Trauma Moulage

I recently volunteered as a moulage patient for an ATLS course at a local Level I trauma center. The nursing coordinator of the course happened to be a guest lecturer in my critical care class this past semester, so she took the opportunity to solicit volunteers. There were only 4 of us from a class of over 100 that agreed to help. Pretty poor showing in my opinion, but whatever. It turned out later that that we were actually paid $50 for helping out, a detail she purposely neglected to mention.

When I arrived at the hospital, I was immediately whisked off into make-up. They applied white theatrical makeup to my face and hands to simulate pallor, and some blue around my lips and fingertips to simulate cyanosis. Then a stab wound was constructed under my left arm, complete with copious fake blood.

I was then given my scenario to read over so I could effectively play the part of the victim. I was to play a young male whose wife had stabbed him with a large butcher knife. Immediately I recognized a problem--the wound was supposed to have been in the 3rd intercostal space at the mid-clavicular line, but they'd placed it under my arm, so it was more like the 6th or 7th intercostal space at the mid-axillary line. Enter the magic migrating wound, and after they'd already cut a hole in the side of my t-shirt!

As I read through the scenario I worked out in my head what my priorities for treatment would be for the patient--or rather I suppose, what I would anticipate the physician to order for the patient. I was pleasantly surprised to discover I pretty much nailed the scenario when I read through the answers at the end.

Essentially I would arrive at the hospital with a BP of 40/palp and a HR of 170 bpm. Additionally the EMT's were reporting a sucking chest wound and JVD. Given the wound location, my mind immediately leaped to three possible causes of the above symptom set--a tension pneumo, a hemo-thorax, or cardiac tamponade. I was most concerned about tamponade, but the other two aren't pretty either, and based on the basic ABC's they'd get addressed first. It turns out my thoughts were correct, and the patient (me) did indeed have all three issues.

When I got into the room for the testing phase of the seminar, I quickly realized that the docs taking the course were the brand-new, freshly minted first year residents coming on board starting July 1st. And that's when things got interesting, and a little scary.

I died the first 4 times.

Usually it was because an over eager doc stuffed an ET tube down my throat and hooked me up to a vent...with a tension pneumo. Once it was because the doc stood around and said, "Um..." a whole lot.

The residents made the same silly mistake over and over again. When they checked for responsiveness, I was instructed to moan. This was to clue them in that I indeed have an airway, and it was intact. However they didn't pick up on that, rather interpreting my moaning as unresponsive, requiring a GCS assessment that ultimately led them to my needing to be intubated. Granted, I was in bad enough shape that I would eventually end up intubated. Unfortunately, they missed some cardinal danger signs like tracheal deviation, decreased/absent breath sounds on one side, and, oh I don't know, a sucking chest wound.

So the course of care should have included a dart or needle aspiration for the tension pneumo. When my condition didn't improve, and breath sounds didn't normalize, a chest tube was in order. And then when vitals again didn't improve, even though breath sounds were equal, the resident would need to diagnose the tamponade. The scenario was set in a small rural hospital, so the residents didn't have access to an ultrasound machine for a FAST, and would have to rely on performing a pericardiocentesis instead.

I do have more educational background than the average nursing student, especially in "big picture" assessment. But it seemed these docs were missing things that I as a nursing student had been taught to watch for, and to assess. Either I'm getting one hell of an education, or some of these residents were a little slow on the uptake.

In all fairness, the other half of the residents I tested with nailed the scenario. Although the majority of them had trouble re-diagnosing the tamponade when symptoms returned as the pericardial sack refilled with blood. And almost nobody thought to attach an EKG lead to the needle to avoid puncturing the heart itself during the pericardiocentesis. Also, surely these first year residents wouldn't be unleashed on the unsuspecting public without supervision...right?

All in all I enjoyed the experience. It was fun and educational. I look forward to auditing the course myself at some point.