Simulation Interest Group Scenario Template



Simulation Interest Group Scenario TemplateTitle: Gynecology Simulation Case 1 - 22 year old femaleTopic: Female with Vaginal Bleeding and Pelvic PainLast Modified: 10/31/2010II.Target Audience: All levels of gynecology students and providersLearning Objectives or Assessment ObjectivesLearning ObjectivesDemonstrate the appropriate and early diagnosis of an ectopic pregnancy.Demonstrate the ability to decide which treatment options are most appropriate for each clinical scenario.Critical actions checklist – a list to ensure the educational /assessment goals are met. This may include:Simple checklist of critical actions – built into the case narrative belowOptimal sequence of critical actions – Make the diagnosis, order appropriate laboratory and radiographic studies, decide to proceed with managementDuration to critical actions– built into the case narrative belowScoring based on performance actions – built into the case narrative belowCase NarrativeScenario Background Given to Participants Chief complaint, triage note, medic report - 22 year old healthy, but anxious, female with vaginal bleeding. The patient complains of lower abdominal pain for the last 3 days, worse in the last 6 hours.Past medical historyIllnesses: mild asthmaSurgeries: noneMeds and allergiesMeds: albuterol inhaler as neededAllergies: NKDAHabits: denies smoking and illicit drug use, drinks alcohol 4 times per week, 3-4 drinks at a timeOB/Gyn Hx: never been pregnant, has regular periods but isn’t sure when her last period was. Has no history of sexually transmitted diseases. Never had a Pap smear.Physical ExamThin, fit appearing female, anxious and in mild distressWt : 53 kg T : 37.2 HR : 105 BP : 90/60 RR : 20Lungs: clearHeart: normalAbdomen: slightly distended, tender to palpation in bilateral lower quadrants with mild rebound tenderness. No masses, HSM, or hernia.PV: not donePelvic UltrasoundUterus: 7.3 cm x 3.5 cm x 4.4 cm Endometrium 2.9 mm with no intrauterine pregnancyLeft ovary: 2.2 x 3.8 x 3.4 cm with left adnexal mass of 4.7 x 6.0 x 2.9 cmRight ovary: 3.3 x 1.5 x 3.8 cm Free fluid in cul-de-sac: moderateLabsUrine Pregnancy Test: positiveHematocrit: 29White blood cell count 12.2Electrolytes, Glucose, Blood Urea Nitrogen, creatinine : normalNPO StatusLast ate 4 hours agoState: ArriveHistory patient gives: The patient is uncomfortable but complies with all requests. Exam: Abdomen is slightly distended, tender to palpation in bilateral lower quadrants with mild rebound tenderness without masses, hepatospenomegaly, or hernia.Phys: HR 105, 90/ 60 What Next: Perform quick history and physical exam, including a visual speculum exam of the vagina. Do NOT perform brisk bimanual exam at this time. Establish IV access and administer fluids. Order pregnancy test and pelvic ultrasound.Transitions:To state: DiagnosisIf: ultrasound & pregnancy testPoints: +200Debrief: You appropriately performed a pregnancy test and pelvic ultrasound examTo state: FluidsIf: Intravenous Fluid > 999cc and < 2001ccPoints: +200Debrief: You appropriately administered IV fluids. To state: FluidsIf: Intravenous Fluid > 2000ccPoints: -100Debrief: You administered a very large initial intravenous fluid bolusTo state: Medical ManagementIf: methotrexate administeredPoints: -600Debrief: You should not have administered methotrexate for this case.To state: Surgical ManagementIf: salpingectomy/salpingostomy orderedPoints: -400Debrief: You appropriately performed surgery to remove the ectopic pregnancy, but you did not appropriately order tests first.To state: DelayIf: >300 sec elapsesPoints: -400Debrief: You failed to act in a timely fashion during this urgent clinical scenarioState: DiagnosisHistory patient gives: The patient's pain is worse and she is beginning to feel light-headed when she sits upExam: The abdomen is more distended and there is clear rebound tendernessPhys: BP 88/58 HR 115What Next: Establish IV access and administer fluidsTransitions:To state: Diagnosis with FluidsIf: Intravenous Fluid > 999cc and Intravenous Fluid < 2001ccPoints: +200Debrief: You appropriately administered intravenous fluidsTo state: Diagnosis with FluidsIf: Intravenous Fluids > 2000 cc were administeredPoints: -100Debrief: You administered a very large initial IV fluid bolusTo state: Surgical ManagementIf: salpingectomy/salpingostomy orderedPoints: +200Debrief: You appropriately performed surgery to remove the ectopic pregnancy, but you should have replaced intravenous fluidsTo state: Medical ManagementIf: methotrexate administeredPoints: -600Debrief: You should not have administered methotrexate for this caseTo state: Delay DiagnosisIf: > 300 sec elapsesPoints: -400Debrief: You should have performed a pregnancy test and pelvic ultrasound exam soonerState: FluidsHistory patient gives: The patient's pain is worseExam: The abdomen is more distended and there is clear rebound tendernessPhys: BP 100/70 HR 95What Next: Perform pregnancy test and pelvic ultrasoundTransitions: To state: Diagnosis with FluidsIf: Intravenous Fluid > 999cc and Intravenous Fluid < 2001ccPoints: +200Debrief: You appropriately administered intravenous fluidsTo state: Diagnosis with FluidsIf: Fluids > 2000 cc were administeredPoints: -100Debrief: You administered a very large initial intravenous fluid bolusTo state: Fluids with Surgical ManagementIf: salpingectomy/salpingostomy orderedPoints: -400Debrief: You appropriately performed surgery to remove the ectopic pregnancy, but you did not appropriately evaluate the patient firstTo state: Fluids with Medical ManagementIf: Methotrexate administeredPoints: -600Debrief: You should not have administered methotrexate for this case To state: Delay FluidsIf: >300 sec elapsesPoints: -400Debrief: You should have performed a pregnancy test and pelvic ultrasound exam sooner.State: DelayHistory patient gives: The patient's pain is worse and she is beginning to feel light-headed when she sits upExam: The abdomen is more distended and there is clear rebound tendernessPhys: BP 84/54 HR 120What Next: Establish IV access and administer fluids. Perform pregnancy test and pelvic ultrasoundTransitionsTo state: Delay & DiagnosisIf: ultrasound & pregnancy testPoints: +200Debrief: You appropriately performed a pregnancy test and pelvic ultrasound exam To state: Delay & FluidsIf: Intravenous Fluid > 999cc and Intravenous Fluid < 2001ccPoints: +200Debrief: You appropriately administered intravenous fluidsTo state: Delay & FluidsIf: Intravenous Fluid > 2000ccPoints: -100Debrief: You administered a very large initial intravenous fluid bolusTo state: Medical ManagementIf: methotrexate administeredPoints: -800 Debrief: You should not have administered methotrexate for this caseTo state: Surgical ManagementIf: salpingectomy/salpingostomy orderedPoints: -600Debrief: You appropriately performed surgery to remove the ectopic pregnancy, but you did not appropriately order tests firstTo state: Critical DelayIf: >300 seconds elapsePoints: -400Debrief: You failed to act in a timely fashion during this urgent clinical scenarioState: Diagnosis with Fluids History patient gives: The patient's pain is worseExam: The abdomen is more distended and there is clear rebound tendernessPhys: BP 100/70 HR 95What Next: Take the patient to surgery for the ectopic pregnancyTransitions;To state: Fluids with Surgical Management If: salpingectomy/salpingostomy orderedPoints: +600Debrief: You appropriately performed surgery to remove the ectopic pregnancyTo state: Fluids with Medical ManagementIf: Methotrexate administeredPoints: -600Debrief: You should not have administered methotrexate for this caseTo state: Delay DiagnosisIf: > 300 sec elapsesPoints: -200Debrief: You should have administered fluids soonerState: Delay DiagnosisHistory patient gives: The patient's pain is worse and she is very light-headedExam: The abdomen is more distended and there is clear rebound tendernessPhys: BP 120 84/84What Next: Establish IV access and administer fluidsTransitions:To state: Diagnosis with FluidsIf: Intravenous Fluid > 999cc and Intravenous Fluid < 2001ccPoints: +200 Debrief: You appropriately administered IV fluids To state: Diagnosis with FluidsIf: Intravenous Fluids > 2000 cc were administered Points: -100 Debrief: You administered a very large initial intravenous fluid bolus.To state: Surgical ManagementIf: salpingectomy/salpingostomy orderedPoints: +200Debrief: You appropriately performed surgery to remove the ectopic pregnancy, but you should have replaced intravenous fluids. To state: Medical ManagementIf: methotrexate administeredPoints: -600 Debrief: You should not have administered methotrexate for this caseTo state: Critical Delay & DiagnosisIf: >300 sec elapsePoints: -200Debrief: You should have acted on your diagnostic tests, pregnancy test and pelvic ultrasound exam, sooner.State: DELAY with FLUIDS History patient gives: The patient's pain is worse. Exam: Phys: BP 89/60 HR 115 What Next: Perform pregnancy test and pelvic ultrasound. Transitions: The abdomen is more distended and there is clear rebound tenderness.To state: Diagnosis with FluidsIf: perform pelvic ultrasound and pregnancy testPoints: +400 Debrief: You appropriately performed pregnancy test and pelvic ultrasound examTo state: Fluids with Surgical Management If: salpingectomy/salpingostomy orderedPoints: +200Debrief: You appropriately performed surgery to remove the ectopic pregnancy, but you really should order pregnancy test and perform pelvic ultrasound to make the diagnosis firstTo state: Fluids with Medical ManagementIf: Methotrexate administeredPoints: -600Debrief: You should not have administered methotrexate for this case To state: DeadIf: >300 seconds elapsePoints: -1000Debrief: You should have performed a pregnancy test and pelvic ultrasound exam and surgery soonerEndState: Fluids with Surgical ManagementHistory patient gives: Patient is recovering from anesthesiaExam: Patient is recovering from anesthesiaPhys: BP 110/80 HR 92What Next: End of case simulation. You met the learning objectives for this caseEndState: Surgical ManagementHistory patient gives: Patient is recovering from anesthesiaExam: Patient is recovering from anesthesiaPhys: BP 90/60 HR 110What Next: End of case simulation. You met the learning objectives for this case but should have administered intravenous fluidsEndState: Fluids with Surgical ManagementHistory patient gives: Patient is recovering from anesthesiaExam: Patient is recovering from anesthesiaPhys: BP 110/80 HR 92What Next: End of case simulation. You met the learning objectives for this caseState: Critical DelayHistory patient gives: The patient's pain is worse and she very light-headedExam: The abdomen is more distended and there is clear rebound tendernessPhys: BP 60/20 HR 140What Next: Establish IV access and administer fluids. Perform pregnancy test and pelvic ultrasoundTransitions:To state: Critical Delay then DiagnosisIf: perform pelvic ultrasound and pregnancy testPoints: +200Debrief: You appropriately performed pregnancy test and pelvic ultrasound examTo state: Delay with FluidsIf: Intravenous Fluids >999cc and <2001ccPoints: +200Debrief: You appropriately administered intravenous fluidsTo state: Delay with FluidsIf: Fluids >2000ccPoints: -100Debrief: You administered a very large initial intravenous fluid bolusTo state: Surgical ManagementIf: salpingectomy/salpingostomy orderedPoints: +200Debrief: You appropriately performed surgery to remove the ectopic pregnancy, but you should have replaced intravenous fluids. To state: Medical ManagementIf: methotrexate administeredPoints: -600Debrief: You should not have administered methotrexate for this caseTo state: DeadIf: >300 seconds elapsePoints: -1000Debrief: You failed to act in a timely fashion during this urgent clinical scenarioState: Critical Delay & DiagnosisHistory patient gives: The patient's pain is worse and she very light-headedExam: The abdomen is more distended and there is clear rebound tendernessPhys: BP 60/20 HR 140 What Next: Establish IV access and administer fluidsTransitions:To state: Diagnosis with FluidsIf: tFluid > 999 and tFluid < 2001Points: +200Debrief: You appropriately admnistered IV fluidsTo state: Diagnosis with FluidsIf: Fluids > 2000 cc were administeredPoints: -100Debrief: You admnistered a very large initial IV fluid bolusTo state: Surgical ManagementIf: salpingectomy/salpingostomy orderedPoints: +200Debrief: You appropriately performed surgery to remove the ectopic pregnancy, but you should have replaced intravenous fluidsTo state: Medical ManagementIf: methotrexate administeredPoints: -600Debrief: You should not have administered methotrexate for this caseTo state: DeadIf: >300 seconds elapsePoints: -1000Debrief: You failed to act in a timely fashion during this urgent clinical scenario. END State: DeadHistory patient gives: The patient is unresponsiveExam: The abdomen is soft. The skin is cyanotic. Heart sounds are absentPhys: BP 0 HR 0What Next: Notify the family. You should review the learning objectives and try this case againInstructor’s NotesThis scenario was created to run on Anesoft Obstetrics Simulator 3?Each trainee will require 15-30 minutes to complete the case and read the didactic part of the case. Included are case instructions for the trainee.Time with a preceptor should occur in close proximity to the case completion to review the decision-making and objectives of the case.Limitations: As for any simulated case, it is difficult to anticipate all trainee selections. Individual management decisions during an actual ectopic pregnancy will vary according to the clinical scenario.Debriefing PlanMethod of debriefing – debriefing comments provided above for each transition made during the case simulation as described in the case ments for the debriefing – provided as abovePilot Testing and RevisionsNumbers of participants – this scenario is modeled from the simulations used by the anesthesia residents over the last 2 decades at the University of Washington. This clinical tool uses a modification, making it applicable to OB/Gyn trainees. It has now been incorporated in the training for the first year OB/Gyn residents. Their surveys reveal that this is a worthwhile activity that allows them to be better prepared for similar clinical scenarios.Performance expectations, anticipated management mistakes: Many junior residents take 5 or more minutes to diagnose ectopic pregnancy.Many residents fail to act to definitely diagnose ectopic pregnancy and fluid resuscitate while they are making management decisions.Evaluation form for participants: Participants receive a detailed printed record of the case simulation and printed debriefing of their case management.Authors and their affiliationsBrenda S. Houmard, MD, PhD and Howard A. Schwid, MDDepartments of Obstetrics & Gynecology & Anesthesiology University of WashingtonSagittal view of the Uterus – No Sagittal view of Posterior Cul-de-SacIntrauterine Pregnancyshowing free intra-abdominal fluidSagittal View of Right Ovary (normal)Sagittal View of Left Ovary andAdjacent mass ................
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