Wound of the Month: Open Pneumothorax (Sucking Chest Wound)

Objective
Using moulage to create a realistic sucking chest wound (see Figure 1)

Time
15–20 minutes

Skill Level
Advanced

Supplies
(Find supplies and more at www.moulageconcepts.com.)

Flesh MoulageGel

Red MoulageGel

Bridal netting, clear, 1 inch × 1 inch

20cc syringe

Extra MoulageGel bottle

IV tubing

1 cup water

1 drop red food coloring

1 teaspoon dish soap

Equipment

20cc syringe

Bowl

Hotpot

Laminated board

Palette knife

Filter needle

Small paintbrush

Tweezers

Technique

Heat the MoulageGel to 140°F. On a laminated board, combine 10cc of flesh-colored MoulageGel with 10 drops of red MoulageGel. Stir the MoulageGel material thoroughly with the back of a palette knife to blend, creating a pink color. Allow the mixture to set fully before pulling up and re-melting in extra MoulageGel bottle for later use.

On the laminated board, create a thick, approximately 1/4 inch wide × 4 inch long, rope of fat, using the pink MoulageGel. (See Figure 2.)

Using a palette knife, create two 4 inch pieces of fat by running the palette knife down the center of the fat rope, lengthwise from end to end. Using the palette knife, cut both fat ropes in half, creating four, 2 inch ropes.

On the laminated board, create a small, approximately 1 inch diameter basic skin piece (base piece) using flesh-colored MoulageGel. While the skin piece is still in the sticky stage, center the bridal netting on the MoulageGel base piece.

Using tweezers, place a small, approximately 1 inch, circle of fat around the perimeter of the base skin piece, securing the pieces in place with flesh-colored MoulageGel. (See Figure 3.)

Using MoulageGel, secure additional pieces of fat along the inside perimeter of the fat rope, taking care to ensure the center remains clear of MoulageGel. Using the IV tubing as a guide, place tubing end side down, centered on the base piece. Begin filling the area around the IV tubing with additional “chunky” pieces of MoulageGel material that have been pulled from the fat rope and glued along the inside edges. Remove IV tubing from the base piece; let this sit approximately 3 minutes or until firmly set. (See Figure 4.)

On the laminated board, create a basic skin piece (crown) approximately 2.5 inches in diameter, using flesh-colored MoulageGel; let the MoulageGel sit approximately 1minute or until firmly set. Using the tip of your palette knife, cut an “X” in the center of crown piece. Carefully remove flaps from the “X,” creating an opening or hole that is slightly smaller than the perimeter of the fat on the base piece. (See Figure 5.)

Gently lift the crown skin piece off the board and place it on top of the fat and base skin piece, maneuvering it in place until fat protrudes through the created opening at the “X.” (See Figure 6.)

Gently pipe in extra flesh-colored MoulageGel material under the crown skin piece along the opening to fill in any holes or air pockets. Using your finger that has been dipped in hot water, smooth any air pockets or wrinkles from the surface of the crown piece.

When the wound is set, carefully lift the wound and flip it over, facedown, and add MoulageGel material where the base piece meets the crown piece to strengthen any weak spots on the underside. Smooth any ridges by dipping your finger in hot water and running over the heated gel. Flip the wound back over, face up, and allow it to sit at least 3-4 minutes or until fully set.

Using a filter needle, create a small opening in the center of the wound by forcing the tip of the needle down through the center and protruding from the other side. Carefully increase the size of the opening to approximately 1/8 inch by maneuvering the needle in a circular motion while applying light pressure. (See Figure 7.)

Working from the underside of the wound, gently push the tip of the tubing up and through the wound cavity, approximately 1/16 inch. Carefully secure the tubing in place by applying additional MoulageGel material around the perimeter of the tubing (do not occlude tubing) and along the underside of the base piece; let this sit approximately 2 minutes or until firmly set. (See Figure 8.)

Creating Sucking Chest Wound Mixture

In a small bowl, combine 1 cup of water, one drop of red food coloring and 1 teaspoon of liquid dish soap, stirring well to combine. Draw bloody mixture into the 20cc syringe and place the tip into the far end of the IV tubing. Apply pressure to the syringe plunger, pushing the mixture through the tubing until it has reached the underside of the chest wound. Add one drop of dish soap to the center of the sucking chest wound. Slowly apply pressure to the syringe, forcing the mixture up and through the tubing, creating bubbles from the sucking chest wound. Continue to apply pressure and retraction to the syringe plunger to regulate the force and consistency of bubbles through the wound.

Quick Fix

No time to make a wound? Remove the underside plastic on a pre-made stoma wound and gently feed IV tubing through the center. Using rubber cement or silicone glue, glue IV tubing to inside of stoma and allow to set.

Training Scenario

Dispatch: Medic 94 Respond Code 3 to MVA, unknown injuries. Highway 162, nearest cross streets, Canal & River Road. Sutter Fire responding. 0230 hours. Dispatch clear.

On Scene: Using a hammer, shatter a large piece of clear Plexiglas or thick plastic and carefully place the shards in a large bowl. Using a utensil, gently toss together blood gel and “glass” pieces, stirring several times to coat the edges in a random pattern. Place a wig on adult patient and using a large tooth comb, tease or tousle the hair to create a disheveled appearance. Carefully apply smaller bloodied shards to wig of patient; place larger shards on patients lap, car seats, floor and perimeter of vehicle. Using a makeup sponge or your fingers, liberally apply white makeup to the patient’s face, blending well into the jaw and hairline. Apply a small amount of light blue eye shadow to the area under the eyes to create dark circles. Using a large blush brush, liberally apply gray eye shadow to the cheeks, forehead and lips of the patient. Apply a light mist of sweat mixture to the chin, upper lip and forehead. Using MoulageGel and a small paint brush, paint the underside of the sucking chest wound and quickly adhere the wound face up to the skin of the patient next to their collar bone. Run the tubing to a bulb syringe under the shirt of the patient and attach in place with paper tape. Instruct patient to gently and slowly apply pressure to the syringe plunger, forcing the foam mixture through the wound opening with each breath.

Use in conjunction with abrasions; lacerations; hematoma; cyanosis, lips; cyanosis, nose; blood, fresh; blood, congealed.

Helpful Hint

Sucking chest wounds can be made in advance, stored covered in the freezer and reused indefinitely. Allow the wound to come to room temperature at least 5 minutes before proceeding to "On Scene."

Cleanup and Storage

Gently remove sucking chest wound from skin of patient, taking care to lift gently on the skin edges while removing the wound, tape and tubing from the chest area. Retract the plunger on a syringe to pull bloody mixture from tubing. Store chest wounds side-by-side—but not touching–to avoid cross-color transference, on a waxed paper-covered cardboard wound tray. Loosely wrap trays with plastic wrap and store in freezer. Bloody mixture can be stored, covered in refrigerator, indefinitely. Using a soft clean cloth or make-up remover towelette, wipe away the make-up and sweat from the skin of the victim. Return the larger bloody shards, wig (with imbedded shards) and bloodied clothing (stored in a plastic bag) to your moulage box for future simulations.

Visit Moulage Concepts at www.moulageconcepts.com for all your moulage supplies and training needs. Recipes are referenced from Medical Moulage—How to Make Your Simulations Come Alive by Bobbie Merica.

Bobbie Merica is the author of Medical Moulage: How to Make Your Simulations Come Alive, Moulage! Bridging the Gap in Simulation and Moulage Magic! Theatrical Tricks to Bring Simulation to Life. All works are based on her popular Moulage Mastery! Bridging the GapTM in Simulation workshops. She received her certification in Moulage-The Art of Injury Simulation; Biological/Chemical/Terrorism and WMD terrorism training through TEEX. Upon discovering the absence of moulage specific to a clinical/hospital setting, she designed and implemented the first of a series of 3D clinical wounds, moulage kits and courses that she teaches all over the country. She began her career as a simulation technologist with California State University, Chico, where her collaborative work in the development of the Rural Northern California Simulation Center earned runner-up honors in Advance magazine 2009 Best Nursing Team contest. She is a contributing author for EMS World and HealthySimulations.com, and medical moulage & trauma expert for the Bureau of Public Health Emergency Preparedness, AZ. She will be offering the Medical & Trauma Moulage Workshop for Simulated Clinical Experiences, August 29–31, at the Little America Hotel & Resort in Cheyenne, WY. For more information, visit www.moulageconcepts.com.

 

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