Team based Simulation

Leading a resuscitation team in the management of a critically unwell patient is an essential skill of an emergency physician, and this is assessed in the simulation station. Typical domains are Medical Expertise, Teamwork and Collaboration, and Prioritisation and Decision-making.

Important information about the Sim stations is found in the "OSCE Simulation Stations" document available on the ACEM Fellowship Examination Resources site.

The Sim station is usually in the context of the candidate arriving as the ‘Consultant in Charge’ to assist and lead the care of a patient in a dynamic and evolving situation as would occur if they were ‘called in to help’. Thus, candidates may be required to provide care at any stage of the patient’s ED journey where a ‘problem’ could occur.

It is likely you will be tasked with leading the resuscitation, and have a team of staff (e.g. a registrar and a nurse) to assist you. The confederates will be real ED staff (not actors), so will have some experience. Usually they will have instructions to follow commands, and have certain prompts to keep the station moving (“I can’t feel a pulse!”), but will have limited ability to prompt you. They are usually competent to perform most procedures under your direction, including cannulation, insertion of IO and intubation. Occasionally the confederates will ask you to confirm your instructions – this does not necessarily mean you have made an error, but would be normal practice in a real resus (e.g. most nurses will be expected to check a dose before it is given).

The simulated patient will respond like a real patient in that their condition will deteriorate or improve depending on their management. In acute cases, vital signs may change and you will be told of these changes. You may ask for vital signs at any time. Subsequent laboratory investigations will realistically reflect deterioration or improvement of the case. The response of a simulated patient to changes in therapy is usually more rapid than in real life.

You will be tested on both how you manage a clinical scenario and how you lead a team. Your communication and professionalism are just as important as your medical knowledge.

Some topics you should practise include:

  • Advanced life support

      • Shockable/Non-shockable rhythm

      • Special circumstances (pregnant, newborn, tox, hypothermia)

  • Post-resuscitation care 

  • Standard intubation – need to be slick at this – may form part of any simulation

  • Difficult intubation or Can’t Intubate/Can’t Ventilate situation 

  • Complications post-intubation e.g. cardiac arrest, hypotension, sudden hypoxaemia, trouble shooting ventilation problems

  • CVS emergencies e.g. cardiogenic shock, massive PE, tension pneumothorax, tachyarrhythmias (unstable wide or narrow complex); bradyarrhythmias (including pacing) 

  • Haemorrhagic shock (e.g. massive GIT, PPH) with Massive Transfusion Protocol activation 

  • Severe asthma

  • Anaphylaxis 

  • Seizures , including eclampsia

  • Precipitous birth, including PPH.

  • Trauma – e.g. severe head injury, haemo/pneumothorax, penetrating chest injury, severe pelvic trauma, abdominal trauma, spinal injury/neurogenic shock

  • Tox emergencies e.g. TCA or CCB overdose, snake bite

  • Paed scenarios – e. g. head injury, anaphylaxis, asthma, APLS, choking, seizures, septic shock, SVT, trauma, neonatal resuscitation

Typical tasks

  • Prepare the team for the arrival of a patient

  • Lead the team in the assessment and management of a patient

  • Lead the team in the resuscitation and stabilisation of a patient

  • Rapidly establish clinical priorities

  • Provide effective and timely interventions

  • Manage post-resuscitation care

  • Take a phone call to discuss referral at the end of the scenario

Domains that have been tested in recent OSCEs

Medical Expertise: Assessment

  • Seeks evidence of time critical diagnoses when performing assessment

  • Identifies important historical details (red flags) diagnostic of an important condition

  • Recognises signs on physical examination that indicate high risk of imminent deterioration

  • Creates a focused investigation plan that confirms or excludes time critical diagnoses

  • Correctly interprets the results of an investigation within the scenario.

  • Generates a relevant list of differential diagnoses after synthesising clinical information found on initial assessment

Medical Expertise: Management

    • Outlines an overall plan for resuscitating a patient

    • Correctly chooses time critical interventions based on assessment

    • Recognises and expedites any specific intervention essential to resuscitation

    • Adapts and initiates standard therapies to that patient, including drugs, fluids, gases, and monitoring

    • Anticipates and manages common complications during and after a procedure.

    • Identifies risks of deterioration in the patient

    • Presents the salient points about the patient’s care in a structured handover

Teamwork and Collaboration

  • Introduces self and purpose as duty consultant and team leader, performs introductions of team members and confirms roles and skills

  • Summarises the current situation, highlights important points and provides a management plan

  • Encourages open team communication by verbalising plan and inviting feedback

  • Issues instructions clearly and appropriately with a time limit for completion i.e. to specific team member/s

  • Uses appropriate communication techniques to negotiate an appropriate outcome for the patient

  • Shares the ‘mental model’ with the team e.g. summarises the current situation, states desired clinical endpoints, outlines plan and priorities

  • Presents the salient points about the patient’s care in a structured handover

Prioritisation and Decision Making

  • Highlights high-risk features identified during initial patient assessment

  • Summarises and prioritises the key issues that must be addressed during and following the emergency encounter

  • Prioritises chosen treatment options to create an appropriate escalating treatment plan

  • Provides a rationale to explain and justify decisions about ongoing treatment and disposition decisions

  • Makes safe and timely decisions for a complex or critical patient presentation

  • Anticipates and prepares for multiple potential problems

  • Demonstrates continued situational awareness with increased task loading.

  • Prioritises a differential diagnosis list to determine the most likely diagnoses in a patient

  • Manages multiple problems simultaneously by prioritising treatment options

ACEM OSCE report feedback

Common themes for candidates who performed well:

  • Appeared to have practised running a team in simulation

  • Demonstrated a considered plan for medical management

  • Managed the immediate issue, then recognised the need for second line therapy

  • Managed the team well and gave clear instructions in a calm manner

  • Provided a succinct and clear summary after the 6-minute mark

  • Provided a wider differential diagnosis

  • Assumed leadership and gave clear directions for stepwise use of strategies to manage the patient’s airway and ventilation.

  • Were organised with clear plan but were flexible to incorporate new information

  • Used multiple strategies to improve the patient’s condition and adapted these strategies to the specifics of the patient.

  • Demonstrated a structured approach to the management of the patient

  • Showed a high standard of ALS/defibrillator/resuscitation care, including reversible causes

  • Able to work very well with their team, perhaps as a result of ‘human factors’ such as use of names and encouragement

  • Knew the drug doses for paediatric resuscitation and the specific therapies for the overdose

Common themes for candidates who performed below expected level:

  • Inadequate medical knowledge

  • Did not read or apply the station’s Candidate Instructions

  • Did not address one or more areas of competing priorities

  • Became fixated on less relevant issues and consequently made poorly prioritised decisions

  • Lacked a well-developed differential diagnosis

  • Lack of stepwise, systematic approach

  • Did not know the correct second-line treatment

  • Failed to prioritise or adequately apply strategies to address both airway and ventilation

  • Said what they ‘would or might do’ but did not effectively act on or apply these strategies

  • Knowledge of common drug doses and equipment sizes was below standard.

  • Failed to adequately follow ALS algorithms or correctly identify the cause of the arrest

  • Demonstrated inadequate prioritisation at the start of the arrest

  • Poor team leadership and communication skills.


  • It is important you can place yourself “in the moment” to make this scenario as real as possible, as it will improve your performance.

  • Practise, practise, practise!

  • Film yourself as this will identify areas of weakness that you are not aware of

  • You should know and follow as closely as possible the most recent resus algorithms for adults and children.