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The art of moulage

Combat Medic Training program students at the Medical Education and Training Campus at Joint Base San Antonio-Fort Sam Houston conduct an emergency cricothyrotomy on a “casualty” during simulation training. The “wounded” manikin also presents with facial burns that were created with moulage techniques. (DoD photo by Lisa Braun) Combat Medic Training program students at the Medical Education and Training Campus at Joint Base San Antonio-Fort Sam Houston conduct an emergency cricothyrotomy on a “casualty” during simulation training. The “wounded” manikin also presents with facial burns that were created with moulage techniques. (DoD photo by Lisa Braun)

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JOINT BASE SAN ANTONIO-FORT SAM HOUSTON, Texas — The saying “train like we fight” is a common idiom in the military training spectrum. As combatants, service members must train for a variety of scenarios that will prepare them to succeed when engaged in real-life conflicts.

Simulation plays an important role in preparing enlisted medical trainees at the Medical Education and Training Campus, or METC, at Joint Base San Antonio-Fort Sam Houston to respond appropriately when faced with an actual life-or-death situation.

For the combat medic trainees in the Department of Combat Medic Training, or DCMT, program who, due to the sheer size and number of classes, will not have an opportunity to see real patients until after they graduate from the program, the realism goes a step further.

The use of high-fidelity human patient simulators that mimic actual patient encounters will prepare Soldier medics with the basic skills that will save lives – on and off the battlefield.

When the training scenario calls for treating casualties with combat wounds or injuries, however, less expensive generic manikins are incorporated and given a makeover to look the part because not many manikins have wounds already on them.

“To better simulate battlefield wounds or injuries our simulation instructors have become moulage artists to make realistic wounds and injuries that give these manikins more realism,” said Donald Parsons, DCMT program director. “This allows the students to actually see and treat wounds they will see on the battlefield, but they can also make their mistakes on the manikin without risking someone’s life.”

These realistic injuries may include an amputation, head and chest gunshot wounds, and other traumas associated with combat injuries. As the combat medic trainees, or Soldier medics as they are called in the training environment, respond to the simulated casualty they are simultaneously reinforcing the skills they learned in the classroom – from a basic injury assessment to more complex wound care.

Camille Espinoza, a civilian DCMT training instructor and simulations technician, heads the process of transforming a generic, low-fidelity manikin into a combat casualty. As an art, moulage is a process of trial and error so Espinoza is always learning new techniques. Her team offers ideas and assists with some of the moulage application.

Espinoza has had to create a way for students to apply needle chest decompressions, or NCD, on the manikins, for example. An NCD is a medical procedure that is most commonly used to treat patients suffering from a punctured or collapsed lung by inserting a needle with a catheter on the end through the chest cavity.

In the past, students would utilize a task trainer for working on specific procedures, such as a NCD, tourniquet, or wound packing among others. The students would assess the manikin first then turn to a task trainer to treat the wounds.

Espinoza modified the chests on the low-fidelity manikins, which are made out of PVC, so that the NCD insertion spots are soft enough to allow students to puncture through the manikin without causing the catheter to bend.  She also gave them trachea inserts that she carved into the manikins, and added injuries that look more realistic.

Now, students can examine and assess the “casualty,” inspect the location of the wounds and perform all of their interventions directly on the manikin itself. A set of manikins was created to use just for testing as well.

One of the biggest challenges with creating the wounds is that the manikins take a lot of abuse when students practice with them because they get moved around a lot to different outdoor locations where dirt and other elements wear down the moulage effect.

Many of the materials would break down or wear off too quickly, so experimenting with different moulage techniques and materials that make the wounds last longer is part of the process. Feedback from instructors was also an important factor in determining what works and what doesn’t.

“A lot of the stuff that special effects people do is usually a one or two time use, so it doesn’t need to last a long time,” Espinoza explained. “Unfortunately, I have students from three Whiskey teams that come down to the simulation lab so we’re running around 1,000 Soldiers through there. I had to figure out what the best materials were, the least expensive, the most effective; there was a whole lot of stuff that was going on trying to come up with the best way to apply the moulage and then hope it doesn’t break up too quickly. It’s all trial and error.”

Through the process of trial and error, Espinoza discovered that silicone-based material helps the moulage stay on longer. If it gets worn out it can easily be cleaned up and redone. The manikins can potentially be used hundreds of times before the moulage wears down, depending on the type of injury.

Some wounds, like amputations, don’t last as long because the manikins are being dragged continuously through the dirt during training. Facial wounds, though, tend to last longer because the face does not make contact with hard surfaces.

Modifying a manikin may take two or three days, depending on the wound being depicted. Some injuries needs to be created in steps and can be time consuming, so an assembly line process is ideal.

Espinoza and her team can line up three to five manikins, start working on one then move on to the next one while the previous one is drying, solidifying or cooling from having to heat the plastic to soften it for an effect.

The most important factor is making sure that the manikin is dry before moving on to the next step. Rushing through a modification may result in the moulage not staying on.

Depicting a shrapnel wound, for example, means that Espinoza will need to cut into the manikin. In order to do this, the area on the manikin where the wound will be created is heated in order to soften it so it can be cut and manipulated to form a wound. Then it will be painted to look realistic and set to dry.

If it’s possible to make use of materials already on hand, Espinoza will find a way to incorporate them into her design as well.

“We don’t want to use more than what we need or waste more than what we have,” she said.

Espinoza has used the popcorn material used for packing boxes to stuff the lower portion of manikin legs where a wound is depicted before adding foam to the area so students could learn how to pack the wound and practice applying tourniquets.  Prior to that, the foam would crack and fall apart.

“We just had to modify a lot of the stuff that we did in order to find the best way to do it.” 

Espinoza takes great pains to ensure she creates as realistic a product as possible.

“I want the students to get that shock and awe when they see the injuries without having that reaction the first time seeing it on a person, on a Soldier, on their battle buddy,” she added. “I would rather they have something as realistic as possible in these manikins without having somebody actually injured." 

A fellow instructor of Espinoza’s, who is now retired, once told her that what they’re doing now is saving lives through other people's hands. Those words have always stuck with her.

“I can do my job through these medics. If I can make something as real as possible so they can get that, ‘oh my god, this is for real!’ reaction and it makes sense, that’s all I really care about. I can get in their head and make them understand that what they’re doing makes a difference.”

To Espinoza, making mistakes on the manikins is the point of the training.

“You have to make mistakes to learn. If the students do it wrong here they can learn from it. I want them to do it wrong, because if they always do it right then what are they going to learn?"

“That’s exactly what I’ve done with these manikins,” she added. “I’ve had to make mistakes to learn how to make them better for the students to make their mistakes so they can get better. I’d much rather they do that here then on the battlefield.”

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