The saying goes “practice makes perfect.” But over the years, I have learned that this isn’t always true. Practice makes permanent. However, when we practice imperfectly, wrong learning takes place and becomes internalized. The idea of creating realistic, immersive training as a powerful learning tool for engaging participants has been in the mainstream for years.  Empirical models support a "train as you fight" scenario as an effective means of recognizing wounds and illnesses in improving patient survival outcomes. We know that realistic, immersive, interactive training scenarios contribute to greater success in the field, higher levels of critical thinking, enhanced learning, fewer misdiagnosed patients, increased engagement, and a faster rate of skill acquisition. The Next Step in Improving Outcomes: A Better Prepared By-Stander Despite vast amounts of resources allocated for research and training, there has been little change in the past 10 years regarding improvement of hospital cardiac arrest survival rates. Evidence validates the value of CPR and early defibrillation as being a major factor in survival, yet even with more training dollars, survival rates numbers have remained primarily unchanged. Maybe the next step in making a major impact is in recognizing the peri-arrest patient, and the underlying cause of the patient in arrest. Since the vast majority of those responsible for early CPR and defibrillation are by-standers, is there anything more we can do to help prepare them? Is showing them a picture, or using words to describe peri-arrest signs enough to make them competent at preventing the arrest state? The reality is by-standers have the greatest impact on survivability than anyone else in the Chain of Survival. The modest survival rates we do have are to be credited to both the greater public and those who arrive to take the reins. Our teams recognize the emergency, and begin CPR within moments of the event. Failure in any segment of this results in zero survival, no matter how advanced, talented, well trained, or well-equipped the rest of the system is. Moulage helps the most essential link in the chain be more prepared and more effective. Let’s face it, most of us are trying to do more with less. Less budget, less time, and less support staff. Moulage is still considered a luxury in many avenues. We are hesitant to add one more step to an overburdened system, especially if this element isn’t perceived as broken. We must learn a new way of looking at things. A new paradigm that enables us to use realistic moulage skills for realistic patients that are seen, treated and cared for by realistic people. While we may acknowledge moulage has many benefits, it still can be difficult to find the resources to build realism into every training scenario due to time, budgetary and skill constraints.  Quick tricks to Build Moulage into Training  There is no shortage of tips on building moulage into the training scenario on both simulator and standardized patient. Here are a few of our favorites:

• Begin with the end in mind. If you can't see, you can't convey it. Tactical, emergency, pre-hospital, medical responders and infection control professionals are reliant on what is seen, felt, heard and even smelled to indicate their course of action.
• Step away from the "wow" factor. We all love a good "wow" moulage moment, it speaks to our skills and our colleagues are impressed - but it can be time and/or budget intensive. Much like the training scenario where you start with the end in mind, remove every aspect that doesn't contribute to the end result. You do not need a patient with full thickness burns to convey smoke inhalation (unless it is specific to your case). Often the desired training outcome is specific to "recognizing" a patient has smoke inhalation, incorporating quick and cost-effective symptoms such as cough, hoarseness, reddened throat, soot at the base of the nares, all cues needed to determine the degree of injury and level of assessment by the responder. The truth is, we never miss the “big stuff”. It is the subtle clues that pass undetected through our assessments both in training and real life.
• Pre-make your wounds, pus, secretions and bodily fluids so they are ready to use and may be converted quickly into other duties. While the Simulation industry has met the demands for pre-made products, there are plenty of free resources available including step by step instruction, tips and recipes for creating your own.
• Challenge yourself- the expert. As experts in the field, you already know what you would be looking for while assessing the patient. That is where your moulage should start- telling the story that strengthens the training scenario. If you have ever had to say "just pretend...." that is where moulage could have carried the story.

When we practice moulage that follows simple techniques, using cost effective products, and supports our scenarios, we give teams an opportunity to establish baselines, identify shortcoming and mitigate risks. Recognize where additional training is required and develop allocation plans for utilizing future training dollars and resources. Evidence supports the effective use of realism, and real patients are suffering when signs and symptoms are missed. http://www.moulageconcepts.com/training