.

What is simulation?

Simulation can be defined as "the act of imitating the behavior of some situation or some process by means of something suitably analogous (especially for the purpose of study or personnel training)".1

In other words, a true simulation seeks to recreate a condition or situation that is as close to reality as it can be, without actually being real. In medicine, this allows the practice of skills or the evaluation of patients in a realistic but safe environment, without causing undue discomfort or creating unnecessary risk to the care provider.

Brief history

Simulation in education has its roots in the aviation industry, when Edwin Link created the first flight simulator in 1929, less than 30 years after the first airplane flight at Kitty Hawk.2

Link wanted to prove there was a safer and less expensive way to learn how to fly. In the medical profession, descriptions of physician level patient simulations began appearing in journals in the early 1960s, with the first description of Objective Structured Clinical Examinations (OSCE) described in 1975.3

Types of simulation

Implementing medical simulation can take one of three general formats:

  1. Standardized patients – Individuals are trained how to behave and react like a patient in a simulated environment. Many times these "patients" are actors, and are chosen based on their age, gender and sometimes real health conditions. The environment may be real, such as a true patient examination room. However, many times the simulations are played out in artificially constructed environments that are wired for sound and video recording.
  2. High fidelity human patient simulators – Technology being produced by companies such as METI, Laerdal and Gaumard include manikins that are beginning to look and behave like real patients. The machines can create the appearance of life by having the eyes blink, the chest move while breathing, and even "speak", either through a speech generator or through the operator's voice via a remote speaker placed inside the machine. The more advanced models can detect the administration of medications and insertion of advanced airway devices and their computer can create a realistic response to those procedures automatically and in real time.
  3. Software-based simulators – The computer gaming industry has dramatically changed our expectations of what virtual reality can look and feel like. Computer-based medical simulation such as ActivSim (McGraw Hill) uses a series of high-fidelity photos and real time reactions to the user's interventions to create a realistic decision-making environment.

Scenario versus simulation: What's the difference?

The key trait to simulation is not necessarily the materials used, but rather the philosophy behind it. The educator has to step out of the active role of teaching and into the more complex roles of facilitating and debriefing.

For example, in a straightforward scenario, the instructor often is the omniscient player – describing the scene, the appearance of the patient, the vital signs and such.

Because of this, students often act as barber poles, constantly spinning away from the "patient" and looking at the instructor for information, direction and both conscious and unconscious feedback to how well they are performing.

In a simulation, the actor looks and acts like the real patient, and knows how to respond to history questioning or a physical examination by the student. The room looks like a living room, kitchen or office space, complete with furniture, medication bottles and anything else to make the scene as realistic as possible.

When the simulation begins, the instructor removes him or herself from the situation and allows the student or team to engage directly with the situation. The event is realistic enough so that the students will feel like they are actually with a patient, with all of the stress and uncertainty that can accompany a real life situation.

The learning begins once the simulation is complete. The instructor conducts a debriefing, where the students are taken back through the simulation via a facilitated discussion.

A recording of the simulation can be played back to the students, helping to demonstrate a valuable teaching point and clarify anything that was said or done.

Each student has the chance to participate in the debriefing, bringing up additional teaching points or revising their own performance during the simulation.


While the full value of medical simulation is not yet understood, it is true that it is here to stay. As in other industries where mistakes can be fatal, medical simulation provides the ability to commit those mistakes safely.

As a result, practitioners can learn to be more accurate quickly and without fear of causing harm or pain to their patients, an ideal learning situation.


1. Princeton University. Wordnet: A lexical database for English. Retrieved 11/22/2012.

2. Rosen KR. The history of medical simulation. Journal of Critical Care 2008; 23: 157-166.

3. Lane JL, Slavin S, Ziv A. Simulation in medical education: a review. Simulation Gaming 2001; 32:297-314.


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