# Studies of moulage as EFFECTIVE training adjunct?



## mycrofft (Sep 27, 2011)

I am seriously looking for any *published studies* (_not testimonials_) about using moulage as a training adjunct and its positive negative or neutral impacts upon real learning. Can anyone give me some citations? My focus is upon makeup-style moulage, but any types of moulage will be considered.

This is to support or undercut my proposition that most moulage as we use it is not an effective use of resources _*vis a vis*_ actual learning. It is fun, it lends an overall sense of reality to those who have never seen the real thing, it is not cheap, it requires man hours to do and clean up and maintain, and the best moulage can only approximate what the real thing looks like which it represents. It also is of little value in treatment of much except soft tissue trauma, and for triage (sort of).

(I am in favor of moulage which mechanically challenges treatment, especially embedded foreign objects, open fractures, protruded eyes, but these can be represented by strap-on appliances or primitive moulage).


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## EMSrush (Sep 27, 2011)

I'm sorry, I don't have any published studies, but I do have a comment to make, albeit unhelpful to you.

I just did my PHTLS class with moulage. It was hard enough to keep a straight face while trying to assess my co-workers. It was worse when I asked what all "the white crap" was on someone's face. I was thinking some type of chemical residue, or something. I could barely contain the giggles when I was told that it was pallor. 

I have also attempted to treat a popsicle stick impalement, before finding out that it was supposed to be an open fx. Moulage tends to encourage folks to look for the moulage, as opposed to doing a proper assessment and initiate treatment. I like your idea of moulage to add mechanical challenge.


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## mycrofft (Sep 27, 2011)

*I've been studying*

Got some leads from a disaster preparedness planner in California, and every one so far has two aspects: statement that simulation is good, and that research is needed to back that up. One study shows that automated simulator manikins yielded better results than moulage, (students with manikin got 70+%, moulage students got 60+%).

I'm in favor of good graphic photos, didactic, then as much practicum as possible (ride-alongs and clinicals).


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## LondonMedic (Sep 27, 2011)

I think it depends what you use it for.

My research has been into patient safety but I have been involved in simulation in a variety of forms to teach a variety of things.

The overall message is that simulation is poor at teaching knowledge but good at teaching technical and non-technical skills and the evidence that I have been involved in producing and have researched is that high-fidelity simulation, replicating the working environment as closely as possible, improves the effect.

Will try to dig some sources up for you when not on nights.


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## Handsome Robb (Sep 27, 2011)

No studies here either but from training both with live patients who have been moulaged up and with high-fidelity manikins I personally would choose the manikins any day of the week.

Moulage is cool and adds an element to simulations but you also are relying on the acting ability of the person. 

Our manikins at school are amazing, they do everything except for move and present skin signs. They take a little bit to get used to, especially the OB manikin. Once you adjust they tend to be much more realistic when it comes to assessment.

This is all my own opinion so take it with a grain of salt. I will say that my service and school have an *amazing* moulage artist though.


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## mycrofft (Sep 28, 2011)

*Thanks responders*

Everything I see says manikins are somewhat better than moulage, that simulation generally is not proven (except in a small study about dermatology) to be superior (and that was not moulage but silicone simulators).


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## LondonMedic (Sep 30, 2011)

mycrofft said:


> Everything I see says manikins are somewhat better than moulage, that simulation generally is not proven (except in a small study about dermatology) to be superior (and that was not moulage but silicone simulators).


As if on cue, look what's in JAMA this month.

Cook DA, et.al.. Technology-Enhanced Simulation for Health Professions Education: a systematic review and meta-analysis., JAMA. 2011 Sep 7;306(9):978-88.
Pubmed ID 21900138


> *Conclusion* In comparison with no intervention, technology-enhanced simulation training in health professions education is consistently associated with large effects for outcomes of knowledge, skills, and behaviors and moderate effects for patient-related outcomes.



It's a bit of an odd meta-analysis, which isn't too surprising given the subject matter, and the selection and analysis are very broad. However, reading the article in full, it's quite nuanced, and there's a lot of data looked at. The consequence of that is that it can only give us broad answers.


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## Markhk (Oct 3, 2011)

My two cents, after having attended a formal moulage training class... 

- I believe that moulage is useful to "stress" new providers (e.g. EMT students, CERT, etc.) to have them translate some of their book knowledge into visual identification, in addition to creating an increase in adrenaline during MCI exercises. Sometimes, I might get students saying how surprised they were on how they reacted at the sight of blood (I'm glad they learned this early on) - but that is the limit to my hopes and expectations of moulage. But this doesn't really require a moulage artist. Literally putting strap ons on people and dousing them with a gallon of blood is generally sufficient to elicit some fear factor in new students. 

- I believe the utility in using it to train seasoned EMTs and Paramedics is questionable. Much more so when the moulage is not done realistically. Some of the makeup I've seen done for ATLS (which is training physicians for goodness sake) was absolutely terrible (e.g. brown grease paint to the side of the neck to show tracheal deviation...) 

- There are problems when we try to handle some of these beautiful appliances during care (ie gelatin prosthetic start to melt, grease paint flakes off, etc.). Questions come up during the transition of care (ie. the patient's prosthetic is missing so the receiving provider doesn't really know what's going on.) Moulage make look good for photo and the media coverage, but again, not sure if it helps providers do better care. 

- Until we replicate the smells (flesh, burned hair, blood) of injury, we cannot call moulage "high fidelity".


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## mycrofft (Oct 4, 2011)

*Thanks so far. London, Markhk, each a reply.*

When I google for "moulage" I get "simulation", and sometimes this is the instrumented and simulating manikins, not moulage. Many of these articles are the equivalent of fancied second-year nursing student papers. 

Mark, sounds about right. Artistic moulage is, in my opinion, mostly for scaring the kiddies. And the fake blood...who ever saw transparent blood that didn't turn black or dry up?

I've seen good return on time and money invested on the latex tie-on prosthetics, and really they are no less unbelievable than most artistic moulage is once you have seen a few of the real thing.


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## Markhk (Oct 4, 2011)

Did you get a chance to see these two studies? (One is pandemic flu though.) 

*Gillett B, et al. Simulation in a disaster drill: comparison of high-fidelity simulators versus trained actors. Acad Emerg Med. 2008 Nov;15(11):1144-51. *

OBJECTIVES:
High-fidelity patient simulation provides lifelike medical scenarios with real-time stressors. Mass casualty drills must construct a realistic incident in which providers care for multiple injured patients while simultaneously coping with numerous stressors designed to tax an institution's resources. This study compared the value of high-fidelity simulated patients with live actor-patients.

METHODS:
A prospective cohort study was conducted during two mass casualty drills in December 2006 and March 2007. The providers' completion of critical actions was tested in live actor-patients and simulators. A posttest survey compared the participants' perception of "reality" between the simulators and live actor victims.

RESULTS:
The victims (n = 130) of the mass casualty drill all had burn-, blast-, or inhalation-related injuries. The participants consisted of physicians, residents, medical students, clerks, and paramedics. The authors compared the team's execution of the 136 critical actions (17 critical actions x 8 scenarios) between the simulators and the live actor-patients. Only one critical action was missed in the simulator group and one in the live actor group, resulting in a miss rate of 0.74% (95% confidence interval [CI] = 0.01% to 4.5%). All questionnaires were returned and analyzed. The vast majority of participants disagreed or strongly disagreed that the simulators were a distraction from the disaster drill. More than 96% agreed or strongly agreed that they would recommend the simulator as a training tool. The mean survey scores for all participants demonstrated agreement that the simulators closely mimicked real-life scenarios, accurately represented disease states, and heightened the realism of patient assessment and treatment options during the drill with the exception of nurse participants, who agreed slightly less strongly.

CONCLUSIONS:
This study demonstrated that simulators compared to live actor-patients have equivalent results in prompting critical actions in mass casualty drills and increase the perceived reality of such exercises.

*Wallace, D, et al. Randomized controlled trial of high fidelity patient simulators compared to actor patients in a pandemic influenza drill scenario. Resuscitation. 2010 Jul;81(7):872-6. Epub 2010 Apr 15.*

Abstract
During disaster drills hospitals traditionally use actor victims. This has been criticized for underestimating true provider resource burden during surges; however, robotic patient simulators may better approximate the challenges of actual patient care. This study quantifies the disparity between the times required to resuscitate simulators and actors during a drill and compares the times required to perform procedures on simulator patients to published values for real patients. A randomized controlled trial was conducted during an influenza disaster drill. Twelve severe influenza cases were developed for inclusion in the study. Case scenarios were randomized to either human actor patients or simulator patients for drill integration. Clinical staff participating in the drill were blinded to the study objectives. The study was recorded by trained videographers and independently scored using a standardized form by two blinded attending physicians. All critical actions took longer to perform on simulator patients compared to actor patients. The median time to provide a definitive airway (8.9min vs. 3.2min, p=0.013), to initiate vasopressors through a central line (17.4min vs. 5.2min, p=0.01) and time to disposition (16.9min vs. 5.2min, p=0.01) were all significantly longer on simulator patients. Agreement between video reviewers was excellent, ranging between 0.95 and 1 for individual domain scores. Times required to perform procedures on simulators were similar to published results on real-world patients. Patient actors underestimate resource utilization in drills. Integration of high fidelity simulator patients is one way institutions can create more realistic challenges and better evaluate disaster scenario preparedness.


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## mycrofft (Oct 4, 2011)

*Not moulage, but I appreciate them!*

Hidden in the hoopla of the second was the fact that they had 12 cases, so the sample was basically 12. THe use of video to reveal fidelity and actual time to treat was a nice touch.

How many manikins and video cameras and video interpreters can one afford and use, though?


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## mycrofft (Oct 5, 2011)

*Let's call the code.*

 Well, between EMTLIFE, another web forum, and my own digging, I am not finding any studies whether moulage per se is efficacious. Quite a few studies of instrumented and otherwise implemented manikin simulators _*as opposed to*_ moulage,  and some about other simulators (e.g., silicone skin reproductions of dermatologic conditions), but nothing which compared _*moulage*_ as opposed to other means; the moulage was not evaluated, just the other means.
My opening assumption is still standing; artistic moulage is inefficacious in time, money, effort, and result.
A note was raised that, for inexperienced students, it is a means to inject a sense of urgency and excitement if the "victims" are also good actors.


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## bigbaldguy (Oct 5, 2011)

mycrofft said:


> Well, between EMTLIFE, another web forum, and my own digging, I am not finding any studies whether moulage per se is efficacious. Quite a few studies of instrumented and otherwise implemented manikin simulators _*as opposed to*_ moulage,  and some about other simulators (e.g., silicone skin reproductions of dermatologic conditions), but nothing which compared _*moulage*_ as opposed to other means; the moulage was not evaluated, just the other means.
> My opening assumption is still standing; artistic moulage is inefficacious in time, money, effort, and result.
> A note was raised that, for inexperienced students, it is a means to inject a sense of urgency and excitement if the "victims" are also good actors.



For what it's worth I agree, I think it's kinda silly and added nothing to the training. Unless you have a Hollywood caliber team it just looks like what it is, a bad Halloween costume.


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## DPM (Oct 11, 2011)

I'm currently at Paramedic School in the US but spent the previous 7 years in the British Army where (surprisingly) we used a fair bit of 'moullage'.

By fat the best that we had was provided by a company called 'Amputees in action', which AFAIK provided the Actors (many of whom were ex-mil) and also their own make up people.

This might have come to late in my career (already been on tour and dealt with real casualties etc) but it was definitely a huge learning experience to the newer guys. Knowing the theory and applying that in the class room was fine, but it was a different kettle of fish when they were treating traumatic amputations on soldier who had actually lost their lower legs (3 between the pair of them!) and they new just how it had felt and exactly how to act. 

That said, I still think that as far as value for money goes, this type of experience is only needed once. When done well, make up / actors etc can give things the necessary shot of realism before you have to do things for real. I looked at it like an inoculation, you only really need it once.


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