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The Importance of Accuracy in Moulage Training

bobbie merica

Perhaps no name is more associated with moulage in EMS than Bobbie Merica's.

Merica’s career in the field catapulted after her 2011 book, Medical Moulage: How to Make Your Simulations Come Alive. The book provides detailed step-by-step instructions on creating moulage and how to effectively train medical providers on scenario development using realistic patient simulations. She’s also the owner of Moulage Concepts Inc., a premier provider of hospital, trauma, mass-casualty and prehospital moulage training, supply and certification.

Merica is certified in biological/chemical/terrorism moulage and provides high-fidelity active shooter and bioterrorism scenario training. She designed and implemented the first in a series of 3D clinical wounds that can be triaged, sutured, debrided and drained, in addition to medical and trauma moulage kits and training courses specialized to the medical, military, veterinary and prehospital communities. She is an international speaker, works as a trauma moulage expert for state bodies around the country, is a contributing author at EMS World and is homeland security exercise and evaluation program-certified.

In this interview Merica discusses the necessity of implementing realistic moulage in medical training, particularly for first responders.

How did you get started in moulage, and what’s your background in the field?

I came to the moulage field from a business perspective, a time-equals-money approach. Simulation didn’t make it over into the hospital nursing arena until about 10 years ago, and I was part of a consortium that came together to create simulation at the nursing level, which would ideally reduce medical mistakes. At that time, because it was so new, nobody created their own interactive moulage simulations. Students were saying it just didn’t really feel real.

I did some research about what you could put on a simulator and developed a few different wounds in accordance with that. I created training processes that told students stories to move them forward in their training scenario. Because I’m a stickler for details, I studied how the wounds really looked in the clinical setting as opposed to a theatrical approach. It all came from watching surgical videos and reading medical manuals—seeing how the wound could be sutured, how it could be developed to meet specific training needs and how it was telling a story in real-life practice. From there I was contacted to write a book.

Even though I didn’t come at it from a medical perspective, it is still a book that approaches moulage from a clinical background. I conducted a great deal of research, because if you’re writing for medical or even tactical professionals, you need to understand their language and their training outcomes. People started learning more about my work, and I received contracts to develop wounds specific to their training outcomes.

At the training level, moulage wounds should really be telling a story that follows the pathophysiological responses. In training scenarios, participants should feel, “This makes sense to me based on my skill and training level; I understand what I’m seeing.” This is what a fresh bruise should look like; this is what a bruise looks like on every skin tone, because sometimes when a bruise is very fresh, it might not present at all. From a medical moulage perspective, we need to continously remind ourselves, "What does this wound look like based on medicine, science and our own experience?" It’s just about creating training that makes sense.

When you finished your book, were you satisfied with how it turned out and was received?

Yes. This book isn’t really like any others. It breaks it up by appropriate cases and diseases. It sets a complete stage so anyone at any point can come in and create a scenario regardless of their skill set. It breaks it up by the ingredients and equipment, and even tells you what an objective could be. Of course, that’s modifiable. You can use any methodology that you see fit for training, but it advises what you would find in a patient chart, the other different wounds that would exist, and quick options.

Step-by-step photos break it down so everyone can succeed. That’s been the other piece I’ve really tried to bring to the table: Moulage hasn’t had a standardization in place, and I’m working to change that. An open pneumothorax should look like an open pneumothorax and include accessory options such as frothy secretions, and it should be recognizable across the board to every single participant.  And it should be accessible; you shouldn’t be required to have artistic ability to create moulage that makes sense.

What steps have you taken to increase standardization?

We will be releasing a press release for a large event that will be happening. We’ve brought together an advisory board of people to review our work to put forth a standardization. I believe those aspects will assist in validating the training scenario, the process development and the importance of telling accurate stories in moulage. We’ve simplified it to an A = B = C process, which I teach across the country. I generally teach in classes of 20–35 students at a time because the process has really been sliced apart at every single level to create moulage that makes sense. We’ve developed capabilities regardless of the artist’s component, so it becomes usable to every training facility.  

Can you explain how clinical requirements of simulation affect the field?

Someone sent them to me on a website that had to do with the new NREMT training standards specific to the portfolio requirement involving comprehensive out-of-hospital care scenarios, and how moulage develops the nonverbal story in managing the call from beginning to end. When I first got into the field, moulage was sort of an afterthought. Because there were no specific requirements, even placing a sign on somebody saying blunt force trauma injury would suffice; occasionally they don't even utilize people. I have seen chairs with a triage tag hooked into it.

Now, the issue with identifying a diagnosis is a participant should know what to do going forward if they have those skills in place. But here’s the key component that I’ve noticed is missing from the whole equation: differential diagnosis—the ability for someone to misunderstand what they’re doing or what they see. Moulage assists with this; it provides sensory realism based on what you see, feel, hear and smell, and when thoughtfully incorporated, allows agencies the ability to understand where their strengths and weaknesses are. It also provides situational assessment opportunities that will assist agencies in aligning their future training dollars. And the simulation component and moulage aspect, done accurately, will assist you in telling those stories.

What advice would you give people who are looking to implement more realistic and effective moulage into training regimens?

It’s like anything else: You need to plan and prepare. When you develop your case scenarios, decide what the takeaway is going to be. Is it triage-specific? If so, then your wounds should accurately represent wounds related to triage. A lot of the time, people will throw in the moulage piece at the end without giving it any thought. They won’t collectively decide what the full-thickness burn is going to look like, what the pediatric patient will look like and how they’re going to present it. Locate an accurate picture on the Internet of an actual case. Practice creating moulage so that everyone in your training knows what these wounds will look like.

Mostly it’s about the planning. You’d never run your training scenarios without a great deal of planning. When you’re building those scenarios, start building in those moulage components. Understand what story you want to tell. Understand what the training outcome is. Is intubation with a full-thickness burn the outcome, or is it identifying the smoke inhalation? If the training outcome is smoke inhalation, then you don’t need a full-thickness burn. It’s not difficult to clarify that a full-thickness burn in the upper airway in the chest and neck has smoke inhalation. If you really want to know if someone has smoke inhalation, bring it back and test it in multiple areas. Create that eye-reddening, some tears coming down, the reddening in the back of the throat. That little bit of hoarseness. Break it out into multiple training avenues, unless intubating the patient with a full-thickness burn is the skill set.

That makes sense, especially going back to what you said about using moulage in less of a theatrical capacity and for mass-casualty incidents.

If it’s a mass-casualty incident, you’re going to have some people who look like those first-line-of-response people, but often a lot of those people look the same. Certainly you should assess the woman screaming and covered in blood, but you might also want to look at that person quietly dying right next to her. It’s about creating all those aspects and using this as a tool to define where those strengths are and, more important, where those weaknesses are so you know how to align future training dollars.

I think every person, every entity and every training site should have access to this level of training. Moulage doesn’t have to be expensive and time-consuming. You can have amazing moulage that tells the whole story, allowing you to spend the next six weeks accurately training your participants to meet outcomes, that will cost you pennies.

Are your products and training generally less expensive than competitors’?

Well, the training aspect is what makes it less expensive. I can show you how to make 10 bullet entries in 10 minutes for less than 50 cents a wound. That’s where we save you time and money. Some people say, “Hey, we have a big budget and just want the premades,” and our premades are beautiful, but it’s about being an absolute stickler for accuracy. Think about anything you’ve ever done incorrectly over and over that created bad habits. If you’re not doing it right, you’re training to not do it right. If you look at other industries that use moulage and simulation, like the military and flight simulation, they have such a high standard of accuracy. They would never allow you to train with things that are “close enough.” Preparation is always  about assessment, intervention, and management to events as they unfold—this is why we train.  

We can show you how to create very realistic and cost-effective wounds, something as simple as first- and second-degree burns that include blisters that are solid or that rupture, depending on the skills of who you’re training. Or recognizing that you have a pregnant woman who just came out of an MCI, and maybe she’s 32 weeks pregnant but ended up with first-degree burns over 25% of her body.

She may not actually realize she’s in preterm labor, and that’s a scenario you could easily put together in less than a minute that would cost you 10 or 15 cents. Moulage is the unique ability to bring multiple components together to tell accurate stories, to ensure we are providing performance opportunities that don't just decrease errors but also increase training experience and insight. Moulage and training realism is an important component, an investment we owe to the men and women who respond to our emergencies everyday; and it's the least we can do to thank them for their dedication.

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