Simulation Interest Group Scenario Template
I.
Title: Gynecology Simulation Case 1 - 22 year old female
Topic: Female with Vaginal Bleeding and Pelvic Pain
Last Modified: 10/31/2010
II.
Target Audience: All levels of gynecology students and providers
III.
Learning Objectives or Assessment Objectives
A. Learning Objectives
1. Demonstrate the appropriate and early diagnosis of an ectopic pregnancy.
2. Demonstrate the ability to decide which treatment options are most appropriate
for each clinical scenario.
B. Critical actions checklist – a list to ensure the educational /assessment goals are met.
This may include:
1.
Simple checklist of critical actions – built into the case narrative below
2.
Optimal sequence of critical actions – Make the diagnosis, order
appropriate laboratory and radiographic studies, decide to proceed with
management
3.
Duration to critical actions– built into the case narrative below
4.
Scoring based on performance actions – built into the case narrative below
IV.
A.
B.
Case Narrative
Scenario 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.
1. Past medical history
Illnesses: mild asthma
Surgeries: none
2. Meds and allergies
Meds: albuterol inhaler as needed
Allergies: NKDA
Habits: denies smoking and illicit drug use, drinks alcohol 4 times per week, 3-4
drinks at a time
3. OB/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.
4. Physical Exam
Thin, fit appearing female, anxious and in mild distress
Wt : 53 kg T : 37.2 HR : 105
BP : 90/60
RR : 20
Lungs: clear
Heart: normal
Abdomen: slightly distended, tender to palpation in bilateral lower
quadrants with mild rebound tenderness. No masses, HSM, or hernia.
PV: not done
5. Pelvic Ultrasound
Uterus: 7.3 cm x 3.5 cm x 4.4 cm
Endometrium 2.9 mm with no intrauterine pregnancy
Left ovary: 2.2 x 3.8 x 3.4 cm with left adnexal mass of 4.7 x 6.0 x 2.9 cm
Right ovary: 3.3 x 1.5 x 3.8 cm
Free fluid in cul-de-sac: moderate
6. Labs
Urine Pregnancy Test: positive
Hematocrit: 29
White blood cell count 12.2
Electrolytes, Glucose, Blood Urea Nitrogen, creatinine : normal
7. NPO Status
Last ate 4 hours ago
C.
State: Arrive
1. History patient gives: The patient is uncomfortable but complies with all requests.
2. Exam: Abdomen is slightly distended, tender to palpation in bilateral lower
quadrants with mild rebound tenderness without masses, hepatospenomegaly, or
hernia.
3. Phys: HR 105, 90/ 60
4. 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.
5. Transitions:
a. To state: Diagnosis
If: ultrasound & pregnancy test
Points: +200
Debrief: You appropriately performed a pregnancy test and pelvic
ultrasound exam
b. To state: Fluids
i. If: Intravenous Fluid > 999cc and < 2001cc
ii. Points: +200
iii. Debrief: You appropriately administered IV fluids.
c. To state: Fluids
i. If: Intravenous Fluid > 2000cc
ii. Points: -100
iii. Debrief: You administered a very large initial intravenous fluid
bolus
d. To state: Medical Management
i. If: methotrexate administered
D.
E.
ii. Points: -600
iii. Debrief: You should not have administered methotrexate for this
case.
e. To state: Surgical Management
i. If: salpingectomy/salpingostomy ordered
ii. Points: -400
iii. Debrief: You appropriately performed surgery to remove the
ectopic pregnancy, but you did not appropriately order tests first.
f. To state: Delay
i. If: >300 sec elapses
ii. Points: -400
iii. Debrief: You failed to act in a timely fashion during this urgent
clinical scenario
State: Diagnosis
1. History patient gives: The patient's pain is worse and she is beginning to feel
light-headed when she sits up
2. Exam: The abdomen is more distended and there is clear rebound tenderness
3. Phys: BP 88/58 HR 115
4. What Next: Establish IV access and administer fluids
5. Transitions:
a. To state: Diagnosis with Fluids
i. If: Intravenous Fluid > 999cc and Intravenous Fluid < 2001cc
ii. Points: +200
iii. Debrief: You appropriately administered intravenous fluids
b. To state: Diagnosis with Fluids
i. If: Intravenous Fluids > 2000 cc were administered
ii. Points: -100
iii. Debrief: You administered a very large initial IV fluid bolus
c. To state: Surgical Management
i. If: salpingectomy/salpingostomy ordered
ii. Points: +200
iii. Debrief: You appropriately performed surgery to remove the
ectopic pregnancy, but you should have replaced intravenous fluids
d. To state: Medical Management
i. If: methotrexate administered
ii. Points: -600
iii. Debrief: You should not have administered methotrexate for this
case
e. To state: Delay Diagnosis
i. If: > 300 sec elapses
ii. Points: -400
iii. Debrief: You should have performed a pregnancy test and pelvic
ultrasound exam sooner
State: Fluids
1. History patient gives: The patient's pain is worse
2. Exam: The abdomen is more distended and there is clear rebound tenderness
F.
3. Phys: BP 100/70 HR 95
4. What Next: Perform pregnancy test and pelvic ultrasound
5. Transitions:
a. To state: Diagnosis with Fluids
i. If: Intravenous Fluid > 999cc and Intravenous Fluid < 2001cc
ii. Points: +200
iii. Debrief: You appropriately administered intravenous fluids
b. To state: Diagnosis with Fluids
i. If: Fluids > 2000 cc were administered
ii. Points: -100
iii. Debrief: You administered a very large initial intravenous fluid
bolus
c. To state: Fluids with Surgical Management
i. If: salpingectomy/salpingostomy ordered
ii. Points: -400
iii. Debrief: You appropriately performed surgery to remove the
ectopic pregnancy, but you did not appropriately evaluate the
patient first
d. To state: Fluids with Medical Management
i. If: Methotrexate administered
ii. Points: -600
iii. Debrief: You should not have administered methotrexate for this
case
e. To state: Delay Fluids
i. If: >300 sec elapses
ii. Points: -400
iii. Debrief: You should have performed a pregnancy test and pelvic
ultrasound exam sooner.
State: Delay
1. History patient gives: The patient's pain is worse and she is beginning to feel
light-headed when she sits up
2. Exam: The abdomen is more distended and there is clear rebound tenderness
3. Phys: BP 84/54 HR 120
4. What Next: Establish IV access and administer fluids. Perform pregnancy test
and pelvic ultrasound
5. Transitions
a. To state: Delay & Diagnosis
i. If: ultrasound & pregnancy test
ii. Points: +200
iii. Debrief: You appropriately performed a pregnancy test and pelvic
ultrasound exam
b. To state: Delay & Fluids
i. If: Intravenous Fluid > 999cc and Intravenous Fluid < 2001cc
ii. Points: +200
iii. Debrief: You appropriately administered intravenous fluids
c. To state: Delay & Fluids
G.
H.
i. If: Intravenous Fluid > 2000cc
ii. Points: -100
iii. Debrief: You administered a very large initial intravenous fluid
bolus
d. To state: Medical Management
i. If: methotrexate administered
ii. Points: -800
iii. Debrief: You should not have administered methotrexate for this
case
e. To state: Surgical Management
i. If: salpingectomy/salpingostomy ordered
ii. Points: -600
iii. Debrief: You appropriately performed surgery to remove the
ectopic pregnancy, but you did not appropriately order tests first
f. To state: Critical Delay
i. If: >300 seconds elapse
ii. Points: -400
iii. Debrief: You failed to act in a timely fashion during this urgent
clinical scenario
State: Diagnosis with Fluids
1. History patient gives: The patient's pain is worse
2. Exam: The abdomen is more distended and there is clear rebound tenderness
3. Phys: BP 100/70 HR 95
4. What Next: Take the patient to surgery for the ectopic pregnancy
5. Transitions;
a. To state: Fluids with Surgical Management
i. If: salpingectomy/salpingostomy ordered
ii. Points: +600
iii. Debrief: You appropriately performed surgery to remove the
ectopic pregnancy
b. To state: Fluids with Medical Management
i. If: Methotrexate administered
ii. Points: -600
iii. Debrief: You should not have administered methotrexate for this
case
c. To state: Delay Diagnosis
i. If: > 300 sec elapses
ii. Points: -200
iii. Debrief: You should have administered fluids sooner
State: Delay Diagnosis
1. History patient gives: The patient's pain is worse and she is very light-headed
2. Exam: The abdomen is more distended and there is clear rebound tenderness
3. Phys: BP 120 84/84
4. What Next: Establish IV access and administer fluids
5. Transitions:
a. To state: Diagnosis with Fluids
I.
i. If: Intravenous Fluid > 999cc and Intravenous Fluid < 2001cc
ii. Points: +200
iii. Debrief: You appropriately administered IV fluids
b. To state: Diagnosis with Fluids
i. If: Intravenous Fluids > 2000 cc were administered
ii. Points: -100
iii. Debrief: You administered a very large initial intravenous fluid
bolus.
c. To state: Surgical Management
i. If: salpingectomy/salpingostomy ordered
ii. Points: +200
iii. Debrief: You appropriately performed surgery to remove the
ectopic pregnancy, but you should have replaced intravenous fluids.
d. To state: Medical Management
i. If: methotrexate administered
ii. Points: -600
iii. Debrief: You should not have administered methotrexate for this
case
e. To state: Critical Delay & Diagnosis
i. If: >300 sec elapse
ii. Points: -200
iii. Debrief: You should have acted on your diagnostic tests,
pregnancy test and pelvic ultrasound exam, sooner.
State: DELAY with FLUIDS
1. History patient gives: The patient's pain is worse.
2. Exam:
3. Phys: BP 89/60 HR 115
4. What Next: Perform pregnancy test and pelvic ultrasound.
5. Transitions: The abdomen is more distended and there is clear rebound
tenderness.
a. To state: Diagnosis with Fluids
i. If: perform pelvic ultrasound and pregnancy test
ii. Points: +400
iii. Debrief: You appropriately performed pregnancy test and pelvic
ultrasound exam
b. To state: Fluids with Surgical Management
i. If: salpingectomy/salpingostomy ordered
ii. Points: +200
iii. Debrief: You appropriately performed surgery to remove the
ectopic pregnancy, but you really should order pregnancy test and
perform pelvic ultrasound to make the diagnosis first
c. To state: Fluids with Medical Management
i. If: Methotrexate administered
ii. Points: -600
iii. Debrief: You should not have administered methotrexate for this
case
J.
K.
L.
M.
d. To state: Dead
i. If: >300 seconds elapse
ii. Points: -1000
iii. Debrief: You should have performed a pregnancy test and pelvic
ultrasound exam and surgery sooner
EndState: Fluids with Surgical Management
1. History patient gives: Patient is recovering from anesthesia
2. Exam: Patient is recovering from anesthesia
3. Phys: BP 110/80 HR 92
4. What Next: End of case simulation. You met the learning objectives for this case
EndState: Surgical Management
1. History patient gives: Patient is recovering from anesthesia
2. Exam: Patient is recovering from anesthesia
3. Phys: BP 90/60 HR 110
4. What Next: End of case simulation. You met the learning objectives for this case
but should have administered intravenous fluids
EndState: Fluids with Surgical Management
1. History patient gives: Patient is recovering from anesthesia
2. Exam: Patient is recovering from anesthesia
3. Phys: BP 110/80 HR 92
4. What Next: End of case simulation. You met the learning objectives for this case
State: Critical Delay
1. History patient gives: The patient's pain is worse and she very light-headed
2. Exam: The abdomen is more distended and there is clear rebound tenderness
3. Phys: BP 60/20 HR 140
4. What Next: Establish IV access and administer fluids. Perform pregnancy test
and pelvic ultrasound
5. Transitions:
a. To state: Critical Delay then Diagnosis
i. If: perform pelvic ultrasound and pregnancy test
ii. Points: +200
iii. Debrief: You appropriately performed pregnancy test and pelvic
ultrasound exam
b. To state: Delay with Fluids
i. If: Intravenous Fluids >999cc and <2001cc
ii. Points: +200
iii. Debrief: You appropriately administered intravenous fluids
c. To state: Delay with Fluids
i. If: Fluids >2000cc
ii. Points: -100
iii. Debrief: You administered a very large initial intravenous fluid
bolus
d. To state: Surgical Management
i. If: salpingectomy/salpingostomy ordered
ii. Points: +200
N.
O.
iii. Debrief: You appropriately performed surgery to remove the
ectopic pregnancy, but you should have replaced intravenous fluids.
e. To state: Medical Management
i. If: methotrexate administered
ii. Points: -600
iii. Debrief: You should not have administered methotrexate for this
case
f. To state: Dead
i. If: >300 seconds elapse
ii. Points: -1000
iii. Debrief: You failed to act in a timely fashion during this urgent
clinical scenario
State: Critical Delay & Diagnosis
1. History patient gives: The patient's pain is worse and she very light-headed
2. Exam: The abdomen is more distended and there is clear rebound tenderness
3. Phys: BP 60/20 HR 140
4. What Next: Establish IV access and administer fluids
5. Transitions:
a. To state: Diagnosis with Fluids
i. If: tFluid > 999 and tFluid < 2001
ii. Points: +200
iii. Debrief: You appropriately admnistered IV fluids
b. To state: Diagnosis with Fluids
i. If: Fluids > 2000 cc were administered
ii. Points: -100
iii. Debrief: You admnistered a very large initial IV fluid bolus
c. To state: Surgical Management
i. If: salpingectomy/salpingostomy ordered
ii. Points: +200
iii. Debrief: You appropriately performed surgery to remove the
ectopic pregnancy, but you should have replaced intravenous fluids
d. To state: Medical Management
i. If: methotrexate administered
ii. Points: -600
iii. Debrief: You should not have administered methotrexate for this
case
e. To state: Dead
i. If: >300 seconds elapse
ii. Points: -1000
iii. Debrief: You failed to act in a timely fashion during this urgent
clinical scenario.
END State: Dead
1. History patient gives: The patient is unresponsive
2. Exam: The abdomen is soft. The skin is cyanotic. Heart sounds are absent
3. Phys: BP 0 HR 0
V.
4. What Next: Notify the family. You should review the learning objectives and try
this case again
Instructor’s Notes
A.
This scenario was created to run on Anesoft Obstetrics Simulator 3®
B.
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.
C.
Time with a preceptor should occur in close proximity to the case completion to
review the decision-making and objectives of the case.
D.
VI.
VII.
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 Plan
A.
Method of debriefing – debriefing comments provided above for each transition
made during the case simulation as described in the case narrative.
B.
Comments for the debriefing – provided as above
Pilot Testing and Revisions
A.
Numbers 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.
B.
Performance expectations, anticipated management mistakes:
1. Many junior residents take 5 or more minutes to diagnose ectopic pregnancy.
2. Many residents fail to act to definitely diagnose ectopic pregnancy and fluid
resuscitate while they are making management decisions.
C. Evaluation form for participants: Participants receive a detailed printed record of the
case simulation and printed debriefing of their case management.
VIII. Authors and their affiliations
Brenda S. Houmard, MD, PhD and Howard A. Schwid, MD
Departments of Obstetrics & Gynecology & Anesthesiology
University of Washington
Sagittal view of the Uterus – No
Sagittal view of Posterior Cul-de-Sac
Intrauterine Pregnancy
showing free intra-abdominal fluid
Sagittal View of Right Ovary (normal)
Sagittal View of Left Ovary and
Echogenic left ovarian mass Uterus:
of IUP.
Normal. No evidence
Adjacent mass
Endometrium: Normal. Thickness: 2.9 mm.
Fibroid(s): None seen.
Right Ovary: Normal.
Left Adnexa: Mass adjacent to left ovary. No discrete
gestational
sac seen. Small cystic area within mass has some blood flow.
Mass is
heterogeneous and measures 4.7 x 6.0 x 2.9cm.
Cul-de-Sac: Echogenic free fluid. Moderate amount
L: 7.3 W: 3.5 D: 4.4 Volume: 58.8 cc
Uterus (cm):
Right Ovary (cm): L: 3.3 W: 1.5 D: 3.8 Volume: 9.8 cc
Left Ovary (cm): L: 2.2 W: 3.8 D: 3.4 Volume: 14.9 cc
Size (cm): Mass: Lt adnexal L: 4.7 W: 6.0 D: 2.9 Volume:
42.8 cc
SUMMARY
Impression: No intrauterine pregnancy is identified. A
heterogeneous
echogenic mass is seen adjacent to the left ovary that measures
6.0
cm in maximal dimension. There is no clear gestational sac
identified in this mass. Echogenic free fluid is also seen in the
pelvis.