Full Instructor Guide

EM Evidence Sim · updated 10 October 2026

This guide explains everything an instructor needs to set up, run and debrief a scenario. New to the app? Start with the Quick Start Guide.

At a glance

A simulation uses up to three screens, all linked online by one six-character session code.

You drive the patient from the instructor screen. The room monitor shows the team only what they have attached. The defib tablet, if used, sends every press back to your event log.

Before the session

Allow 10 minutes to set up the screens and test them before the team arrives.

Equipment

All devices need an internet connection, and any up-to-date web browser. You do not need an account to run the built-in scenarios.

Pre-flight checklist

• Open emsimulator.com on the instructor laptop and note the session code
• Open the room monitor and tap Tap to Enable Sound if it shows (it only appears while the browser is blocking sound)
• Link the defib tablet, if you are using one
• Check the badge on the instructor screen reads Live and names the linked screens
• Load your scenario and read its brief
• Turn the room monitor's volume up and check you can hear an alarm
• Change one vital sign and check the room monitor follows

Session codes and linking screens

The six-character session code (for example K7PQ3M) links every screen in one simulation. It never uses look-alike characters (no 0/O or 1/I/L), so it is easy to read out. It shows at the bottom of the start screen and as "Session ID" in the top right corner during a scenario.

• Same code all day: one code can run any number of scenarios with the same group. The linked screens stay linked between scenarios.
• New code: open Connect patient screens on the start screen and press New code for a new group. Screens on the old code must join again.

Ways to link a screen

Checking the link: the badge in the instructor top bar shows the connection.

Hover over the badge to see each linked screen and when it was last heard from.

Choosing a scenario

When you open the app it asks What is this device for? Choose Controller on your laptop (a patient screen chooses Patient screen). The start screen then asks What do you want to run? with a card for each way to start; All options takes you back to the cards. The Scenario library covers most teaching; Defib Sim is for defibrillator skills and Ventilator Sim for ventilator skills. Setting up the patient screens is optional before you start: with nothing set up the app uses one screen, and Connect patient screens (or Screens during a scenario) sets them up whenever you are ready.

Human factors. Random and Builder can add a challenge: Blindfolded Lead, Silent Team, New Junior, Missing Kit or Distracted Senior. It shows as a badge on your screen so you can brief the right person.

Paediatric scenarios. WETFLAG starts hidden on the room monitor. Tick Show WETFLAG on Monitor from the start on the start screen (under the scenario options) if you want the team to see it straight away. You can show or hide it at any time during the scenario (see Paediatric scenarios).

The brief. Loading a library, random or saved scenario opens a brief before anything starts:

• Patient Brief: name, history, medicines and allergies
• Required Equipment
• Clinical Progression: how the scenario is expected to unfold
• Key Interventions the team should perform
• Guidelines & Resources
• Learning Objectives: what the debrief scores against

Press Start Scenario to begin, or Back to Setup to choose another.

Resume Previous? If the instructor tab was closed during a scenario, the setup screen offers to resume it. The app saves your progress every few seconds.

Scenario paused. Pressing Back during a scenario pauses it and returns to the setup screen, which shows Return to scenario. Press it to carry on where you left off, then START. Starting a different scenario replaces the paused one.

A tour of the instructor screen

The screen has a top bar, the patient on the left, and treatments and the event log on the right. Drag the divider between the columns to widen either side.

Top bar

Left column: the patient

Each grey bar is a section. Click its title to open or close it; a closed section shows a one-line summary. The app remembers which sections you keep open on that device.

Right column: treatments and the log

• Search finds any treatment by name or route (for example "IM").
• Tabs: Common, Drugs, Airway, Breathing, Circulation, Procedures, Investigations, Voice and Assessment. In Common, the scenario's Recommended actions sit at the top in an amber box.
• Voice: type what the patient says and press Speak; it is read aloud on whichever screen plays sound.
• Assessment: tick or cross Safe Approach, Team Leadership, Communication, CPR Quality, Defib Safety and Re-evaluation as you watch.
• Event log (bottom): always on screen; see The event log, notes and flags.

Simple and Full view

Simple is the default and is remembered on each device. It hides:

• the drug-timing detail lines in Drugs on board
• the "+ Invasive" button that attaches IV access, an arterial line and capnography in one go (the separate buttons stay)
• the pH and K+ tiles
• the defib's shock-response settings and "Next shock converts to" (one line shows what is set; click it to switch to Full)
• the Quick Sim preset list (a preset that is running stays on screen)

Nothing is removed in either view.

On a phone, the obs tiles, rhythm, clock and START/PAUSE sit at the top, and the page scrolls.

Running the patient

You mirror what the team does: they act in the room, you press the matching control, and the patient and room monitor respond.

Monitoring and access

The room monitor only shows what the team has attached. Open Monitoring & access to see a chip for each item.

• Click a chip to attach it (○) or remove it (●). Removing one blanks its trace and number on the room monitor. Every change is logged.
• Attach puts on the standard four: ECG, SpO2 probe, NIBP cuff and temperature probe. Capnography, the arterial line and IV access are separate, deliberate steps.
• Remove all takes every monitor off. IV access stays, because it is a route, not a monitor.
• POC glucose and POC VBG take a one-off reading at that moment. Click again to take a new one.

Vital signs

Your tiles always show the patient's true values, even when the team cannot see them; "not on monitor" means the team cannot see that number yet.

1. Click a vital's tile.
2. Type the new value. For ETCO2 you can also pick the capnogram shape: Auto, Obstructive, Force normal, Rebreathing or Curare cleft (see Capnography).
3. Under Get there, choose Now, 30 s, 2 min or 5 min for a gradual change. BP starts on Now; everything else starts on 30 s.
4. Press Confirm. For BP there are two buttons instead (see below).

A heart rate you set yourself is kept if you later change the rhythm. ARREST and ROSC reset it.

What you type wins over treatments already given. For example, with high-flow oxygen on, setting the SpO2 lower takes it lower and keeps it there; the oxygen no longer pushes that number up. Treatments given afterwards act as normal.

Blood pressure

Changing the BP never sends it to the team by itself. The room monitor and the defib tablet keep showing the last cuff reading until the cuff cycles, as in real life. The cuff cycles when the team presses Cycle on the monitor or NIBP on the defib, when you press Cycle NIBP Now, or every 3 minutes while auto is on.

When you set a BP with Now and the cuff is on, you choose:

• Change, don't send: the patient's BP changes now. The team sees it the next time the cuff cycles.
• Change and cycle cuff now: the BP changes and the cuff starts measuring straight away. The cuff noise plays and the new reading appears after about 5 seconds.

If you pick 30 s, 2 min or 5 min instead, the BP drifts to the new value and the team sees wherever it has got to at the next cuff cycle.

Auto NIBP: on/off, next to Cycle NIBP Now, is the same switch as Auto on the room monitor: the cuff measures every 3 minutes. Like everything else it waits until you press START. An arterial line, once attached, shows the BP continuously. Manual Reading shows a one-off cuff reading on the room monitor without changing the patient (for example a spurious reading).

Capnography

Once capnography is attached, the room monitor draws the capnogram at half the speed of the ECG, as some defibrillators do. Several breaths fit on screen, and each one is wide enough to read its shape. The height of the plateau always matches the ETCO2 number.

The ETCO2 control (tap the ETCO2 tile) chooses the shape: Auto, Obstructive, Force normal, Rebreathing or Curare cleft.

Treatments and drugs

Find the treatment by search or tab and click it. The app then:

• logs it with the time
• applies its effect over a realistic time course: onset, peak and wearing off
• shows it in Drugs on board with its phase (for example ONSET), strength and time left
• for infusions and oxygen, keeps it running until you click it again; use + and − in Drugs on board to change an infusion's rate

If the team gives a drug before its prerequisite (for example an IV drug with no IV access), the app records a safety flag. Child doses follow the RCUK paediatric guidance (see Paediatric scenarios).

Investigations

The team can tap 12-Lead, VBG, CXR, Urine, POCUS or CT Head on the room monitor to see results. From the Investigations tab you can also send a result yourself:

• Scenario finding: the scenario's own result. The box under the button shows what it says (and its image) before you send it.
• Results with a real image: real X-rays, CT scans, 12-lead ECGs and ultrasound images, each with a written report. Untick Show the written report with the image to send the image alone, so the team has to interpret it.
• Written reports without an image, or a result you type.

In Quick Sim and Defib Sim, Investigations: send or change lists every result with a purple Send button, so you can put any result on the patient screens whenever you choose.

On the room monitor an image appears with its report; tap it to fill the screen. Many scenarios now come with their own real image (for example a tension pneumothorax, subarachnoid haemorrhage or anterior STEMI). When the team taps 12-Lead in a scenario with a real ECG, they see that ECG while the patient is still in that rhythm; after a change of rhythm (for example into VF) the monitor draws the 12-lead from the live rhythm instead. The images are real, openly licensed clinical images from Wikimedia Commons; their authors are credited under each image and on the image credits page.

Deterioration

Patient condition shows the mode:

• AUTO: the patient gets worse on their own, at the rate the scenario sets, unless the team treats them.
• MANUAL: the obs only change when you change them.

Better and Worse move the patient towards the scenario's improved or worsened obs over 30 seconds, in either mode. In many scenarios, giving one of the key treatments starts the improvement by itself, and the log says "Patient condition IMPROVING".

Quick Sim has no scenario, so it leaves out treatments, drugs, deterioration and scoring. Its right side holds the full rhythm list, presets (Full view), Better and Worse, and the event log.

Arrests, rhythms and the defibrillator

All rhythm and resuscitation controls are in the Rhythm & resus section.

The panel under these buttons shows the current rhythm (marked shockable, sync cardiovert or pulseless), the number of shocks, total and last energy, and whether CPR is running.

Using the defib panel on your screen: choose the energy (the recommended energy is marked), then Charge and SHOCK. SYNC switches synchronised cardioversion on and off. CPR start/stop and Rhythm check +2m (jump forward two minutes) are there too, with the CPR cycle timer.

What a shock does. By default a realistic model decides: the energy, the rhythm, whether CPR is running and the drugs given all count. In Full view you can override it:

• Next shock converts to: the next shock gives exactly the rhythm you pick.
• Shock response: converts on the 1st to 5th adequate shock, never (refractory), Auto or the realistic model.
• Unsync shock with a pulse: whether an unsynchronised shock into a perfusing rhythm causes VF (never, sometimes or always).
• After ROSC: whether VF comes back.
• Cardioversion succeeds at: the lowest energy at which cardioversion works.

When a shock converts the rhythm, or fails to, a pop-up tells you on your screen only. The team never sees it.

Learner defib on a tablet. For defib skills with a real-looking device, use the defib tablet (see Running a Defib Sim). It works in a normal scenario too: join the tablet as a patient screen (the QR code in Screens), then tick only Defib for its number.

Running a Defib Sim

In a Defib Sim the learner works a defibrillator on a tablet, and you run the patient from the Defib controller, which replaces the normal instructor screen.

Setting it up

1. On the setup screen, choose the Defib Sim card.
2. Choose the mode:
   • Education: the defib shows pulse-check results and RCUK hint cards.
   • Assessment: no pulse-check results or hint cards, as on a real defib. Feedback comes in the debrief.
3. Choose a scenario: Ventricular Fibrillation, Pulseless VT, VT with a pulse (unstable), SVT with life-threatening features, Fast AF with life-threatening features, Complete heart block, Symptomatic bradycardia, Free play (starts in sinus rhythm; you change it), or Custom scenario.
4. Check age, weight and sex. A patient under 18 gets the paediatric hint cards, energies and drug prompts.
5. Press Start Defib Sim, then link the tablet with Join (QR code) or Open defib.

Hover hints. On the defib, resting the mouse on any button or display shows what it does (keyboard focus shows it too). On a tablet a tap just presses the button, with no hint. The hints describe the controls only, so they show in Assessment as well.

Custom scenarios run a sequence of up to five rhythms. Each step moves on at a trigger you pick: on analyse, on shock, on pacing capture, or after 30 s, 60 s or 2 min. Save, Load, Export file and Import file keep sequences on that device or share them. During the run, Next step and Restart sequence let you move it on by hand.

The clock. It starts when you press START, or by itself at the learner's first press on the defib. A banner warns you while it is not running. If you PAUSE, presses are still logged but the clock stays stopped until you press START.

The Defib controller

Closed sections show a one-line summary, for example "Never converts · cardioversion at 200 J".

How shocks resolve by default. Defib Sim uses Auto: an arrest converts on the third adequate shock, and a cardioversion on the first adequate synchronised shock. "Adequate" means at least 150 J for an adult (3 J/kg for a child) to defibrillate, and 75 J (1 J/kg) to cardiovert. These thresholds are simulator settings, not guideline values. An unsynchronised shock into a rhythm with a pulse causes VF.

Pacing captures electrically at the scenario's threshold (it varies by up to 15 mA each run) and gives a pulse about 10 mA above it. Demand pacing is inhibited by a faster native rate.

Debrief. The debrief lists good practice and areas for improvement: pulse checks, mode, SYNC, energies, time to first shock, drug timing, sedation before cardioversion, analgesia for pacing and capture. Certificate prints a certificate of completion.

The ventilator and Ventilator Sim

The simulator includes a transport ventilator: the same device as the standalone ventilator trainer. It works in any scenario, and Ventilator Sim builds scenarios around it. The physiology is a teaching model, not validated physiology.

Where the candidate uses it

• On the room monitor tablet. In the controller's Ventilator section, press Show the ventilator on the patient screens (Ventilator Sim does this for you; the same button then reads Take the ventilator off the patient screens). The candidate can flip between the ventilator and the obs without stopping it. The defib and the ventilator share that screen, so opening one closes the other.
• On its own tablet. Join the tablet as a patient screen, then in Screens tick only Ventilator for its number. Monitor, defib and ventilator screens can all run at once, in sync.

Starting a Ventilator Sim

1. On the setup screen, choose the Ventilator Sim card.
2. Choose Education (the ventilator shows its alarm troubleshooting help) or Assessment (no help on the screen; feedback in the debrief).
3. Choose a scenario: AECOPD (start NIV), cardiogenic pulmonary oedema (CPAP), obesity hypoventilation (NIV), ARDS (lung-protective ventilation), severe asthma (intubated), after RSI in the ED (set up from scratch), troubleshooting (DOPES), mucus plugging (bronchoscopy teaching) or interhospital transfer. Intubated scenarios start with the tube recorded and the patient sedated and paralysed.
4. Press Start Ventilator Sim. The ventilator opens on the room monitor; link a tablet instead if you prefer.
5. Press START when the candidate begins, so the event log, the obs graph and the debrief have real times.

The full instructor screen is available, with the scenario's brief at the top of the Ventilator section and its likely treatments in Recommended actions: needle decompression and finger thoracostomy, bronchoscopy, suction, sedation and paralysis, nebulisers and the rest of the treatment list. Re-running the same scenario gives the candidate a fresh ventilator.

What the ventilator does to the patient

While it is ventilating, SpO2 follows the oxygen and PEEP, CO2 follows the ventilation and settles over 3 to 5 minutes, the RR is the ventilator's rate, and low SpO2, high CO2 and air trapping change HR and BP. This happens whether or not the clock is running, and not in a cardiac arrest. Any obs you type yourself stay as you set them until you press Release to ventilator; I set them turns the link off altogether.

Controlling it

Anaesthetics / ICU: the anaesthetic machine and the ICU ventilator

The Anaesthetics / ICU card asks which Machine: the anaesthetic machine (the default) or the ICU ventilator. The anaesthetic emergencies run on either; the ICU ventilation scenarios run on the ICU ventilator.

The anaesthetic machine is a recreation of an anaesthetic machine: it starts switched off. Press On / Standby; the Standby page shows whether the system test and leak test have been passed today. The tests need the Y-piece sealed on the circuit plug (touch the Y-piece beside the bag) and the APL valve set (not at Spont), and fail with a leak (the circuit leak problem). Start... then the rotary knob starts therapy; Quick start Man/Spon starts hand ventilation at once. In Man/Spon, press and hold the bag to give a breath: the APL valve sets the pressure limit, and left closed with a high fresh-gas flow the bag fills and the airway pressure climbs ("Airway press. continuously high"); Spont opens it. The ventilator modes are on the tabs along the therapy bar (VC - AF, VC, PC, PSV, with SIMV/CMV). As on the machine, touch a setting (yellow), turn the knob, and press the knob to confirm: a change that is not confirmed within 15 seconds is dropped, and a new mode shows in light green until the knob confirms it. The fresh gas (Air or N2O, FG O2, FG flow), the sevoflurane vaporiser, O2+ and the emergency O2 (Aux. O2 / Add. O2) are all simulated: the inspired O2 rises slowly at low fresh-gas flows, and the gas field shows the inspired and end-tidal gases and xMAC (set the patient's age in the Start dialog). The screen areas, setting names, ranges, start values, alarm texts and priorities follow the manufacturer's instructions for use; the layout, colours, the hardware arrangement, the gas model and some alarm wording and delays are the simulator's. The controller's remote control works as for the other ventilators; on the anaesthetic machine its O2 button sets FG O2 to 100%.

Hints and the guide on the anaesthetic machine. Resting the mouse on any control, display or part of the hardware shows what it is and how to use it (on a tablet, a tap simply presses it). In Education, a Guide column beside the machine says in plain words what is happening (the mode, the breaths, the gas, the tidal volume per kg, why an alarm is showing and what to check) and has How do I… step-by-step help, for example changing mode to PC-SIMV: it outlines the next thing to touch and ticks off each step. The candidate can hide it with its Guide button; it is not shown in Assessment. The hint and guide wording is the simulator's own teaching text, not the manufacturer's.

The ICU ventilator:

The Anaesthetics / ICU card uses a recreation of an intensive care ventilator: a widescreen display with the main controls along the bottom and the keys below the screen. It has everything the transport ventilator page has, plus volume-controlled (S)CMV and SIMV with an inspiratory pause (so Ppeak and Pplateau separate a resistance problem from a compliance problem), wider ranges, and the ICU ventilator's names for the adaptive modes (APVcmv, APVsimv). Start it like Ventilator Sim: pick Education or Assessment, a scenario, then Start ICU ventilator scenario (or Start anaesthetic machine scenario on the anaesthetic machine). A ventilator tablet joined to the session moves to the chosen machine by itself.

Anaesthetic emergencies (listed first) follow the Association of Anaesthetists' Quick Reference Handbook (QRH, June 2023 edition), with the guideline number in each name: cardiac arrest under anaesthesia (2-1), desaturation after intubation with an endobronchial tube (2-2), high airway pressure (2-3), bronchospasm (3-4), anaphylaxis at induction (3-1), hypotension and bradycardia after induction (2-4, 2-6), malignant hyperthermia (3-8: CO2 production starts at twice normal, dantrolene brings it back; you raise the temperature) and oxygen and power failure (4-1, 4-2). For the anaphylaxis and hypotension scenarios, set Patient condition to Auto for a patient who worsens until treated. The theatre drugs added for them are ephedrine, glycopyrronium and IV adrenaline 50 micrograms. The scenario text and effect sizes are the simulator's and should be checked by the facilitator.

Debrief. Any session that used the ventilator gets Ventilator feedback: when ventilation started, the pre-use check, alarm limits, tidal volume per kg of ideal body weight, plateau and driving pressure, AutoPEEP, SpO2 time in target, and when each problem was injected and how long it took to fix (for example "fixed 2 min 10 s later"). A Ventilator Sim debrief is headed with the scenario and its mode and is not scored against learning objectives. The targets are the simulator's teaching targets for each scenario, not a guideline: the troubleshooting scenarios (DOPES, mucus plugging, transfer) accept up to 8.5 ml/kg, the tidal volume the ventilator starts on, while ARDS and after RSI keep 6 to 8 ml/kg.

Paediatric scenarios

Child scenarios follow the Resuscitation Council UK (RCUK) Guidelines 2025: the Paediatric advanced life support and Paediatric cardiac arrhythmias algorithms, and the Paediatric emergency drug chart.

WETFLAG. The brief for a child scenario shows the WETFLAG values worked out from the child's weight. If you do not give a weight, it is estimated from age using the RCUK chart. WETFLAG starts hidden on the room monitor. To show it to the team, press Show WETFLAG on Monitor in the Rhythm & resus section; press Hide WETFLAG on Monitor to take it away again. To have it showing from the start, tick Show WETFLAG on Monitor from the start on the setup screen.

Doses during the scenario. When the team gives a drug to a child, the log shows the weight-based dose (for example atropine, adenosine, amiodarone, buccal midazolam, levetiracetam, 10% glucose and calcium gluconate). IM adrenaline for anaphylaxis follows the age bands. Tools → Drug calculator works out doses for any weight.

Shocks for a child. Defibrillation is 4 J/kg. From the 5th shock in refractory VF or pulseless VT, up to 8 J/kg is accepted without a flag. Cardioversion starts at 1 J/kg and doubles up to 4 J/kg.

Newborns. Newborn scenarios show the Newborn life support steps (Guidelines 2025) as prompts in the log.

The event log, notes and flags

Everything that happens is logged with its scenario time: treatments, obs changes, rhythm changes, shocks, monitoring on or off, and your notes. The log feeds the debrief.

• Where: the Event log section at the bottom right of the instructor screen, newest first. It stays on screen throughout. Full log (or Tools → Full simulation log) opens the whole log.
• Add a note: type in the box under the log and press Add note, for example "Team leader identified".
• Add a flagged note: type the note and press Flag instead.
• Flag an existing entry: click the small flag beside it. Click again to remove the flag.

Flagged entries appear in the Flags and warnings row of the debrief graph, so you can find the moments to discuss.

Safety flags count sequence deviations: actions done before their usual prerequisite was in place, such as an IV drug before IV access. Nothing is blocked; the team can still do it. When there is at least one, an amber Safety flags button appears in the top bar. It opens the list, with arrests, shocks and your flagged moments shown separately as significant events. Safety flags are not used in Quick Sim.

Finishing and the debrief

Press Finish (or F) and confirm. The debrief opens on your laptop only. The room monitor shows "Simulation complete" and asks the team to turn to you, with no score or diagnosis.

Pressed Finish by mistake? Back to scenario, at the top of the debrief, returns to the same run, paused, and the patient screens come back with it. Press START to carry on.

Quick Sim has no scenario, so it has no score; the graph and the log still work.

The obs graph

Every version (a full scenario, Quick Sim and Defib Sim) finishes with the same graph, Obs, interventions and changes. It shows the patient's true obs every 5 seconds over the whole session. What the team could see depended on what was attached.

• Rhythm along the top. Time without a pulse is red, and the same red shading runs down every chart below.
• One small chart each for heart rate, blood pressure (systolic and diastolic), SpO2 and respiratory rate. ETCO2 is added while capnography was attached. Temperature, glucose, pH and GCS are added only if they changed.
• Numbered markers underneath, in four rows: Rhythm, arrest and shocks; Team actions and treatment; Facilitator changes (the obs you changed or trended, with the values before and after, the patient's voice, presets, and the ventilator problems, lungs and settings you changed); and Flags and warnings. Markers that would overlap share one label, such as "5 +2".
• What happened, under the graph, lists every numbered marker with its time. Click one to mark it on the graph.
• Move the pointer over the graph, or click it and use the arrow keys, to read every value at that moment.
• Show the obs as a table lists the values every 30 seconds.

The graph records while the scenario clock runs. Every mode opens not started (the controller says "Not started: press START"): nothing about the patient changes until you press START, and anything given before then is recorded and starts acting when you press it. In Defib Sim the clock also starts at the learner's first action on the defib, and in Ventilator Sim when the ventilator first breathes for the patient. Press START at the beginning or there will be no graph. The graph is kept if you reload the page and resume, and it is in the printed and downloaded report.

Keeping a copy

• Download PDF saves the debrief as a PDF you can open on any phone, tablet or computer, including the log and your instructor notes. Write your notes before you download.
• Print opens the report ready to print or save as PDF.
• Certificate (Defib Sim only) asks for the learner's name and prints a certificate of completion.

Exit to Menu returns to the setup screen. The session code and any linked screens stay the same, ready for the next scenario.

Tools, sound and shortcuts

The Tools ▾ menu in the top bar holds the extras.

Room monitor timer. Show Timer, above the waveforms, puts a timer on the room monitor that you start and pause from your screen. It is useful for the team's own timings.

Keyboard shortcuts (they work straight after you click a button, except Space, which then presses that button again; they do nothing while you are typing in a box or a pop-up is open)

Troubleshooting