Goodbye ‘Voice in the Ceiling’…

By: Victoria Brazil (@SocraticEM) ————————————————————————— It’s a scene we all know too well. A tense emergency department simulation. A patient clutching their chest lies on the trolley — a manikin, of course — as monitors beep and the team swings into action. A doctor calls for pain relief. A nurse is hastily attaching ECG leads. Everyone looks at the manikin. And then… it happens. A robotic, disembodied voice floats down from the ceiling speaker: “The patient is gasping for air.” Participants freeze. Was that… ‘God’? ‘Santa’? Was it the sim tech? The facilitator? Is the patient now gasping, or was that five seconds ago? Welcome to the uncanny world of simulation — where the Voice in the Ceiling tries to breathe life into a plastic manikin, and learners try to decode an experience that can feel more like charades than clinical practice. We’ve been reflecting on this in our own simulation programs. And — thanks to research from our Visually Enhanced Mental Simulation (VEMS) work — we’ve come to a surprising but satisfying conclusion: It’s time to say goodbye to the Voice in the Ceiling. So What Are We Doing Instead? We now put the facilitator — a real human — right in the room. Standing beside the manikin, facing the participants, narrating the patient’s clinical presentation in real time. They say things like: “He looks pale and sweaty. He’s clutching his chest and breathing rapidly — around 30 breaths a minute. His voice is strained as he tries to speak.” Instead of trying to make the manikin “act,” we describe what the patient is doing, sounding like, and looking like. No ventriloquism. No ceiling voice. No confusion about what the patient is experiencing. It’s a BRIDGE (Bedside Real-time Information Delivered by Guide Educator) and it’s already changing the way our learners (and faculty) engage with simulation. The facilitator bridges the gap between the manikin and the learner’s clinical brain. What Does This Look Like in Practice? Imagine a trauma call in the ED. A manikin arrives via ambulance, strapped to a scoop stretcher. The team huddles at the bedside. Instead of standing behind a one-way mirror or pressing “play” on a vocal prompt, the facilitator is right there; ‘completing the pattern’ of cues that the team are expecting to see and hear. “You hear him groaning softly. His left leg is twisted at an awkward angle. Blood is oozing from a scalp wound. He tries to sit up, but grimaces in pain.” As the scenario unfolds, the facilitator updates the team on the patient’s evolving clinical state — pulse thready, pupils unequal, response to analgesia — all spoken in human tones, grounded in the tempo of real patient care. And crucially, this narration isn’t a distraction. It’s context. It helps participants interpret vital signs, decide on interventions, and understand the urgency of the moment — without needing to guess what the manikin is meant to be doing. Why It Works Our VEMS research showed us something important: Manikins are confusing. Despite encouragement toward a ‘fiction contract’, learners struggle to reconcile the visual mismatch between a motionless plastic face and the rich, dynamic clinical scenarios we expect them to manage. And when we layer in clunky audio prompts or artificial “patient voices,” the cognitive dissonance grows. The result? Confusion, distraction, and — at times — disengagement. By embedding the facilitator and using rich, real-time descriptive narration, we reduce this friction. Learners stop trying to guess what the sim is telling them, and start doing what they do best: clinical reasoning and teamwork. But Isn’t that lower fidelity? We don’t think so. In fact, we’d argue this increases fidelity — not in terms of tech, but in terms of cognitive realism. Our goal isn’t to trick learners into thinking the manikin is alive. It’s to help them think like clinicians, make timely decisions, and act with confidence. This approach lets us focus on what matters: Clinical cues that drive decisions Shared mental models among the team Psychological safety by reducing ambiguity And yes — we still use vital signs monitors, blood pressure cuffs, and ECGs. But the facilitator is the bridge between manikin and meaning. Want to Try It? You don’t need a fancy setup to ditch the Voice in the Ceiling. Just try these steps: Pre-brief the expectations – “The facilitator will act as the BRIDGE in this sim, giving the cues you’d expect to have.” Put the facilitator in the room — positioned near the patient but outside the clinical “action zone.” Narrate the clinical cues — describe what the patient would be doing, looking like, and sounding like. Keep it brief, vivid, and in sync with the scenario. Use tech to support, not lead — monitors and moulage still play a role, but narration carries the weight of the performance. Debrief the difference — ask learners how it felt. Did they understand the patient’s presentation more clearly? Did it help or hinder their decision-making? This won’t be a universal solution. It won’t fit every simulation. But for many acute care scenarios — trauma, resus, deteriorating patient — it offers a simpler, clearer, and more human way to simulate. Goodbye, Voice in the Ceiling. It’s been real. Sort of… Photo generated by Chat GPT