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Simulated Injury in Preparation for Disaster

A conversation with Hamish MacPherson, Caroline Thomas and Francesca Laura Cavallo. This interview includes images of simulated injuries and accidents.

Caroline Thomas is a Senior Instructor with Casualties Union, a charity whose members act as casualties and patients for the training of medical professionals, the emergency services, and those who teach first aid, nursing and rescue. I was introduced to Caroline by Francesca Laura Cavallo, an independent curator, writer and researcher engaged in the long term project ‘Rehearsing the Disaster’ which is concerned with pre-disaster scenarios and the proximity between risk assessments, fiction writing and art. In 2016 Francesca and I made There She Lies Motionless, a performance inspired by Caroline’s work which we presented at Manifesta 11 in Zurich. I sat down with them both to find out more about what’s involved in acting as a casualty.

Hamish MacPherson: The thing that occurred to me is that there’s a very specific kind of knowledge about how to feign – is that the right word? – or simulate an injury or an illness which is different from explaining what the illness is in a first aid book. So I wonder if you could talk about that.

Caroline Thomas: We present to each new member a training manual which has instructions on how to simulate both the physical visual injuries, but also how to act them as well as medical problems like strokes and heart attacks. It’s not how to treat it – Casualties Union doesn’t teach first aid: it’s how to make it look real and how one would behave. For example, when you’re expressing pain, you don’t just sit there going, “Ooh ouch, my leg hurts.” You use your body and your expression [winces] “Ooh, my leg hurts” and [her voice straining] even your voice and [now speaking as if in agony] if it’s absolute agony [back to her regular speech] you breathe differently because you’re tense inside. So somebody who’s really feeling awful, doesn’t breathe like a normal person would. And there’s the white knuckle syndrome: “Oh God, I can’t bear any more!” in extreme cases.

HM: I can see now your knuckles are white [from clenching hands].

CT: For example, when I create a wound they want me to take my blood-stained tea-towel and press hard on it for direct pressure. If I really did that, my wound makeup would be ruined. Instead I make a little tent with the cloth but tense my hand so that it looks as if I’m pressing really hard when I’m not, so the wound is undamaged, ready for the next person to come in and treat it. So it’s basically method acting. You don’t just read in your manual, “Right, apparently I’ve got to frown a bit and breathe a little heavily”: you’ve got to feel it from inside and your entire body is expressing the pain or the distress and anxiety that you’re feeling. It takes practice. It’s experience.

HM: Could you talk me through simulating a stroke? How would you teach me that?

CT: If you have just had a fairly minor stroke you are still responsive and can talk. When you’re practising how to do it and you want to have the droopy one side of your face, you’ve got to have a mirror. The first time I did this I sat in front of a mirror and practised making my mouth droop, but it doesn’t work because that takes muscle. And the whole point of this side of my face is that there’s no muscle power. So rather than droop the left side, I ignore it and use only the right side for expression. So when they say “Give me a big grin” I go… [demonstrating a grin on just the right side of her face].  But the left side has to be totally expressionless. My right eyebrow is expressing anxiety and I can move the right side of my lips. It also affects the tongue which moves to the strong side because it can’t pull to the weak side. So your speech… [demonstrates tongue position producing slurred speech] ...that’s why the schpeech is schlightly schlurred. And of course this arm... [with a trembling weak voice] “I’ve got no schtrength in thith hand...and I can move thith leg and thit ,… [now sounding very afraid, almost crying] ...I can’t move the other leg...I’m frightened. My mother had this...” If I say “What’s happening to me? I don’t understand.” Then they shouldn’t say, “Oh, I think you’re having a stroke” because that’s frightening. But if I say, “My mother had this and she got worse,” the first aider could say, “What was it your mother had?” “She had a stroke and I think I’m having one too”. And then they can say, “Okay, if this is a stroke it’s not a very serious one, we’ll get you to hospital straight away.” So it brings out the caring reassurance in them and makes them use tactful words. Whereas sometimes I’m having my heart attack, and they come in in pairs and one will say to the other, “Ring 999 tell them she’s having a heart attack.” And I go [acting scared, shaking] “Oh no!” And I say to them afterwards, “That is quite scary to be told, ‘You’re having a heart attack’.” Now if I already suffer from angina, which is a chronic condition but not the same as a heart attack, my doctor would say, “There is a danger that one day you could have a heart attack.” So if I’m an angina sufferer, I’m probably thinking, “There’s something wrong here, this should be getting better. I had my spray but it’s getting worse. Somebody help me!” And then I will say to them, “I do get angina, but this is not that, it’s worse. I think I’m having a heart attack.” And then they can get on the phone saying, “She thinks she’s having a heart attack. She’s a bit blue around the lips, she’s profusely sweating and she’s struggling for breath.” Whereas if I say to them, “No, I think it’s just indigestion, I expect it will go” then they should say, “She’s having chest pains” and the ambulance service will understand. So just, by acting the role with a bit of thought, you can also help their communication skills.

HM: Can you say where these simulations take place? Because I recently did a very basic one day first aid course and the simulation there involved lying down in the recovery position, but with what your;e doing it seems like a very high level of expertise required...

CT:   I often attend first aid courses. First Aid at Work no longer has to have a formal exam, so we’ve lost a bit of business from that. There are first aid organisations who don’t want us because they’re not having an exam; they’re assessing their students throughout the course. But there’s one London training organisation who have stopped doing exams but their students love Casualties Union so they still use us on the last day. It’s not part of the assessment, although I do at the end get rolled over into the recovery position as part of the exam and we get them to do it right before they leave the building. I’m totally floppy and it’s better to do it on a trained flop than on each other. So I spend two hours there and stage a heart attack, a stroke, a wound, a fracture, a head injury, a seizure, low blood sugar in the diabetic, all sorts of medical scenarios or accidents that they might come across in their workplace. And I act it as realistically as if I was doing it for hospital A&E consultants. Why give them a lesser service? Why make it less realistic, or less frightening just because they’re beginners? I scare them with my heart attack, I’m conscious when they find me; I act severe pain and then collapse unconscious. They put me in the recovery position and I then stop breathing and they have to roll me back and say, “Well, this is where I would do CPR [1].” And I say, “Okay, we’ll stop there”. But then they say to me, and they’re sweating, they say, “That was so, so scary because I forgot it was pretend and I really thought this woman’s life is in my hands. I’ve got to do the right thing. And it was stressful in the extreme, but I think now if it happened again in real life, I could handle it because I’ve had a practice on you.” So I’m quite happy to frighten these people!

HM: I think just then what you showed us with the stroke was so...very different to see...

CT: There’s a huge variety in our work. Last January we were in the Channel Tunnel covered in bullet wounds for paramedics and armed police to look after in a staged terrorist scenario. It was quite exciting. I’ve also been hoisted on the end of a rope off the coast of Norway into a helicopter! It was a huge Scandinavian exercise involving all four countries, all the emergency services and the military. There were 800 casualties on a Swedish ferry. I went over to help make up and then I acted a fractured pelvis. I was stretchered up to the top deck. Down came a rope, hovering above was a Finnish helicopter, and up I went. It’s better than bingo!

FLC: I was thinking about this ability of moving in and out of role. Actors have characters and they enact things, but they present themselves in contexts where we expect them to be acting. This sort of framework of Casualties Union and the training is very much more ambiguous, so I found it fascinating the way you kind of go in and out of role, like you’re talking to us at the same time as you are simulating a stroke…

CT: Yes, you switch on and off as needed.

FLC: So the switching thing is different from the traditional performing arts or theatre?

CT: It is acting, I know I’m acting if I’m doing a heart attack, I’m not feeling really stressed. I’m not feeling real pain obviously, but I’m using my imagination to the extreme as if I were, and expressing that as I believe I would in real life. But when the acting stops and they say, “Right, finished, thank you very much”, then I’m back to normal.

HM: Does it ever happen within a scene that you might move in and out of a role?

CT: In a first aid class you act it and then you stop and then you act it for the next person or we do something different. In the Channel Tunnel we created our bullet wounds and were taken into position but there’s a lot of hanging around. You’re sitting in the central service road between the railway tunnels, and you wait and wait. Half an hour later you hear some shouting and up come the armed police to check whether you’re the baddie or not, so at that moment you start acting and then they disappear and it’s all quiet again for another 45 minutes. And you don’t act through that as it would be exhausting. The real injured person would be lying there, bleeding saying, “Christ, why doesn’t somebody come to help me?” But we just stop acting and have a chat. Ian was sitting next to me and I was lying on the ground because you can’t have them seeing you sitting up and then suddenly you lie down, you know, you’ve got to be in position. I said to him, “Keep an eye open for them.” He said, “I’m seeing a torch.” So I started crawling along the tunnel floor. But then he says “Oh no, it’s alright, it’s one of the safety observers” and I stopped and relaxed. So there is some in and out of role, even on a major exercise.

“I’m in a lot of pain – help me!” 

“Yeah, yeah, just sit down. We’re busy.”

FLC: Also it happens that when you act as a casualty you really believe in the simulation, whilst other participants in the exercise often don’t as much. I found this when we did the exercise at the airport.

CT: Yes, they didn’t participate properly. One of the hardest things is when the people who are supposed to be caring for you don’t take it seriously. We carefully created our injuries as realistically as we could for this plane crash incident. We got into place in the mock plane. The fire brigade came in, got us out and escorted us appropriately to a triage tent. I walked in, acting pain and anxiety and a paramedic said, “Okay, just sit down there.” And I said, “I’m in a lot of pain – help me!” He said “Yeah, yeah, just sit down. We’re busy.” You can’t talk to a patient like that! Then one came up to me and looked at the card that was hanging round my neck – I hate these cards; they turn us into dummies – and it stated what injuries I had and where, then my pulse rate, breathing rate, blood pressure and level of consciousness. We can act abnormal consciousness levels and breathing. We can’t change our pulse or blood pressure at will. It’s on those vital signs that they triage us and that’s the purpose of the card. If your blood pressure is plummeting, you are Priority 1: serious and urgent. If it’s holding well, you’re coping with your injuries so you are P2. If you’re able to walk you’re P3. He looked at the card and giggled a bit. I said, “My leg is bleeding badly.” “Yes, I know, it says so on this card.” He never looked at my injuries and we barely made eye contact. What a waste of time doing the makeup. And if he doesn’t want me to act, what’s the point of me being here? It turns out that all that exercise was interested in was being able to triage correctly. Now they could have done that round a table, as I sometimes do with my St John Ambulance members whom I train.  They have to sort into the three priorities the cards I’ve prepared showing each casualty’s vital signs. That airport exercise was not a happy one. We earned some money for our charity, but it didn’t recompense the humiliation of not being allowed to act or to show our injuries. Our member who works at the airport agreed with me and told them that, when they want us again, they must promise to do it our way or we won’t go. And next year they did it right – it was totally different and a pleasure to be part of.

HM: What are the situations where they really need your simulation skills more than any anything?

CT: It’s where the emergency services want to question and examine us, diagnose our injuries and medical condition, treat us appropriately and sort out the serious from the less serious because if you’ve only got a limited number of ambulances, you’ve got to decide who goes first – that’s triage.

FLC: In a way every kind of training is useful if you have real people, even if we don’t have any injuries...

CT: Like the passenger reception centre exercise at another airport. Airports have to test the ability to handle a plane load of uninjured but frightened people. They’ve had a nasty landing and the plane can’t go, so they’ve got to get out, they’ve got to be taken to somewhere that’s safe and warm and be fed and watered, and then got home to wherever they need to be. So we have to act the fear and distress and sometimes anger, and we’re happy to do that. Occasionally they say, “Let’s spice it up. Why don’t we have somebody suddenly springing a nosebleed?” So I might ask a staff member to take me to the ladies cloakroom and I’ll take a small container of Casualties Union blood with me. I’ll come back with blood on my face and clothes and a handful of toilet paper and they’ve got to deal with that. Or sometimes one of us has said, “I’m feeling dreadfully faint” and they’ve got to handle that. We only present these complications by prior agreement.

We also offer feedback. There are two kinds of feedback. One is during the scenario, so if a policeman came up and waved his arms and shouted, “Get back, get back!” I’d act like a frightened old lady, reacting as you would to how you’re treated. But the other type of feedback is in a debrief afterwards, “How do we think it all went? Did that go well?” And then we’ll put our hand up and say, “Can I make a suggestion,” And we’ll bring up things that we think could be improved. Even in a first aid class, in a more simple situation, you’ve still got those two feedbacks. One is where I’ve got, say, a broken collar bone and they say, “You’ll be alright.” [mimes patting someone’s shoulder] “Aaarghh! Don’t do that.” You give instant feedback as they treat you. Or if they put you in a nice sling and you say, “Thank you, that’s so much better. You give them positive and negative feedback as appropriate. And then we’ll have a debrief afterwards and I’ll say things like, “I think you invented that sling is not the arm sling, it’s not the triangular sling, but I have to say it did its job. Though a standard sling would have been more comfortable.”

Acting unresponsive is one of the hardest things to do.

HM: Can you talk to me about flopping?

CT: Acting unresponsive is one of the hardest things to do. If you are deeply unconscious from an abnormal cause other than sleep, then your muscles go relaxed. You’re lying there, they have probably opened your airway, checked that you are breathing and rolled you into the recovery position. They might not do it very well and put you into a position like this [demonstrates with chin tucked down]. Now among your floppy muscles is your tongue, which flops to the back of your throat and covers up the trap door that you breathe through. So I’ll go [demonstrates sound of struggling breath]. I’m actually breathing quite happily, but I’m giving some sounds of air obstruction until they think, “Oh my God, I must do something” and they open the airway with the head-tilt-chin-lift technique and the breath rushes in. With the limbs, if they pick your knee up to pull you over and let it go, it’s got to flop out. If they pick your hand up, it’s got to go crashing down. Of course, if they pick up my head and let go, I will let it down gently because I don’t want to be hurt. It will come out in the debrief. But they are often astonished at how floppy I am because it’s not like that when they practise on each other. It doesn’t help if you make the recovery position easy for them; you’ve got to flop exactly where you’re put. If they roll you over too far and you’re on your tummy, you’ve got to make the point afterwards that, “If you restrict my diaphragm, my breathing is going to be so shallow, that I’m not going to get enough oxygen.” The life saving manoeuver of the recovery position is so important that if we don’t act it realistically they’ll make mistakes on real people.

HM: And is falling or collapsing related to that? Are you taught how to faint?

CT: Some people are able to do the sort of knee-twist-slump-down technique. I personally don’t. I’m 76. I don’t want to break any bones and I’ve never been very athletic. I was terrible at gym. I hated jumping over vaults in case I fell so I’m very, very nervous about physical injury. But you can easily act a faint without falling. You can walk into the room and say, “I don’t feel well; I think I’m going to faint!” And they should get you down. If they don’t, I’ll get down safely and I’ll be in a position so that I can slump without hurting myself. Similarly with an epileptic seizure, we are not allowed to do the Tonic Clonic fall from standing or off a chair, because you could injure yourself really seriously. But there are ways around it. We can either send a pair of first aiders out and bring them in while I’m having my seizure or I can go into the classroom and say to the trainer, “Mary, do you mind if I lie down somewhere? I think I’m going to have one of my turns, I’m getting my tingling feeling. You understand don’t you?” She says “Yes, Caroline, lie down over there, it’s alright, you’re safe here.” Some people with epilepsy get a sensation, known as an aura, that their seizure is about to start and it gives them time to get safe. So then I lie on my back and suddenly I’ll make a noise, go stiff then do the convulsions and the trainer will get two people to look after me.

HM: How do you perform a convulsion or a fit like that?

CT: There are many different kinds and lots of variation. In the Absence Seizure the person may stop talking, nod a few times, roll the eyes, and then return to normal with, “Sorry, what was I saying?”  Then there’s the Tonic Clonic, which is the rigid stage, holding breath and then the convulsions which can go on for a few minutes. And in between those, there are many others. You know, when you go to bed at night, sometimes your leg gives a twitch. Well the whole body can do that, or a spasm that lasts a few seconds, followed by confusion. Then there’s the type where they have impaired awareness; they can see things but don’t recognise what to do with them and behave irrationally, perhaps fiddling with their clothing, making strange noises, mouthing movements, and after a few moments it’s all over. First aiders need to know how to handle them, especially the Tonic Clonic Seizure which is violent and they can hurt themselves. I’ve had them shouting at me, trying to wake me up, and so I come round terrified and have another seizure. In the debrief you explain that everything must be quiet and calm and let the seizure finish in its own time without interfering other than protecting them. One man was standing astride over me shouting, “Wake up!”, and when I came round I screamed, which frightened him! It’s a wonderful learning tool. In the debrief he promised never to do that again.

FLC: I’ve always been very intrigued by your emotional involvement in this. I know you’ve been doing this for a very long time…

CT: Since 1982.

FLC: So has this changed? Do you feel that it’s tiring to do this, to go in and out from these states?

CT: It takes a lot out of you, but I’m still full of energy. There was one day when I had to do makeup in one hospital in the morning in another hospital in the afternoon and act in a Red Cross competition in the evening. Three duties in one day was tiring. It’s like acting on stage: exhausting. But it also stimulates you and keeps you going.

FLC: Do you think about whether it could happen to you for real? It’s what happened to me when I volunteered for Casualties Union. It wasn’t particularly difficult to act something because I could connect emotionally.

CT: Yes, I’m constantly thinking I could have this. If I’m acting a car crash incident I think to myself how dreadful it would be to be in a crashed car. It’s why I use cars as little as possible. And incidentally, the other thing I do which is associated with this, but it’s not Casualties Union, is the UK Rescue Organisation which runs competitions for fire-fighters in cutting people out of smashed cars. I’m one of their assessors and I’ve got a program of weekends throughout the year when I travel around the country and spend a day or more being cut out of several cars, some on their side or upside down. I climb inside and wait to be rescued. I have a radio mike so that the medical assessor outside can hear what’s going on, but cannot see after I am covered with plastic sheeting to protect me from glass. So when I am out after the test I confirm whether “I’ll just feel your pulse” actually happened correctly. But, car travel makes me nervous!

FLC: It’s still about this emotional connection or disconnection: does knowing so much about these things makes you feel that you can control them a little bit or not?

CT: It makes me more careful with my health probably, but then I always have been. You know, I eat sensibly. I don’t smoke, I don’t drink much. I cross the road carefully. Actually being in Casualties Union makes you more safety aware, because when we’re staging a scenario like falling off a ladder, you think, “Now how could this accident happen? Where would I have fallen? What would happen to the ladder? And the paint pot and spilled paint?” So when I need to use a ladder to pick mulberries, I think very carefully about how I can make this really safe. There are programs on TV and YouTube about people doing stupid things on skateboards and so on. I cannot watch it any more. I can see what’s going to happen and then it happens. The lucky ones jump up and it’s okay because they’re on grass and they are young and fit, but I think, “If there had been a wall there you’d have smashed your head.”

HM: Have you ever been in a situation where you’ve been attended to for real by a first aider?

CT: Do you know, I don’t think I have, other than kind people helping me up when I trip on the pavement. I’ve always treated myself. I’ve never broken a bone apart from official surgery, as in a tooth implant where they had to break my jaw and bunion surgery where they broke my toe to straighten it. So I know what broken bones feel like, but I’ve never had a serious accident.

FLC: Don’t you put yourself in a very vulnerable position when you are acting as casualty?

CT: Yes, you’re vulnerable to having a hand trodden on and all sorts of things. Or you get cold and wet. But if there’s a serious danger on any big exercise, then we have safety observers to watch over you. The vulnerability adds to the realism but it’s good to know that there’s somebody walking around with a yellow tabard saying, “Are you alright? Not getting too cold?” because occasionally strange things happen. At London City Airport years ago when it was still being built they used an open space – later a runway – for a plane crash exercise. I was put at the bottom of sloping area at the edge and had to act unconscious. Somebody placed me in the recovery position and went off to deal with other casualties. Suddenly I found I was in a puddle; the hose from a fire appliance had got disconnected and water was rushing down filling up my hollow. I was relieved when the safety officer said, “Caroline! Stop acting! Get up!”

FLC: I’m also interested in this myth we have with being rescued. I suppose as kids we grow up with this, you know, even fairy tales have these things like being rescued.

CT: The knight in shining armour? Yeah.

FLC: I was just thinking about it...

CT: Sometimes when the participants who are supposed to be rescuing these casualties, when they finally appear, I think, “Oh Christ what are the going to do with me”; they drop the stretcher and they haven’t got the dressings with them and they’re a bit hopeless…”

FLC: I’m just thinking about narratives and happy endings in a way, like every exercise is somehow a happy ending because everybody gets rescued in the end. So you go through this distress, the pain in the exercise...

CT:  Knowing that we’ll get rescued and taken to a safe, warm place and there’ll be a cup of tea later. Yeah. But it’s not what drives me, what drives me to lie in the puddle, in the cold, waiting to be rescued, is the knowledge that they’re going to be better at their job at the end of it. There’s the purpose.

FLC: Yeah. So my other question is about the different kinds of exercises. There are the ones that are made for professionals like first aid or the emergency services And then now we are seeing a widespread emergence of different kinds of training like exercises that are directed to the wider population like you know, Manchester shopping Centre, fire shooting exercise that involves big companies and they do this big choreography in this space. Or maybe what has happened in America; something that really struck me, in the last mass shooting in the school [2] in an article I read they said that basically they were waiting for this to happen and they had rehearsed it many times...

CT: But I read that when the shooting started, the kids all got down below and they’d obviously had a drill to do that and that’s splendid. It’s like the fire drill, but it involves other dangers like shootings. Yeah, it’s vital that are also trained...

FLC: So you think it’s good to involve the wider public population...

CT: Absolutely...

FLC: this kind of exercise?

CT: ...because a crowd could hamper the rescue by running around like headless chickens in a panic. If Grenfell Tower [3] had been better drilled in what to do; always come down the stairs and get out whatever happens in this building, then people wouldn’t have sat upstairs waiting to be... [4]

FLC: Yeah they followed the procedures that they were told to do by the firefighters [5].

HM: To stay in their homes...

CT: Yes. It was a mistake. I think at that stage they didn’t realise what the problem was with the cladding and that it was just going to go the film Towering Inferno.

FLC: Yeah, it’s just sometimes the training itself is designed in a way that may work, but also may not work and maybe cause more problems than alleviate problems...

CT: If the actual situation differs from what they’ve been trained for then they’ll do the wrong thing. I guess it’s inevitable. You can’t prepare for everything. 

“Look what we’re doing to protect you.”

FLC: And also it’s somehow very political and this is very evident. Do you think about  these exercises as being very political?

CT: No. I don’t really think about it.

FLC: Because...and I’m talking about obviously the ones that transcend the realm of the professionals like these gun shooting exercises in America that are somehow designed to prevent these things to happen, but at the same time nothing is being done to deal with...

CT & FLC: ...with the guns...

FLC: it feels in that sense it is a little bit more like an escape, like a very ridiculous...

CT: “Look what we’re doing to protect you.”

FLC:  Yes, but at the same time it’s actually, “No, what you’re showing to us to pretend that you are protecting us…” Which is a little bit what happened I suppose here during the Cold War and the time of the nuclear fallout...

CT: Yes because I can remember all that, back in the late fifties with the Cold War, Russia rattling its sabers. We were all told how to get into your cellar and fill up the gaps and live down there and take your radio and lots of batteries. And nobody did anything of course but that was the scare and it would have been totally ineffective. But we felt at the time that we were being thought about. That they were giving us tips on how to save our own life. It was rubbish. It wasn’t going to work.

FLC: It was for you even as a young person, that was completely rubbish?

CT: I have to say I just laughed at it. I don’t think anything was going to happen. I didn’t think the Russians would be so beastly and happily they weren’t.

FLC: And in that case all the drills were completely pointless anyway because if there is a nuclear explosion there’s no drills that work.

CT: Stuffing paper into the gaps between the walls and the floor and the ceiling, things like that. It’s not going to protect you from nuclear fallout. But I’m in this because I know that accidents happen and that people suddenly fall ill in emergency and somebody has got to be able to look after them. We help them prepare for that, not only getting their techniques and protocols right, but being emotionally prepared to deal with it. I give them the dress rehearsal. A first aid student rang me up and said, “You came to our course, you acted a heart attack, you went into cardiac arrest. I dealt with you and you scared the shit out of me. But I felt more confident. A few weeks later my grandfather collapsed with a heart attack. I did to him what I did to you. He recovered, he is sitting beside me and would like to say thank you” and he passed the phone. So I know it works. And how many other cases have happened, small or large, where the work we do has benefited people in real life?

HM: A big question for me is where does this embodied knowledge come from about these situations?

CT: Our training manual is issued to new members, although it didn’t exist when I first joined. I helped write it! If you are a first aider you treat real casualties and you store them up for simulating later. I also look at the real life A&E films like ‘24 Hours in A&E’. I record them so I can stop and freeze the picture and look at the injury, observe how the dried blood looks: it’s the colour of dark red wine. I watch how they’re reacting to their injuries and the facial expressions. A huge influence on me was the late Mr Peter London who had been a consultant at the Birmingham Accident hospital. He was my mentor. He used to come to our annual training weekends and give presentations and slides of real injuries and anatomical explanations. I learnt so much from him, scribbled it all down, came back, put it on a computer. I bought an Amstrad in 1987 and I’ve still got all the data. Since then I have been bringing it into my own first aid lessons and articles that I’ve written for magazines. Peter London with his huge knowledge of accidents and medical emergencies has influenced Casualties Union a lot.

HM: And would he demonstrate? Would he show video? Some things are harder to capture in words and it seems really useful that you can see ’24 hours in A&E’ because you can see physically what’s happening...

CT: His technology at the time – the 1980s --  was slides and talk. To learn acting and make-up, we join Casualties Union as a Trainee, we do basic training: simple wound, simple bruise, simple acting. When you pass your exam you become a qualified Member. Then you can become a Demonstrator, Advanced Member, and an Instructor. I’m a Senior Instructor so I worked my way up, and all the time we’re learning from more experienced members, from the real casualties I’ve treated and the medical people like Peter London. I’ve only had television since 2002 when my partner Stephen died because he wouldn’t have it in the house. So then I was able to watch things on that. On the Internet you can search for images of burns and other injuries and copy those. You have to sort out the fake from the real because sometimes they’ll put up halloween makeup pictures. I can usually tell if it’s real or not. So there are lots of resources available.

HM: When someone is planning one of these larger incidents, such as the Channel Tunnel, are there people who are experts to place casualties in different locations realistically?

CT: The people who place us in position in the big exercises airports and tunnels are usually the people who run the airports and manage the tunnels. They tend to say to us, “Just spread around a bit. You lot go back 20 yards and you lot go 40 yards further on and just lie wherever you like.” So it’s not very carefully done.

FLC: They never stage the incident itself, it’s always just afterwards.

CT: Normally that’s so, but an exception was the big shopping mall called the Galleria in Hatfield. With other volunteers to boost numbers we were about 100 casualties. It was in the middle of the night and the mall was obviously closed down. We did our make up in a corner and then we were asked to position ourselves: some to hide behind shop counters - it was a shooting attack - others to be wounded lying in the open spaces and a few to be dead. They said, “There’s going to be a lot of noise, including loud bangs, but don’t be frightened because it’s obviously all fake”. Then they actually staged it. There were gunshots and a man came rushing through, shooting these little blanks off. He was the terrorist gun man who had caused the injuries. Then in came the armed police to make the scene safe before the paramedics could enter. So that was probably the most realistic scenario I’ve been in. But yes, usually it’s only the aftermath. In a road tunnel we are in the smashed cars, an alarm goes off and the emergency services, who are stationed nearby, wait a realistic few minutes before they arrive and deal with us.

HM: At the Las Vegas concert shooting in 2017 [6], before the emergency services arrived and even during the shooting  people were already tending to wounds and evacuating.

CT: Yes. I’ve never done anything quite like that. It’s mostly, “Sit quietly and wait until we give you the signal that the emergency services have arrived, and then start acting.” Because otherwise you’re doing it for anything up to twenty minutes. You’re only acting panic and fear and that is exhausting. You need the adrenaline of real life fear to keep you going, to gIve you the energy to do it. Acting it is very tiring and you just run out of steam and start chatting. Then you have to get it all going again when they come So there’s a balance between realism and being able to create it. 

HM: I saw that Casualties Union does mortuary training for major disasters. What is that?

CT: The morticians in the mortuaries cope with the normal daily run of deaths. But if there’s a major incident involving dozens, maybe hundreds of deceased people, like a bomb blast, they will be overwhelmed. So the police, both the Metropolitan Police and the British Transport Police here in London and other police forces around the country have teams that are trained in mortuary work. It’s called DVI: Disaster Victim Identification. And the whole aim is to find out who this person is and get all their belongings together: clothes, rings and watches, and return them if they can find their next of kin. We help the police train for it. Our men wear boxer shorts or swimming trunks and the women wear a swimsuit, then underclothes and overclothes and a few odds and ends like credit cards either in our pockets or loose in the body-bag. We lie on a mortician’s table, happily with a warm blanket under us. The police team are in white hooded overalls and gloves. They put into practice everything they have learned on their course: the protocols and techniques of photographing and recording everything that they see as each garment is taken off. They’ll remove a glove and examine it: “Marks and Spencer, size medium, what’s it made of? Brown leather...” It’s all recorded. Every garment is taken off right down to the swim suit, which doesn’t come off, of course. Meanwhile we just lie there still and quiet. We’ve got a bit of pallor make-up on our faces to make ourselves look as dead as possible.

FLC: You’ve got a lot of time to think while they’re doing this...

CT: Actually you have to concentrate because you have to act floppy and not help. Now, about two years ago in the spring, they did a huge exercise at a disused power station in Dartford. They staged an incident where a building had crashed down onto a station with a train and they had lots of students as casualties, whom they kept feeding into the train through a secret tunnel because the whole thing lasted four and a half days. They had teams of emergency service personnel from Europe who came over and had a go. But we weren’t involved with that. We were in the enormous police mortuary tent with dozens of beds. We provided ten people every day to be strip-searched in this DVI system. We just lie there as still as possible. You can hear the police say, “How are we going to get this jacket off? It’s a bit tight on her. Would it be best if we sat her up?” So they try that and you just go with it as a corpse would and they try their various methods. Then the trainer will come up and say, “Okay, you’ve had a go, let me show you the correct way...” and off it comes. And that’s how they learn. One police team was from Belgium. Three weeks later they had to deal with the Brussels suicide bombing incident [7]. They told the London police that our exercise had helped hugely. Occasionally somebody will come up and say, “You’re shivering a little bit, are you cold?” and I’ll quietly say that I am so they fetch a blanket. If you’re feeling unwell or you get a cramp, you can say, “I’m just coming out of role a second as I have cramp in my leg…right I’m back in role.”

HM: Do the people that are undressing you talk to you, like maybe “Oh, sorry!”

CT: No, they talk to each other, such as: “Look, you hold her head up and I’ll try and slip this over. Oh that’s not working. Let’s try it another way.”

Every garment is taken off right down to the swim suit, which doesn’t come off, of course. Meanwhile we just lie there still and quiet.

HM: And how is it to be in someone’s hands like that? To be undressed?

CT: It’s strange but you get used to it. I took one of my colleagues there once and she said “ Please, never again! It’s been a long time since someone pulled my knickers down and it felt weird!” So not everybody likes it, but I don’t force my members to do anything that they really feel uncomfortable with. I do everything – I’m brave! It really doesn’t worry me. I just keep focused – I’m here because they’ve got to practise on me so that they do it well on a real person. The police have to learn how maintain dignity and respect for the deceased.

HM: Does it feel like you’re getting a unique insight into what it is to be a dead body being looked after?

CT: I’ve learned a lot. In the Dartford mortuary tent not only did we have fingerprints taken, which we often get done, but something happened that doesn’t usually happen; we got wheeled on our trolleys through the big tent to the orthodontics area where a team of dentists examined our teeth and recorded it on a computer. Fascinating. They hold your mouth open, look at every tooth and describe it: whether it’s whole and healthy or if it’s got a filling, or is missing. They’re not allowed to say, “It’s gold” because it might not be gold. They have to say, “It’s yellow metal” and somebody else is sitting at a computer typing it all in and they’ve got codes for each tooth. I had four days of that. It was rather fun. And when they finished and I could stop acting, one of them said, “Tell your dentist that he or she has looked after your teeth very well indeed.” And I did!

HM: And after they’ve undressed you do they check for distinguishing marks or do you hear people describing your body?

CT: They don’t seem to do that now, but the very first time I did it they were looking for blemishes in great detail. I was wearing a one-piece swimsuit and I’ve got moles all over my tummy so they didn’t see those, but they discussed the shape of my nose and one of them said, “Would you call it aquiline?” and I started giggling because my nose is far from aquiline and, and when they said, “I think her ears are pierced” I felt like saying “No, they’re not!” But they don’t seem to be looking for skin marks so much now. Maybe the original DVI training was to get every mole, every shape of the ear and all the rest of it. Ear lobes are a wonderful identification so I’m surprised they don’t do it any more – they can be compared with photographs of the deceased while still alive. Things may have changed..

FLC: Maybe they have more scientific methods now, like testing...

CT: And DNA is used a lot more. Once they unzipped my body bag and found a credit card loose in the body bag, which the trainer had told me to put it there to test them, because there’s no guarantee that it’s mine. Someone said, “Where did this credit card come from?” and a policewoman said, “I think it came out of her knickers.” I thought that’s a very safe place to keep a credit card, unless you’re going to a restaurant and then you might find it rather awkward when you get the bill. But you have to lie still controlling your facial muscles and trying not to giggle. I’ve had to get quite good at that!

[1]  Cardiopulmonary resuscitation – chest compressions with artificial ventilation.

[2] On 23 January 2018 a 15-year-old student shot 16 people, killing two other 15-year-olds, at Marshall County High School, Benton, Kentucky, USA.

[3] The Grenfell Tower fire broke out on 14 June 2017 in the 24-storey Grenfell Tower block of flats in North Kensington, West London, United Kingdom. It caused 72 deaths.

[4] Dr Barbara Lane wrote one of five expert reports published at the start of the fact-finding stage of the public inquiry into the Grenfell Tower fire. In it she said that advice to “stay put” during the fire had “substantially failed” within around half an hour of the blaze starting.

[5] “The stay-put policy is standard for all fire brigades when dealing with high-rise blazes. It is based on the premise that high-rise buildings can be expected to contain a fire in the apartment where it started, a principle known as compartmentation.” Jamie Doward (2018) ‘Fresh controversy over firefighters’ ‘stay-put’ advice at Grenfell’ in 24 Jun 2018

[6] On October 1, 2017, a gunman opened fire on a crowd of concertgoers at the Route 91 Harvest music festival on the Las Vegas Strip in Nevada, leaving 58 people dead and 851 injured.

[7] On 22 March 2016, three coordinated suicide bombings occurred in Belgium: two at Brussels Airport in Zaventem, and one at Maalbeek metro station in central Brussels.

All images courtesy of Caroline Thomas/ Casualties Union.