This week’s post is written by Dr. Cheryl ffrench. She is the Director of Simulation for the Department of Emergency Medicine at the University of Manitoba and is also one of the advisory board members for EMSimCases.
Emergency Medicine is Sensory
Emergency Medicine is a very sensory specialty. Walking into the resuscitation room, the appearance, sound and sometimes smell of the patient provides a wealth of information before introductions are even made. Recognition of the “sick” patient is something we strive to teach our residents and medical students. Simulation is an excellent tool to help teach core emergency medicine skills. The principles of crisis resource management are essential to the practice of emergency medicine and simulation provides us with an excellent tool to bring them to light. However when the simulation stem describes an 80 year old female patient in respiratory failure and the learners walk into a room to find a manikin that more closely resembles a 25 year old Arnold Schwarzneger, despite being asked to suspend their disbelief, their approach to the patient can’t help but be different. Similarly when asked to assess the trauma patient, the visual cues of finding the stab wound or open fracture help to re-enforce both their clinical skills and the simulation experience. Most manikins used in simulation today are large robust health males in the prime of their simulated lives. However, this does not reflect the patient population of most emergency practices.
Simple Fixes to Improve Realism
Simple measures can turn a “he” into a “she” like remembering to exchange the external genitalia and adding a simple wig. Suddenly the patient has a more feminine appearance that reflects the other 50% of our patient population. A grey wig can make him (or her) age to an extent but investing in some costume masks found at any party store can take the manikin’s healthy 25 year old skin and give the illusion of a face wrinkled by time. These masks fit most standard adult size manikins. The softer and more form fitting the mask, the nicer it is for the learner to work with when intubating but even the less pliable masks have little impact on airway management so long as they come with an open mouth on the mask.
Moulage in Trauma
The wounds and injuries that our trauma patient present with often dictate our index of suspicion for the severity of their illness and thus our level of concern. Seeing the bleeding wound in the centre of the chest or over the anterior neck raises a level of anxiety and serves as a constant reminder of the seriousness of the trauma. That is difficult to create if the learners are simply told by the confederate that there is a “big stab wound” or an “expanding hematoma” as these findings can be easily lost or forgotten without the visual reminder in the midst of a chaotic simulation case. Stab wounds can be easily added with some basic halloween “wounds” found at any halloween or party store. For the more creative, they can also be even more realistic though some simple techniques that are described at the end of this blog.
More Simple Adjuncts
The placement of a pregnant abdomen on the trauma patient provides another prompt for the unique management principles for that patient population. Place a fetal manikin in the belly and suddenly you have a perimortum csection case that will never be forgotten. Bubble wrap underneath the skin on the manikin’s neck creates the textile feel of subcutaneous emphysema which if also moulaged with bruising on the skin provides your learners with a frightening airway scenario that keeps most emergency practioners up at night. Moulage combined with either the use of preset vocals or some voice over acting will help to create a unique emergency medicine simulation experience that your learners won’t soon forget.
When applying makeup to Mannequin skins, it is important to first prepare the area so that the makeup does not stain the skin. Here are some helpful tricks, courtesy of Jane Fedoruk, a Simulation Technician at the University of Manitoba:
- Wipe the area for application with a thin layer of Vaseline or baby oil.
- Lightly wipe again with a dry cloth to remove excess oil.
- Apply makeup lightly and avoid rubbing it into the pores of the skin.
- Avoid putting the makeup on until as late as possible. Leaving the colours on for extended periods of time increases the probability of a stain.
- As much as possible, use only products provided or sanctioned by the mannequin company.
- Be particularly careful when using red or blue based makeup as they stain the most.
- Remove the moulage as soon as possible after use, and clean the area with mannequin cleaner to remove the oils.
All photos courtesy of Cheryl ffrench and Jane Fedoruk.