Casualty Simulation - Making it Real(ish)

Author: Annina Lux.
Photo credit: Andy Pfaffinger and Patrick Möhrlein, Notfalldarstellung Augsburg-Stadt.

As you have probably discovered by now (or are about to, considering the topic of this website), scenarios are an amazing way to practice first aid skills. And even though they can and should be challenging and useful, they can (and at least sometimes should) also be a lot of fun. What makes them even more challenging (and sometimes way more fun) is not having to pretend to find some bruises while doing a body check, or to be told where that large amount of blood you have been hearing about in your briefing comes from, but to be able to actually find out yourself, and more importantly, deal with it. And the good news: this sort of casualty simulation, or cas sim, is not even that hard to do! Granted, you might not be able to perfectly reconstruct that horrible blockbuster movie scene, but you can definitely make your scenarios look realistic!

And even better- this doesn't have to be difficult or expensive! So, here are 10 steps for doing amazing cas sim without having prior knowledge or a large budget...

1. SAFETY FIRST- What does that D from DRSABC stand for? Ah yes, danger...Well, unsurprisingly, safety first also applies to cassim. Cas sim lives from being creative and trying out new things. However, whatever you do, make sure it is safe- for you, your casualty, the first aiders, and any other people that happen to walk by or see you. The most obvious concern here is the stuff you use as make-up. Whatever you use, make sure anyone who comes in contact with it is neither allergic nor sensitive to it! This goes especially for any creative ingredients you have come up by yourself, or any products that have not been dermatologically tested. The last thing you want is to actually fabricate a casualty by forgetting about that nut allergy of your casualty when you mixed your fake blood using food colour containing traces of nuts...This also applies to any extra props you might use- make sure that knife you are leaving next to the casualty will not hurt any of the people involved...However, this also goes for the psychological side- think about what effect a screaming and crying person covered in blood will have on anyone walking past. Always let porters etc know what you are up to, and that they should not be worried. While you might be happy to deal and able to psychologically cope with someone covered in blood, this might not apply to all others walking past...If you plan a scenario in a public place (such as a forest), make sure to let the scenario supervisor know that she or he should explain what is going on to any passers by. If you are thinking big and planning a major incident or multiple casualties, make sure you provide first aiders and casualties with some mechanism to let you know if any problems arise-a bleeding or bruised person can easily be missed in these scenarios...So, remember that D, even in cassim...

2. SHOPPING- this is the fun part. Basically, there are no rules (except the safety first one...). Anything you can think of is a possibility. With cassim, most make up and ingredient choices work on a trial and error basis. This means that whatever you are thinking of doing doesn't have to be expensive. Most things you will ever need you can get at supermarkets or fancy dress stores without spending a fortune. The basic things you will need are:

Basic theatre make-up: red, brown, yellow, black, white and blue theatre foundations make-up will serve you as foundation for anything you want to do, from cyanosis to burns to contusions and shock. Check out the offer in your local fancy-dress shop, supermarket or discounter shops to see what you need. Usually, it pays off to get some coloured make up pens, too, as they will help you with more detailed lines and structures you want to make. The best time to get this sort of stuff is around Halloween, unsurprisingly...So consider bulk-buying then if you are planning more cassim fun throughout the year.
Fake blood- while you can make fake blood yourself quite easily, for example by mixing red food colour with water and gelatine, you will probably need some real fake blood to make more detailed injuries or injuries that need to keep up for a longer amount of time. Fake blood is also useful if you want your casualties to have it in their mouth, as it doesn't taste as funny as food-coloured yogurt. Consider using blood capsules for convenience reasons. You can get these and normal fake blood cheaply online, too...
Structural props: to make some injuries, such as fractures, wounds or burns, you will also need something to help you build the particular structure of that type of injury. Paper tissues are a major help here: take apart the layers, use some water, and form them in whatever way you need to simulate cuts, wounds, fractures etc...Getting cheap tissues is actually not only great budget-wise in this case, but also useful, as you can usually take it apart into its different layers a lot more easily than the more expensive ones. Vaseline is also useful, both to make that tissue stick, and to enhance structures of injuries.
Props: Don’t forget to think about the “props” your casualty might need- have they vomited, or wet themselves? If so, buying some canned vegetable soup and some apple juice makes sense. Equally, remember to buy (safe) props that you want first aiders to find on scene. Transparent plastic champagne glasses make for great broken glass, for example, and you can make the shards of glass safe quite easily by covering any sharp edges with thick transparent selotape if needed. Again, fancy dress shops or Halloween sales are a great way of buying general stocks of props. Remember to keep track of your props and save them for future cassim fun!
Other things: There are literally no boundaries to your ideas. Be creative. Think about what you could use in a particular scenario, and go browse through your local supermarket, discounters and other shops to see whether you find anything that might be useful in your cassim. If you are unsure, try it out!
Clean-up: Make sure you have enough wet wipes, paper towels and soap to get your casualties cleaned up after the scenarios! Although make-up is usually very easily removable, removing cassim can leave your skin a little sensitive, you might want to get some skin cream to make it a little.

3. PREPARATION- Cassim takes a lot of preparation, and this is not limited to just buying all the stuff needed. Make sure you plan enough time for you to prepare all the things you need before your casualties get there- have make-up and props ready, and check your location for suitable places to do your scenarios. Remember that you need to be able to clean up afterwards (fake blood stains don’t really look great on carpets…). Make sure your casualties get there early, and confirm with them that they are happy with their scenarios. Timing is crucial here, and you will need more time than you think! Make-up will have to dry, be redone, or changed, and clothing will have to be prepared, too. A lot of the challenges will only become obvious when you are actually in the process of getting your casualties and location ready, so leave yourself enough time to solve any problems that may arise. So make sure you plan time generously, especially the first times you do cassim!

Photo showing cassim preparation. — Take your time! Making up casualties can be a time consuming process, and details are what makes your cassim realistic! The cyanosis of this patient, for example, will occupy your first aiders much longer than the head wound, which they are likely to just cover with a bandage. Subtleties are important, and they take time!

4. CLOTHING- Cassim clothing is really important in making our scenario more realistic. Ask your casualties to bring old clothing they don’t mind to get cut, torn or dirty, and ask them to bring something to change into when you are done. If you are planning to do more cassim, ask your friends or family for any clothing they might be able to donate. Save torn or dirty stuff from old scenarios. That way, your first aider can cut or tear any clothing they want, like they would with a real casualty…Remember that sometimes one casualty might need multiple sets of clothing if you have different groups practicing the same scenario, depending on the damage done…

5. MAKING UP CASUALTIES- As mentioned above, much of this is trial and error, but here are some basics: Think about what your simulated condition should look like. For example, if it is a wound, what does it look like? How large is it, how deep? What does the surrounding area look like? Is it accompanied by anything else, such as hypovolemic shock? Before starting the actual make-up process, think about what needs to be done:

Basic layer: This is the first layer of makeup you will be applying. What does the basis and immediate surrounding of the injury look like? What colours do you need to reconstruct this?
Injury itself: Build the structure and particular details of the injury on top of your foundation.
Surroundings: What does the area surrounding the injury look like? Is it reddened? Swollen?
Accompanying conditions: Think about any conditions that accompany the injuries. Is the person cyanotic due to shock? Have they been vomiting after obtaining that head injury?
Fake Blood: While you should apply some fake blood when making up the injury itself and the surrounding area, save the big mess for just before the scenario. Otherwise, your fake blood will dry, or be all over the place before your first aiders even get there.

If you are unsure what an injury or condition looks like, look it up! Find some photos in your first aid manual or medical sites online and use them to get an idea of what you want your casualty to look like. However, don get bogged down in reproducing injuries perfectly. All injuries look a little different, and so will your cassimed one! There are also some great tutorials on youtube if you are unsure about where to start with your make-up- but honestly, most of the time, just going for it will give you a better result than trying to rigidly reproduce something you have seen in a video!

6. SCENARIOS- Make sure your casualty, observer and all props are ready and in the right location. To make the scenario as realistic as possible, tell your casualty to stick to their role at all times- should anything be unclear, make sure the observer answers questions, and not the casualty. The casualty staying in their role actually makes a huge difference!

7. BETWEEN SCENARIOS- Make sure there are enough supplies ready for your casualty to prepare for new rounds of scenarios. They might have to change into a new set of clothing, or cas sim make-up/fake blood might have to be redone A useful trick to portion and store fake blood is by filling it into the finger parts of first aid gloves. To open the glove finger, your casualty can simply cut or bite the finger tip. This is also great if your casualty is meant to vomit blood, or to simulate continuous heavy bleeding during your scenario…

8. CAS SIM DEBRIEF- Like scenarios, your cas sim should always have a debrief. Ask your casualties and observers on how the make-up worked, whether there were any problems, and whether they have any ideas for future cas sim. Possibly get some feedback from your first aiders on your cassim, but be careful that just because they did not recognise that cyanosis doesn’t mean your cassim was bad- scenarios are supposed to be challenging, and recognising everything at the first glance would be counterproductive. Subtleties are highly welcome! So be sure to make a distinction here…Think about what you could do better next time, what additional ideas you have and what you don’t want to do again.

9. CLEAN-UP- plan enough time and resources for your casualties to clean up, and to clean up the location. Let reusable cassim clothing dry, and consider washing it if you have already used it multiple times. Clean and save your props, and make sure your make-up is stored correctly- finding out you forgot to put that li on your theatre make-up two months later would be annoying…

10. ENJOY- after all the effort you put into this, enjoy the results. Cassim is challenging for first aiders, but it is teaches them A LOT. So even if your first aiders did not do as well as you would have liked, be sure that the scenarios did have an effect on them! Now that you have all worked hard on this (and hopefully also enjoyed it), go for that post-meeting get-together or a coffee with your colleagues. Just make sure all your casualties have been de-cassimed first to avoid any stares or real casualties ;)

So, as said multiple times, cassim lives from trial and error, so go ahead and give it a go! Make sure you plan enough time to experiment or redo make-up, and don’t be scared to go for bold ideas! Don´t be shy- just select a few scenarios from the site and give it a go!

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