Hematemesis (vomiting blood) accompanied by an alcoholic odor is a serious medical situation that strongly suggests upper gastrointestinal (GI) bleeding related to alcohol consumption. It requires immediate emergency medical evaluation.
Emergency Warning Signs
- Large amounts of blood or “coffee ground” material.
- Dizziness, faintness, or confusion (suggests shock).
- Rapid heartbeat or cold, clammy skin.
- Severe abdominal pain.
- Black, tarry stools (melena).
Potential Causes
The combination of alcohol and bleeding often points to:
- Mallory-Weiss Syndrome: A tear in the esophagus caused by severe, forced vomiting or retching after heavy alcohol intake.
- Esophageal Varices: Enlarged veins in the esophagus—usually due to alcohol-related liver cirrhosis—that can rupture and cause severe bleeding.
- Hemorrhagic Gastritis: Severe irritation or inflammation of the stomach lining caused by alcohol, which can lead to bleeding.
- Peptic Ulcer Disease: Alcohol can cause ulcers in the stomach or duodenum that may bleed.
- Isopropanol Toxicity: Ingestion of rubbing alcohol (isopropyl alcohol) can lead to gastritis, vomiting, and a strong alcoholic odor.
Why it’s Serious
Chronic alcohol consumption can suppress blood cell production and lead to nutritional deficiencies. When combined with rapid blood loss, this can quickly lead to anemia, hemodynamic instability, and high rebleeding rates.
The Patient
Goal: To simulate hematemesis in a kidney basin from a chronic alcoholic that arrives in the ED smelling like he is flammable.
Sub-Goal: Full end-stage liver failure scenarios
This is “Sully,” a character designed to test both the clinical skills and the emotional resilience of your students. His backstory provides the “why” behind the “flammable” smell and the catastrophic bleeding.
Patient Profile: Arthur “Sully” Sullivan
- Age: 54
- Occupation: Former heavy equipment operator (Unemployed for 4 years)
- History of Present Illness: Brought in by EMS after being found by his landlord in a “pool of dark fluid.” He was last seen “fine” (though intoxicated) 24 hours ago. On arrival, he is intermittently combative, screaming about “the spiders on the ceiling” before vomiting a massive amount of bright red blood.
Clinical Status (The “Sim” Reality)
- Skin: Deeply jaundiced (pumpkin-orange tint), cold, and “leaking” sweat.
- Abdomen: Tense, distended (Ascites), and covered in “snake-like” veins (Caput Medusae).
- The Scent: He smells like a broken bottle of cheap gin mixed with something earthy and rotten (Fetor Hepaticus).
- Mental Status: Grade III Hepatic Encephalopathy. Disoriented to person/place/time. He is currently in Hemorrhagic Shock.
Character Nuances for the Actor/Instructor
If you have a voice-capable mannequin or a live actor for the pre-intubation phase, use these “Sully-isms”:
- The “Flammable” Breath: Every time Sully exhales, the room should smell like a distillery.
- The “Liver Flap”: If a student tries to take his blood pressure, his hands should do the rhythmic “asterixis” flap.
- Dialogue Loops: * “Is it raining? Why is the floor wet?” (He’s sitting in his own blood).
- “Get the dogs off me… they’re biting my stomach.” (Referred pain from the varices).
- “I just need a glass of water… just one glass.”
The “Family Twist” (For Ethics/Social Work Integration)
About 10 minutes into the code, Sully’s daughter, Sarah, arrives.
- Her Role: She is exhausted and “done.” She loves her dad but has seen this cycle ten times.
- The Conflict: She tells the team, “He told me last Christmas if it ever got this bad again, to just let him go. He’s tired of being yellow.”
- The Goal: This forces the students to decide: Do we keep suctioning this “Gusher” and push the Blakemore tube, or do we stop the aggressive measures and pivot to comfort care?
Sully’s Labs (The Paper Trail)
If the students ask for labs, give them these “Criticals”:
- Hemoglobin: 5.2 g/dL (Normal: 13.5–17.5) — He is empty.
- INR: 4.8 (Normal: 1.1) — His blood is like water; it won’t clot.
- Ammonia: 180 mu mol/L (Normal: 15–45) — The reason he’s seeing spiders.
- Platelets: 32,000 (Normal: 150k+) — His “factory” is broken.
Sully is the perfect “Trainwreck” patient. He is technically difficult to intubate, hemodynamically unstable, and presents a massive biohazard risk. Good luck to your students—they’re going to need a lot of suction and even more PPE.
Scenario Complexity Levels
Breaking this massive scenario into “Levels” is a great way to ensure students aren’t overwhelmed while allowing you to reuse the same “Sully” character and props. You can treat this like a video game where the medical complexity increases with the student’s rank.
Here is a recommended Four-Level Progressive Simulation Path.
Level 1: The “First Responder” (Basic Assessment)
Target: EMT, CNA, or First-Year Nursing Students.
Focus: Recognition, PPE, and Safety.
- The Scenario: Sully is in the triage area or a hallway. He is awake but disoriented. He smells “flammable” and is yellowish.
- The Key Task: * Universal Precautions: Recognizing the need for gloves/mask before touching the patient.
- Positioning: Placing him in a side-lying position to prevent aspiration.
- Vital Signs: Correctly identifying tachycardia and the “thready” pulse.
- The “Stop” Point: Sully vomits a small amount (250mL) into the basin. The students must call for help and apply oxygen.
Level 2: The “Med-Surg” Nurse (Clinical Stability)
Target: Senior Nursing Students or Junior Med-Surg Residents.
Focus: Pharmacology and Laboratory Interpretation.
- The Scenario: Sully is admitted to a room. He is stable but “sick.”
- The Key Task:
- Diagnostic Pattern: Linking the jaundice, ascites, and alcohol smell to liver failure.
- The “Liver Cocktail”: Correctly identifying and preparing Octreotide, PPIs, and Ceftriaxone.
- Fluid Management: Starting a large-bore IV and hanging a cautious 500mL bolus of saline.
- The “Stop” Point: Students must recognize the “Asterixis” (hand flap) and report that the patient’s mental status is declining (Hepatic Encephalopathy).
Level 3: The “ER/ICU” Team (Shock & Resuscitation)
Target: Senior Residents, ICU Nurses, or Paramedic Students.
Focus: Hemodynamic Crisis and Mass Transfusion.
- The Scenario: Sully is in the ER and the “Massive Emesis” event occurs. The basin is overflowing.
- The Key Task:
- Shock Management: Recognizing the BP drop ($70/40$) and activating the Massive Transfusion Protocol (MTP).
- Airway Protection: Preparing for RSI (Rapid Sequence Intubation) while managing a “flooded” airway.
- Team Lead: Delegating roles (Airway, Circulator, Recorder, Scribe).
- The “Stop” Point: The patient is successfully intubated (using the SALAD technique) and the first unit of blood is hanging.
Level 4: The “Specialist” (Advanced Interventions)
Target: Critical Care Fellow, GI Fellow, or Experienced Trauma Teams.
Focus: Mechanical Tamponade and Ethics.
- The Scenario: Sully is intubated, but the “Gusher” won’t stop. Blood is backing up into the ET tube. GI is 30 minutes away.
- The Key Task:
- The Blakemore Tube: The team must physically insert and secure the Sengstaken-Blakemore tube, checking gastric and esophageal pressures.
- Ethics under Pressure: The daughter (Sarah) enters mid-procedure. The team must manage a critical procedure while communicating with a grieving, conflicted family member.
- The “Stop” Point: The bleeding is controlled mechanically, and the team makes a plan for transfer to the OR or ICU.
Running The Scenario
Running this scenario as a Hybrid Simulation—using both a Standardized Patient (SP) and a high-fidelity manikin—is the “gold standard” for medical education. It allows you to simulate the complex human emotions of a patient like Sully while still performing invasive, messy procedures that would be impossible on a human actor.
Here is how you can practically execute this “hand-off” transition.
1. The Hybrid Model: The “Theatrical Hand-off”
You cannot (and should not) perform the SALAD maneuver or insert a Blakemore tube on an SP. The best way to do this is a two-stage approach:
- Stage 1 (The SP): Start with the SP sitting on the edge of the bed or slumped in a chair. They handle the “flammable” smell, the jaundice makeup, the combativeness, and the initial small vomit (using a hidden mouthful of your recipe).
- Stage 2 (The Manikin): As Sully “crashes” and loses consciousness, have the room lights flicker or create a distraction (like the daughter entering) to swap the SP out for the pre-moulaged manikin. Alternatively, use a “Split-Manikin” setup where the SP’s head is visible for the interview, but the “medical” body is the manikin’s.
2. Technical Doability: Manikin vs. SP
On the Standardized Patient (SP)
- Jaundice & Scleral Icterus: Highly doable with theatrical makeup and safe, yellow-tinted contacts.
- Asterixis (The Flap): Very easy for an SP to act out; very hard for a manikin to replicate.
- Behavioral Encephalopathy: An SP can portray the “spiders on the ceiling” delirium far better than any instructor voice-over.
- The Smell: Apply the “Alcohol/Vinegar” sponges to the SP’s gown.
On the Manikin
- Ascites & Fluid Wave: Best done on a manikin using a water-bladder insert.
- Massive Hematemesis: Manikins are designed for this. You can run tubes into the esophagus to provide a continuous “gusher” that the students must suction.
- The Airway (SALAD): This requires a manikin with a realistic upper airway (vocal cords, epiglottis) that can handle being submerged in fluids.
- Blakemore Tube: Only doable on a manikin. The gastric balloon must be inflated inside the manikin’s chest/stomach cavity.
3. The “Mess Factor” Challenges
If you use the “Variceal Gusher” recipe, you need to prepare for the cleanup:
- Manikin Staining: Food coloring (especially red) can permanently stain silicone.
- Fix: Apply a thin layer of Vaseline or a specialized silicone barrier spray to the manikin’s “skin” before the “blood” hits it.
- Internal Clogging: The cornstarch and tomato chunks in the recipe can clog the internal drains of high-fidelity manikins (like Laerdal SimMan).
- Fix: Do not use the manikin’s internal plumbing. Run an external “bypass” tube from a bag under the pillow directly into the mouth.
- The “Flammable” Scent: Rubbing alcohol can degrade certain plastics over time.
- Fix: Use the alcohol-soaked sponges on the gown only, never directly on the manikin’s skin.
4. Resource Requirement Checklist
| Feature | Difficulty | Requirement |
| Icterus/Jaundice | Low | Yellow makeup, contacts. |
| Hematemesis | Medium | The “Gusher” recipe + external pump. |
| Ascites | Medium | 2L water bag + weighted prosthetic. |
| Shock (Vitals) | Low | Sim-monitor software (e.g., SimPad). |
| Blakemore/SALAD | High | Advanced airway manikin + specialized tubes. |
If you have the budget, start with the Standardized Patient for the first 5 minutes to build the “human” connection and test the students’ ability to handle a combative, smelly patient.
As soon as the “Massive Emesis” event happens, have the SP “pass out” and transition the students to the Manikin for the intubation and shock management. This “Transition of Care” is exactly what happens in the ER when a patient moves from the waiting room to the Resuscitation Bay.
How much “mess” is your simulation lab tech willing to tolerate? That is usually the deciding factor!
The Challenge
This scenario is a classic “moulage” challenge. To simulate a high-fidelity GI bleed (specifically esophageal varices, which is the likely culprit for a chronic alcoholic in this state), you need to capture three things: the viscosity of blood mixed with gastric juices, the color of a massive hemorrhage, and that unmistakable odor.
Here is a recipe designed for medical simulation.
The “Variceal Gusher” Recipe
This recipe creates a high-volume, bright-to-dark red hematemesis that looks—and smells—disturbingly real in a kidney basin.
Ingredients
- Base: 2 cups of warm water.
- Thickener: 3–4 tablespoons of cornstarch (for a mucous-like consistency) or chocolate syrup (for depth and viscosity).
- Coloring: * 1 tablespoon red food coloring (liquid or gel).
- A tiny drop of blue or green food coloring (to take away the “cherry” look and make it look venous/deoxygenated).
- 1 teaspoon of instant coffee granules or cocoa powder (to simulate “coffee ground” emesis—partially digested blood).
- Texture: 1/4 cup of canned crushed tomatoes or soggy oatmeal (to represent partially digested food or sloughed mucosal tissue).
- The “Flammable” Scent: 1/2 cup of cheap vodka or rubbing alcohol.
- Pro Tip: For a more “organic” chronic alcoholic scent, mix the alcohol with a splash of apple cider vinegar to mimic the ketoacidotic/fermented breath often found in end-stage liver disease.
Instructions
- Mix the Base: In a large bowl, whisk the cornstarch into the warm water until smooth. If you want it thicker (more like “clotted” blood), use more cornstarch.
- Add the “Blood”: Stir in the red food coloring. Add the instant coffee/cocoa powder slowly; you want some of it to remain “speckled” to look like digested blood.
- Create the Texture: Fold in the crushed tomatoes or oatmeal. This provides the “chunkiness” that makes observers instinctively reach for the suction.
- The Final Touch (The Smell): Just before the simulation begins, pour in the alcohol/vinegar mixture. This ensures the “flammable” scent is fresh and hits the students the moment they lean over the basin.
Non-Staining Fake Blood Options
If you want to run this simulation without the “Red Dye #40 anxiety” of staining a $60,000 manikin, you have to move away from food coloring and toward professional-grade synthetic bloods or alternative pigment sources.
Here are the best non-staining options for a high-volume GI bleed.
1. Professional “Stain-Free” Sim Bloods
The simulation industry has developed specific fluids designed to be “non-staining” on medical-grade silicone.
- Pocket Nurse No-Stain Blood (suitable for in-mouth use)
- North American Rescue Simulated Blood Concentrate (Non-staining) – 1 Gallon of concentrate yields 64 gallons of simulated blood.
- Robert Smith Silicone Simulated Blood (suitable for in-mouth use) – Washable and will not bead on silicone.
2. The “Chocolate Syrup & Blue” Trick
This is a veteran Sim-Tech secret for creating dark, realistic “GI Bleed” blood that is significantly less likely to stain than red food coloring.
- The Recipe: Use Sugar-Free Chocolate Syrup as your base. Add a small amount of Blue food coloring (blue stains far less aggressively than red).
- Why it works: The brown of the syrup provides the bulk of the color. The tiny bit of blue makes it look like deoxygenated venous blood. Because you aren’t using red dye, you avoid the “pink stain” that usually haunts manikins.
- Cleanup: Chocolate syrup is water-soluble and breaks down easily with Dawn dish soap.
3. Water-Based Theatrical Bloods (Drip-Dry)
Look for brands like Ben Nye or Mehron specifically labeled “Stage Blood” or “Scab Blood.”
- Ben Nye Stage Blood: This is corn-syrup based and peppermint-scented. It is designed to be washed out of costumes.
- Pros: Highly realistic viscosity.
- Cons: Can be sticky. You must wipe it off immediately after the sim.
4. The “Beet Juice” Alternative
If you want a natural pigment, organic beet juice is surprisingly effective.
- Why it works: Beet pigment (betanin) is a large molecule that doesn’t “sink” into silicone as easily as the synthetic dyes found in grocery store food coloring.
- The Look: It has a deep, “liver-failure” purple-red hue that looks very much like esophageal variceal blood.
5. Non-Staining Thickening Agents
Since you need “chunks” and “viscosity” for the SALAD technique, use these manikin-safe thickeners:
- Methylcellulose (Slime Powder): This is the clear goo used in Ghostbusters. It’s inert, doesn’t grow mold as fast as cornstarch, and rinses perfectly clean.
- Metamucil (Psyllium Husk): Mix with water to get a “gritty” texture that simulates partially digested blood (coffee grounds) without staining.
The “Safety Layer” Checklist
Even with “non-staining” products, you should always take these three steps:
- The Silicone Barrier: Spray the manikin’s face and chest with Polydimethylsiloxane (PDMS) spray (often sold as “Silicone Shine” for cars or specialized Sim-Barrier). This creates a microscopic shield that makes any liquid bead up and roll off.
- The “Pre-Wet” Rule: Never apply fake blood to a “dry” manikin. Wipe the manikin down with a wet cloth or a little bit of soapy water first. A moist surface is much harder for dyes to penetrate.
- The 20-Minute Rule: No matter what product you use, do not let the blood sit. Assign one student or a tech to “de-blood” the manikin with baby wipes the second the scenario ends.
Comparison of Blood Types
| Product | Staining Risk | Realism | Cost |
| Food Coloring | High | Low (Too bright) | Very Low |
| Chocolate Syrup | Low | High (Venous) | Low |
| Pocket Nurse Blood | Very Low | Medium | High |
| Beet Juice | Medium | High | Low |
| Stage Blood | Medium | Extreme | Medium |
For “Sully,” use Chocolate Syrup mixed with a little bit of Methylcellulose and a dash of Blue food coloring. It looks like a catastrophic GI bleed, it’s thick enough to clog a suction tip for the SALAD challenge, and it’s the safest “homemade” recipe for your equipment.
Does this give you enough confidence to start the “messy” part of the sim, or are you still worried about the manikin’s face?
Clinical Presentation Tips for the Simulation
To make the scenario truly immersive, consider these additions:
- The “Fetor Hepaticus”: If you want to be hyper-realistic, add a tiny bit of boiled cabbage water or garlic powder to the mix. This mimics the “breath of the dead” scent associated with portal hypertension and liver failure.
- Application: Don’t just put it in the basin. Smear a little around the mannequin’s mouth and on the front of their gown.
- The Basin: Place the kidney basin on the edge of the bed or in the patient’s lap. For added realism, place a few suction catheters nearby that are already “clogged” with the mixture.
Safety Note: If you are using rubbing alcohol for the scent, ensure the simulation environment is well-ventilated and keep it away from any actual sparks or open flames (especially if you’re using real oxygen nearby).
Scenario Advancement Possibilities To Consider
Does this patient have any other symptoms you’re planning to simulate, like jaundice or ascites?
If you’re going for the full “end-stage liver failure” look, jaundice and ascites are the “gold standard” for a realistic ED simulation. They provide immediate visual cues that tell the staff, “This is portal hypertension, and that hematemesis is likely a variceal rupture.”
Here is how to bring those features to life without ruining your mannequin.
1. Jaundice (Icterus)
The goal is a sickly, yellow-orange tint to the skin and the “whites” of the eyes.
- The Skin: Use a yellow-based theatrical foundation or a light dusting of yellow cornmeal/turmeric powder mixed into a base of lotion. Focus on the face, neck, and palms.
- Pro Tip: Don’t overdo the bright yellow. Aim for a “muddy” yellow-tan. Real jaundice often looks like a bad spray tan gone wrong.
- The Eyes (Scleral Icterus): This is the hallmark. You can use yellow-tinted costume contact lenses for a high-fidelity actor. For a mannequin, a tiny bit of yellow gel eyeliner or water-soluble face paint in the corners of the eyes (the canthi) works wonders.
- Spider Angiomas: Use a fine-tipped red lip liner to draw tiny, star-shaped broken capillaries on the chest and upper back. These “spiders” blanch when pressed, which is a great test for students.
2. Ascites (The “Fluid Wave”)
Ascites is the massive abdominal swelling caused by fluid backup in the peritoneal cavity.
- The “Belly”: Use a weighted pregnancy prosthetic or a partially filled 2-liter water bladder (like a CamelBak reservoir) tucked under a skin-colored silicone layer or a tight t-shirt.
- The “Fluid Wave” Test: If you use a water-filled bladder, students can actually perform a “fluid wave” test—tapping one side of the flank and feeling the vibration on the other. It’s incredibly satisfying for clinical teaching.
- Caput Medusae: These are the distended, engorged veins radiating from the umbilicus, named after the snake-haired Gorgon.
- The Look: Use a blue or deep purple grease pencil or body paint. Draw thick, tortuous “serpent-like” lines spiraling out from the belly button across the distended abdomen.
- Pro Tip: Apply a thin layer of clear lip gloss or liquid latex over the blue lines. This gives them a “raised” and slightly translucent look, making them appear as if they are bulging right under the skin’s surface.
3. Asterixis (The “Liver Flap”)
This is a classic neurological sign of hepatic encephalopathy where the patient loses motor tone rhythmically.
- For a Live Actor: Instruct them to hold their arms straight out in front of them with their wrists cocked back (the “stop” position). Every few seconds, their hands should suddenly drop and then snap back up. It should look like a bird flapping its wings in slow motion.
- For a Mannequin: This is harder to pull off physically, but you can simulate it by having the instructor “bump” the mannequin’s hand periodically or by describing the “flapping” to the students when they attempt to check for a pulse.
4. Hepatic Encephalopathy (The Mental Status)
The buildup of ammonia in the brain causes a very specific type of delirium.
- The Behavior: The patient shouldn’t just be “drunk.” They should be disoriented to time and place, potentially combative, or inappropriately sleepy (somnolent).
- The Dialogue: Have the actor or the voice of the mannequin repeat loops, ask for people who aren’t there, or struggle to follow simple commands like “squeeze my hands.”
- The “Handwriting” Test: Give the patient a clipboard and ask them to draw a clock or write their name. In real encephalopathy, the handwriting becomes illegible and shaky (apraxia).
5. Sarcopenia & Brusing (The “Fragile” Look)
Chronic alcoholics often suffer from severe malnutrition despite the “big belly” of ascites.
- Muscle Wasting: Use contour makeup (darker browns/tans) to hollow out the temples and the spaces above the collarbones (supraclavicular notches). This makes the patient look “sunken” and chronically ill.
- Ecchymosis (Easy Bruising): Because the liver isn’t making clotting factors, these patients are covered in bruises.
- Method: Smudge purple and yellowish-green eye shadow on the shins, the tops of the hands, and around where the IV might go.
- The “Petechiae”: Use a red fine-tip pen to make tiny “pinprick” dots around the ankles to simulate broken capillaries from low platelets.
6. The Finishing Touch: “Fetor Hepaticus”
If the “flammable” smell is the opening act, the “Breath of the Dead” is the encore.
- The Scent: To simulate the musty, sweet, fecal odor of a failing liver, mix a tiny amount of garlic powder and canned corn juice into a spray bottle.
- Application: Lightly mist the patient’s gown. It creates a sickeningly sweet, earthy smell that students will never forget.
With the hematemesis in the basin and these physical signs, you’ll have a simulation that is visceral enough to make even a veteran ER nurse take a step back.
Scenario Advancement Possibilities To Consider
Are you planning to have the “patient” go into hypovolemic shock during the scenario, or are we sticking to the initial assessment?
If the first half was about setting the scene, this is where the simulation turns into a high-octane emergency. When a patient with variceal bleeding “crashes,” it happens fast.
To simulate hypovolemic shock in this patient, you need to transition from “sick” to “actively dying.”
1. The “Shock” Moulage (The Pale & Clammy Look)
As the patient loses blood volume, their body diverts blood away from the skin to the core.
- The “Sweat” (Diaphoresis): Mix 3 parts glycerin with 1 part water in a spray bottle.
- Pro Tip: Apply a thin layer of cold cream to the mannequin’s forehead and neck first, then spray the glycerin. It creates big, heavy droplets that don’t evaporate, giving that “cold sweat” look.
- The Pallor: Use a white or light grey theatrical foundation (often called “Clown White” but used sparingly) or a very pale face powder. Apply it over the jaundice you created earlier. The result should be a “muddy grey-green” that looks like the patient is about to expire.
- The Lips: Use a tiny bit of blue eyeshadow or a “cyanotic” lip tint on the corners of the mouth to show poor oxygenation.
2. The Vital Sign Progression (The “Slide”)
If you have a monitor, this is the story you tell with the numbers. Shock isn’t a single moment; it’s a downward spiral.
| Stage | Heart Rate (BPM) | Blood Pressure (mmHg) | Mental Status |
| Initial | 105–115 (Tachycardia) | 110/70 (Compensated) | Anxious, “Something is wrong.” |
| Early Shock | 125–140 | 95/60 (Dropping) | Confused, trying to get out of bed. |
| Late Shock | 150+ (Weak/Thready) | 70/40 (Decompensated) | Somnolent, barely responsive. |
| The End | 40 or PEA | Unobtainable | Unconscious. |
3. The “Second Wave” (The Climax)
To push the students into “Shock Mode,” you need a second, larger emesis event.
- The Trigger: When a student touches the abdomen for a “fluid wave” test or starts an IV, have the patient let out a wet, gurgling groan and “dump” a pre-hidden liter of your “Variceal Gusher” mixture into the basin.
- The Suction Challenge: This is where the cornstarch and crushed tomatoes from the recipe pay off. The “clots” will actually clog the standard suction tips, forcing the students to use a Yankauer or even the suction tubing alone (the “French” method). It adds massive stress to the simulation.
4. The Physical Exam “Tells”
Instruct your students (or have the mannequin’s voice) notice these three things:
- Capillary Refill: If they press the jaundice-stained fingernails, the color shouldn’t return for >4 seconds.
- The “Thready” Pulse: If they feel the radial pulse (wrist), it should be incredibly fast but so light it feels like a vibrating string.
- Peripheral Coldness: If possible, keep the “sweat” spray in the fridge so it’s physically cold when the students touch the mannequin’s skin.
5. Clinical Safety Warning (The “Flammable” Factor)
Since you’ve made the patient smell like a distillery (using real alcohol/vodka), be mindful of the simulation environment:
- Oxygen: Remind students that in a real ER, high-flow oxygen + a “flammable” patient + a potential cautery or defibrillator is a fire risk.
- Mannequin Care: Ensure the alcohol or food coloring won’t permanently stain the silicone skin. (Most high-fidelity mannequins handle glycerin well, but test the “blood” on an inconspicuous spot first).
The “A-Ha” Moment: The goal is for the students to realize that the blood in the basin is only 10% of the problem—the other 90% is the blood that should be in the patient’s veins but isn’t.
Scenario Advancement Possibilities To Consider
Are you planning for the students to attempt a specialized intervention, like a Sengstaken-Blakemore tube or a massive transfusion protocol?
If you want to maximize the educational impact—and the “wow” factor—of this simulation, I recommend a two-pronged “Airway & Tamponade” climax.
For a patient who is actively hemorrhaging and in shock, the transition from “medically managing” to “crisis intervention” is the most critical learning point. Here is what I recommend for the final phase of your simulation:
1. The “SALAD” Airway Maneuver
Since your patient is vomiting your “Variceal Gusher” recipe, their airway is a disaster zone. Most students will try to intubate and fail because they can’t see anything through the “blood.”
- The Recommendation: Teach the SALAD Technique (Suction Assisted Laryngoscopy and Airway Decontamination).
- The Setup: Have a second person (or the instructor) continuously squeeze a bag of the fake blood into the mannequin’s mouth during the intubation attempt.
- The Lesson: Students must learn to lead with the suction catheter, park it in the esophagus to “drain the swamp,” and then intubate above it. It’s a high-stress, high-dexterity skill.
2. The “Hail Mary”: The Sengstaken-Blakemore Tube
In a massive variceal bleed that won’t stop, the Blakemore tube is the legendary “last resort.” It’s a large tube with two balloons (one gastric, one esophageal) that physically crushes the bleeding veins.
- Why it’s great for Sim: It’s a complex, multi-step procedure that most residents have only read about.
- The Stressor: To make it realistic, have the monitor show the heart rate climbing to 160 (SV-Tachy) while they struggle to get the tube down.
- Pro Tip: If they don’t check the balloon pressures or anchor the tube correctly (using a football helmet or a traction weight), have the “blood” start spraying again to show the intervention failed.
3. The Massive Transfusion Protocol (MTP)
Shock isn’t just about stopping the leak; it’s about replacing the fluid.
- The Recommendation: Force the team to activate the MTP.
- The Gear: Bring in a Rapid Infuser (Level 1 or Belmont) if your sim lab has one.
- The Lesson: This tests communication. Who is calling the blood bank? Who is tracking the “Lethal Triad” (Acidosis, Coagulopathy, and Hypothermia)?
- Simulation Detail: Give them “fake” blood bags (water with red food coloring) and tell them the blood is “cold.” If they don’t use a fluid warmer, have the mannequin go into a shivering/rigors state or develop an arrhythmia on the monitor.
4. The “Ethical Pivot” (Optional but Powerful)
Since this is a chronic alcoholic with end-stage liver disease (jaundice, ascites, encephalopathy), the prognosis is grim.
- The Twist: Mid-resuscitation, have a “family member” (played by an actor or the instructor) arrive and mention that the patient “never wanted to be on a machine.”
- The Lesson: This forces the students to pivot from Aggressive Resuscitation to Palliative Ethics in the middle of a literal bloodbath. It’s a gut-punching lesson in the reality of the ED.
Summary Table for your Sim Design
| Feature | The Goal | The “Moulage” Required |
| Airway Crisis | Master the SALAD technique | Active “bleeding” from the mouth during intubation. |
| Circulatory Collapse | Manage MTP & Rapid Infusers | Empty IV bags and a “Cold” mannequin. |
| Mechanical Tamponade | Deploy the Blakemore Tube | A messy, lubricant-heavy tube insertion. |
| Team Dynamics | Close-loop communication | Noise, “family” interference, and monitor alarms. |
Final Recommendation: Start with the SALAD Airway and finish with the Blakemore Tube. It turns a “medical case” into a “surgical emergency” and will be the one simulation your students talk about for the rest of the year.
Scenario Advancement Possibilities To Consider
Do you have the equipment for a Blakemore tube, or should you stick to the more common “intubation and pressors” route?
This is where the simulation branches based on your learning objectives. Are you testing mechanical technical skills (Option A) or clinical decision-making and pharmacology (Option B)?
Here are the recommendations for both pathways.
Option A: The “Surgical” Route (SALAD & Blakemore Tube)
Best for: Advanced learners, Emergency Medicine Residents, or ICU teams.
This option focuses on the “hands-on” chaos of a high-volume bleed where the patient is literally drowning in their own hematemesis.
1. The Airway: SALAD Maneuver
Because your “Variceal Gusher” recipe contains chunks (tomatoes/oatmeal), standard suction will fail.
- The Setup: Hide a 500mL bag of fake blood under the mannequin’s pillow, connected to a tube in the corner of the mouth. An assistant “pumps” the bag as soon as the laryngoscope enters the mouth.
- The Goal: The student must use the Yankauer as a “plow” to clear the airway and then park it in the left side of the esophagus to allow visualization of the vocal cords.
2. The Intervention: The Sengstaken-Blakemore Tube
- The Mechanics: This tube has a gastric balloon (250-300mL) and an esophageal balloon.
- The Challenge: Students must remember to test the balloons in water first, lubricate the tube excessively (more “visceral” mess), and use a manometer to ensure they don’t rupture the esophagus.
- The “Anchor”: For realism, have them secure the tube using a football helmet or a 1L IV bag hanging over a pulley. It looks archaic and dramatic—because it is.
Option B: The “Medical” Route (Intubation & Pressors)
Best for: Nursing students, Medical students, or standard ED staff training.
This option focuses on the physiological “balancing act” of managing shock with fluids, drugs, and standard airway protection.
1. The Volume Dilemma
- The Scenario: The patient is hypotensive (70/40). Students will instinctively want to start Norepinephrine (Levophed).
- The Teaching Point: In hemorrhagic shock, you don’t need “squeeze” (pressors), you need “tank” (blood).
- The Twist: If they start pressors before blood/fluids, have the heart rate spike to 170 and the blood pressure drop further on the monitor. This teaches them that “clamping down” on an empty heart causes cardiac arrest.
2. The “GI Cocktail” (Pharmacology)
The students should be tasked with ordering and hanging the “Big Three” for variceal bleeds:
- Octreotide: To reduce portal pressure.
- Proton Pump Inhibitors (PPI): High-dose infusion.
- Ceftriaxone: Prophylactic antibiotics (crucial for cirrhotic patients with GI bleeds to prevent SBP).
3. Standard Intubation
Instead of the “Gusher” during the procedure, focus on the hemodynamic collapse that happens after induction.
- The “Crash”: As soon as they push the sedative (Propofol or Etomidate), the patient’s BP should bottom out ($50/palp$).
- The Lesson: They must be prepared to “resuscitate before they intubate.”
Comparative Summary
| Feature | Option A: Surgical/Mechanical | Option B: Medical/Stabilization |
| Difficulty | High (Technical) | Medium (Cognitive) |
| Mess Level | Extreme (Active pumping of “blood”) | Moderate (Blood stays in the basin) |
| Key Equipment | Blakemore Tube, Manometer, SALAD kit | IV pumps, standard RSI kit, “Fake” Blood |
| Success Criteria | Successful balloon placement & airway control | Proper fluid resuscitation & Med administration |
| Ending | Transfer to GI/OR for emergent scope | Stabilization for ICU transfer |
Pro-Tip for the “Flammable” Smell
Regardless of the option you choose, keep the “Alcohol/Vinegar” scent localized. Wet a few 4×4 gauze sponges with the mixture and tuck them into the mannequin’s “armpits” or inside the collar of the gown. As the students lean in to listen to breath sounds or intubate, the scent will rise and hit them—creating that immediate, visceral realization of the patient’s history.
Take decisions based on which routes feel more like the “vibe” of your training session.
Setup & Cleanup
Here is a curated list of products to help you build, protect, and clean this scenario.
1. Recommended Manikins (The “Body”)
You need a manikin with a “non-electronic” or “protected” airway that can handle fluids.
- High-Fidelity: Laerdal SimMan 3G / ALS: These are the industry standard. They can simulate the monitor changes and have realistic lung sounds.
- Note: Use an external “bypass” tube for the blood to avoid ruining the internal sensors.
- Procedural: AirSim Advance Bronchi (TruCorp): If the focus is strictly on the SALAD technique and Blakemore insertion, this head is unmatched. The silicone is incredibly durable, and the airway is anatomically “wraparound” to handle heavy suctioning.
- Cost-Effective: Nasco Life/form Adult Airway Management Trainer: A “low-tech” rugged head that you can pour liters of fake blood through without fear of breaking a $100k computer.
2. Protection: “The Barrier Layer”
Before the “blood” hits the manikin, you must prime the surface.
- Sim-Safe Barrier Spray: Products like Moulage Concepts Barrier Spray or even a thin layer of Vaseline on the face and chest. This prevents the red dye from leaching into the porous silicone.
- Press’n Seal Plastic Wrap: Wrap the “non-visible” parts of the manikin (the torso under the gown, the hair/wig) in Glad Press’n Seal. It sticks to the manikin but keeps fluids out of the electronics.
- Absorbent Underpads (Chux): Layer these underneath the manikin’s back and the bedsheets. Use the heavy-duty, plastic-backed versions to save your mattress.
3. The “Moulage” Toolkit (The Look & Smell)
- Jaundice: Ben Nye “Mellow Yellow” Creme Color or Mehron Paradise Makeup (Yellow/Ochre). These are professional theatrical grade and wash off easier than food coloring.
- The Smell:Apple Cider Vinegar (for the fermented smell) and Rubbing Alcohol (for the flammable scent).
- Cleanup Tip: Soak these in Gauze Sponges placed in the manikin’s armpits or a small cup hidden in the bedframe so you aren’t spraying chemicals directly on the equipment.
- Scleral Icterus: Yellow Gel Eyeliner (water-soluble) applied to the “whites” of the manikin’s eyes. It wipes off with a damp cloth.
4. Specialized Clinical Gear
- The Tube:Sengstaken-Blakemore Tube (20 Fr). These are expensive.
- Budget Tip: Look for “expired for clinical use” tubes on medical surplus sites for simulation.
- Suction: Yankauer Suction Tip (Rigid) and extra-large bore suction tubing.
- The “Gusher” Pump: A 500mL Pressure Bag or a large handheld syringe (60cc) connected to IV tubing to manually “pump” the blood during the emesis event.
5. Cleanup Essentials (The “Aftermath”)
- Isopropyl Alcohol (70%): The “magic eraser” for most theatrical makeup on silicone, but use it sparingly as it can dry out the material.
- Dish Soap (Dawn): The best degreaser for the cornstarch/syrup blood recipe.
- Enzymatic Cleaner: If you use real organic material (like tomatoes or oatmeal), use an enzymatic cleaner (like those for pet stains) to ensure no bacteria grows in the manikin’s crevices.
- Baby Wipes: Keep these at the bedside. They are the fastest way to “de-jaundice” the manikin immediately after the sim before the color sets.
The “Pro” Setup Checklist
| Item | Purpose |
| Silicone Lubricant | Sprayed inside the airway to make the Blakemore tube slide realistically. |
| Glycerin | To create “cold sweat” on the forehead. |
| Secondary Drain | A bucket hidden under the bed with a hole in the mattress to catch the runoff blood. |
| Utility Sink | Do not attempt this sim unless you have a deep sink nearby for the post-sim “bath.” |
Always do a “patch test” of your fake blood on a small, hidden area of the manikin (like the back of the neck) and leave it for an hour to ensure it wipes off clean before you do the full “Gusher” in front of students!
Spot The Error Challenge – Classroom Exercise
Using this image for a “Spot the Error” exercise is a brilliant way to transition from the e “safety first” reality of clinical practice to the “cool factor” of simulation.
If you were to show this to a group of experienced ED nurses or trauma surgeons, here are the errors they would catch immediately, ranked from “Life-Threatening” to “Technically Incorrect.”
1. The “Splash Zone” Failure (PPE)
The Error: Inadequate Eye and Body Protection.
- The Reality: In a real variceal bleed, blood doesn’t just flow; it sprays. A massive GI bleed is one of the “wettest” events in medicine. If that patient coughs or the suction line kicks back, the team is getting a face full of blood.
- Correction: Every person in that room should be wearing full-face shields or goggles and fluid-impermeable long-sleeved gowns. In the image, eyes are exposed, and arms are bare—a massive risk for blood-borne pathogens (especially given the high prevalence of Hepatitis C in chronic alcoholic populations).
Teaching Tip: Ask your students: “If this patient coughs right now, which one of you is going to the Occupational Health clinic for an HIV/Hep-C exposure protocol?” That usually drives the PPE point home!
The “Real-World” Lesson: If a student walked into this room dressed like the people in the photo, a veteran Charge Nurse would likely grab them by the collar and force them into a yellow gown and a face shield before letting them touch the patient.
2. The Suction Technique
The Error: Passive Suction Placement.
- The Reality: The clinician on the right is holding the suction catheter almost like a straw. In a SALAD maneuver, the suction shouldn’t just be “in the mouth”; it must be aggressively “parked” in the upper esophagus (behind the larynx) to act as a drain so the intubator can actually see the vocal cords.
- Correction: The suction tip should be deeper and held firmly to “decontaminate” the view for the laryngoscope.
3. Bed Height and Ergonomics
The Error: “Back-Breaking” Positioning.
- The Reality: The clinician intubating is hunching over significantly. This is a recipe for a failed airway attempt because it ruins the “line of sight.”
- Correction: The bed should be raised so the patient’s head is at the level of the intubator’s xiphoid process (mid-chest). This allows the clinician to stand up straight and look directly down the airway.
4. Gravity is the Enemy
The Error: Patient is Flat/Supine.
- The Reality: When a patient is actively vomiting, laying them flat on their back is an invitation for aspiration pneumonia.
- Correction: While you have to be flat to intubate, during the “pre-oxygenation” phase, the bed should be in Reverse Trendelenburg (head up, feet down) or tilted slightly to keep the blood from flowing back into the lungs.
5. The “Missing” Staff
The Error: Where is the Recorder?
- The Reality: You have three people focused on the “head and belly.” In a shock scenario, you need a “Clean Hands” person at the computer or a whiteboard recording the time of meds (Octreotide, TXA, Sedatives) and how many units of blood have been given.
- Correction: A “Recorder” is vital to prevent “over-resuscitation” or missing a critical med dose during the chaos.
The “Hidden” Clinical Catch (Pro Level)
The Error: The Pulse Oximetry (85%) and the BP (70/40).
- The Catch: In a patient this “shunted” (vasoconstricted and pale), a finger probe (Pulse Ox) is almost always inaccurate. The blood isn’t reaching the fingertips.
- Correction: A good clinician would be asking for an Arterial Line or an ABG (Arterial Blood Gas) because you cannot trust a finger probe on a patient in profound hemorrhagic shock.
The Error: The MTP (Massive Transfusion Protocol) Setup.
- The Reality: On the right side of the image, the blood bags are hanging by gravity.
- Correction: In a patient with a BP of 70/40, gravity is too slow. Those bags should be inside Pressure Bags or hooked up to a Rapid Infuser (like a Level 1 or Belmont) to “slam” the blood in at 500 mL/min.
Which of these errors do you think your students would miss most often?