Advanced Medical Moulage: Logic, Materials, and Safety

Participant Management and Triage Strategy

• Grouping Participants by Experience:

  • New volunteers often arrive with a casual interest in "Halloween" aesthetics.
  • Experienced participants ("old hats") often have deep knowledge but may have faced challenges where they lacked support.
  • Distinguish between those who can function independently and those who require constant supervision.

• The Triage Ratio:

  • In mass casualty incidents, the injury distribution typically follows an $80/20$ or even a $5/80$ rule:
    • $80\%$ of injuries are minor, such as cuts and scrapes (low acuity).
    • A small percentage represents high-acuity, life-threatening wounds.
  • Strategy: Match high-acuity injuries with the most experienced providers to prevent less-experienced staff from becoming overwhelmed or constantly seeking guidance.

Strategic Value in Moulage Application

• The Scale of Time, Effort, and Cost:

  • Every makeup application must be evaluated based on its "worth" within the training context.
  • Scenario A (Low-Cost/High-Maintenance): An injury created with scar wax and a nose prosthetic may have minimal material cost but requires significant time. If the first responder squishes the wax during direct pressure, the artist must redo it, exponentially increasing the "time cost."
  • Scenario B (High-Cost/High-Effort): A complex prosthetic might take an hour to apply. While high quality, if that hour prevents $15$ other students from receiving moulage, the training value is diminished.

• Capacity Planning:

  • Applications must be balanced against the total patient count (e.g., treating $50$ patients in one hour).
  • Match the complexity of the makeup to the available timeframe and the specific learning objectives of the session.

Reference Material and Clinical Realism

• The "Morgue" Library:

  • Practitioners should maintain a digital "morgue" on their laptops—a collection of real-world injury photos for reference.
  • Active networking with trauma survivors can be a source of high-quality reference material. If a person shares an anecdote about a car accident, request the original photos of the injuries.

• Avoiding Artistic License:

  • Do not base makeup designs on other makeup applications ("makeup off of makeup"), as this leads to unrealistic deviations.
  • Example: Stab Wounds. A common artistic misconception is that tissue always extrudes. In reality, a clean, straight-on "in and out" wound often results in a "pucker" because skin tension pulls the edges back.
  • Example: Cyanosis. Students often imagine cyanosis as a bright "Smurf" blue. Real cyanosis does not look like a cartoon character; it is subtle and medically specific.

• Recommended Resource:

  • The War Surgery in Iraq and Afghanistan handbook provide excellent reference images for blast trauma and high-velocity injuries. This resource is often available as a free PDF via government/tax-funded domains.

Anatomy, Physiology, and Simulation Safety

• Clinical Accuracy:

  • Moulage must be anatomically appropriate. Placing a femur fracture on a forehead is a categorical error.
  • Consider tissue depth. A deep laceration on the forehead should not show significant fat because the subcutaneous fat layer there is minimal to non-existent.

• Educational Media Case Study:

  • The "Iranian bank robber gunshot" video is a notable educational tool. It documents a person with an olive skin tone progressing through the stages of shock, moving from Alert and Oriented ($A \text{\&} O \times 4$) to near death over eight minutes.

• Hygiene and Tool Maintenance:

  • Cream wheels must be discarded if there is any doubt about cross-contamination (e.g., double-dipping an applicator from a patient's face back into the pot).
  • Know the chemical properties of all materials to avoid permanently staining or damaging silicone mannequins.

Adhesives and Sealers

• Temporary vs. Permanent Adhesives:

  • Silpoxy: A permanent silicone adhesive. It will bond a hairpiece or prosthetic to a silicone-based mannequin forever. It should never be used for temporary applications.
  • Distinguishing between these is critical for equipment longevity.

• Makeup Sealers:

  • Ben Nye Vinyl Seal is a recommended product for ensuring makeup stays in place during rigorous simulation activity.

Support and Wellbeing for Victims

• Prebriefing Protocols:

  • Victims must be screened regarding clothing. Despite instructions, volunteers may arrive in expensive or new clothes that they do not want ruined by blood or cutting.
  • Verify footwear; moulage blood often runs down the body and can permanently stain shoes.

• Psychological Safety:

  • Perform a "pulse check" on volunteers. Some may have personal trauma related to the scenario (e.g., a person assigned a car accident scenario who previously lost parents in a real collision).
  • If a victim becomes distressed, remove the makeup immediately and let them leave without any sense of guilt.

• Physical Safety and Environmental Risks:

  • Victims are "baby ducks" and require constant supervision.
  • Check hydration, dietary needs, and temperature.
  • Hypothermia Risk: Even on a $100^{\circ}F$ day, a victim lying on a cold concrete floor in a factory can become hypothermic. Never sacrifice a participant's well-being for a visual effect.

Advanced Makeup Materials and Techniques

• Two-Dimensional (2D) vs. Three-Dimensional (3D):

  • High-quality highlighting and shadowing can make a flat injury appear three-dimensional.
  • Many cinematic injuries (e.g., Tom Cruise/Brad Pitt) are actually 2D applications that rely on light-hit and shading to simulate swelling and depth.

• Alcohol-Activated Makeup:

  • Industry standard for over $20$ years; highly expensive and durable.
  • Activation: Requires approximately $99\%$ Isopropyl Alcohol ($IPA$). Do not use anything lower than $91\%$.
  • Storage Warning: If the kit is closed while the alcohol is still wet, the pigments will act as a glue and bond the palette shut, potentially cracking the casing upon reopening.
  • Travel Note: When flying, $IPA$ must be drained as it is flammable. The labels on these bottles are often taped over because alcohol can dissolve the ink on the labels.

• Cream Makeup:

  • Easier for beginners but has drawbacks: it is highly transferable (smears) and colors become muted when set with powder.

• Prosthetic Fitting and Shore Hardness:

  • Shore Hardness: Terms used to describe silicone flexibility. Ratings include the "A" chart and the "Double O" ($00$) chart.
    • $00\text{-}20$ is a very soft, flexible silicone.
    • Higher numbers indicate harder, less flexible material.
  • Flat Mold Memory: Most prosthetics are cast in flat molds. Silicone has "memory" and wants to return to its original flat shape. If applying a stiff prosthetic to a curved area (like an arm or a large patient's abdomen), you are fighting the material's urge to flatten out.
  • Hairy Surfaces: To apply a prosthetic over hair, use a silicone-based adhesive to glue the hair down as flat as possible first. Add an extra layer of adhesive over the flattened hair to create a barrier before attaching the prosthetic.

• Gelatin Foundations:

  • Pros: Cheap, easy, and reusable.
  • Cons: Fragile and porous.
  • The Stuart Bray Method: Uses a mixture of sorbitol, glycerin, and prosthetic-grade gelatin. Unlike basic Nox gelatin, this professional recipe prevents molding or mildewing.
  • Sealing Requirement: Gelatin is an "open-cell" medium. If it is not sealed with a product like Ben Nye Vinyl Seal, it will absorb liquids. For example, blood sprayed on the surface can soak through the gelatin and stain the skin or the prosthetic itself, turning it dark royal red.

Questions & Discussion

• Question: What color is cyanosis in the mind of a student?

• Answer: Students almost always say "blue," but the practitioner must correct them, as it is not the bright blue of a "Smurf."

• Question: Are you a medical practitioner?

• Answer: (Negative response) The practitioner emphasizes that while not a medic, one must know "just enough A&P" to avoid placing injuries in impossible locations.

• Question: Is alcohol-activated makeup flammable?

• Answer: Yes, it is highly flammable.

• Question: If a participant is hairy, do you use hair gel to glue the hair down?

• Answer: It depends on the size of the wound. For small lacerations, silicone-based adhesive is used to flatten the hair first, then the prosthetic is applied on top. For very hairy individuals, it may be better to select a different volunteer.