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 ObjectivesA. 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 below2. 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 below4. Scoring based on performance actions – built into the case narrative below

IV. Case NarrativeA. Scenario Background Given to Participants B. 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 asthmaSurgeries: none

2. Meds and allergiesMeds: albuterol inhaler as neededAllergies: NKDAHabits: 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 ExamThin, fit appearing female, anxious and in mild distressWt : 53 kg T : 37.2 HR : 105 BP : 90/60 RR : 20Lungs: clearHeart: normal

Abdomen: slightly distended, tender to palpation in bilateral lower quadrants with mild rebound tenderness. No masses, HSM, or hernia.

PV: not done5. 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 cmRight ovary: 3.3 x 1.5 x 3.8 cm Free fluid in cul-de-sac: moderate

6. LabsUrine Pregnancy Test: positive

Hematocrit: 29

White blood cell count 12.2Electrolytes, Glucose, Blood Urea Nitrogen, creatinine : normal

7. NPO StatusLast ate 4 hours ago

C. State: Arrive1. 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 testPoints: +200Debrief: You appropriately performed a pregnancy test and pelvic ultrasound exam

b. To state: Fluidsi. If: Intravenous Fluid > 999cc and < 2001ccii. Points: +200iii. Debrief: You appropriately administered IV fluids.

c. To state: Fluidsi. If: Intravenous Fluid > 2000ccii. Points: -100iii. Debrief: You administered a very large initial intravenous fluid

bolusd. To state: Medical Management

i. If: methotrexate administered

ii. Points: -600iii. Debrief: You should not have administered methotrexate for this

case.e. To state: Surgical Management

i. If: salpingectomy/salpingostomy orderedii. Points: -400iii. 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 elapsesii. Points: -400iii. Debrief: You failed to act in a timely fashion during this urgent

clinical scenarioD. 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 tenderness3. Phys: BP 88/58 HR 1154. What Next: Establish IV access and administer fluids5. Transitions:

a. To state: Diagnosis with Fluidsi. If: Intravenous Fluid > 999cc and Intravenous Fluid < 2001ccii. Points: +200iii. Debrief: You appropriately administered intravenous fluids

b. To state: Diagnosis with Fluidsi. If: Intravenous Fluids > 2000 cc were administeredii. Points: -100iii. Debrief: You administered a very large initial IV fluid bolus

c. To state: Surgical Managementi. If: salpingectomy/salpingostomy orderedii. Points: +200iii. Debrief: You appropriately performed surgery to remove the

ectopic pregnancy, but you should have replaced intravenous fluidsd. To state: Medical Management

i. If: methotrexate administeredii. Points: -600iii. Debrief: You should not have administered methotrexate for this

casee. To state: Delay Diagnosis

i. If: > 300 sec elapsesii. Points: -400iii. Debrief: You should have performed a pregnancy test and pelvic

ultrasound exam soonerE. State: Fluids

1. History patient gives: The patient's pain is worse2. Exam: The abdomen is more distended and there is clear rebound tenderness

3. Phys: BP 100/70 HR 954. What Next: Perform pregnancy test and pelvic ultrasound5. Transitions:

a. To state: Diagnosis with Fluidsi. If: Intravenous Fluid > 999cc and Intravenous Fluid < 2001ccii. Points: +200iii. Debrief: You appropriately administered intravenous fluids

b. To state: Diagnosis with Fluidsi. If: Fluids > 2000 cc were administeredii. Points: -100iii. Debrief: You administered a very large initial intravenous fluid

bolusc. To state: Fluids with Surgical Management

i. If: salpingectomy/salpingostomy orderedii. Points: -400iii. 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 Managementi. If: Methotrexate administeredii. Points: -600iii. Debrief: You should not have administered methotrexate for this

case e. To state: Delay Fluids

i. If: >300 sec elapsesii. Points: -400iii. Debrief: You should have performed a pregnancy test and pelvic

ultrasound exam sooner.F. 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 tenderness3. Phys: BP 84/54 HR 1204. What Next: Establish IV access and administer fluids. Perform pregnancy test

and pelvic ultrasound5. Transitions

a. To state: Delay & Diagnosisi. If: ultrasound & pregnancy testii. Points: +200iii. Debrief: You appropriately performed a pregnancy test and pelvic

ultrasound exam b. To state: Delay & Fluids

i. If: Intravenous Fluid > 999cc and Intravenous Fluid < 2001ccii. Points: +200iii. Debrief: You appropriately administered intravenous fluids

c. To state: Delay & Fluids

i. If: Intravenous Fluid > 2000ccii. Points: -100iii. Debrief: You administered a very large initial intravenous fluid

bolusd. To state: Medical Management

i. If: methotrexate administeredii. Points: -800 iii. Debrief: You should not have administered methotrexate for this

casee. To state: Surgical Management

i. If: salpingectomy/salpingostomy orderedii. Points: -600iii. Debrief: You appropriately performed surgery to remove the

ectopic pregnancy, but you did not appropriately order tests firstf. To state: Critical Delay

i. If: >300 seconds elapseii. Points: -400iii. Debrief: You failed to act in a timely fashion during this urgent

clinical scenarioG. State: Diagnosis with Fluids

1. History patient gives: The patient's pain is worse2. Exam: The abdomen is more distended and there is clear rebound tenderness3. Phys: BP 100/70 HR 954. What Next: Take the patient to surgery for the ectopic pregnancy5. Transitions;

a. To state: Fluids with Surgical Management i. If: salpingectomy/salpingostomy orderedii. Points: +600iii. Debrief: You appropriately performed surgery to remove the

ectopic pregnancyb. To state: Fluids with Medical Management

i. If: Methotrexate administeredii. Points: -600iii. Debrief: You should not have administered methotrexate for this

casec. To state: Delay Diagnosis

i. If: > 300 sec elapsesii. Points: -200iii. Debrief: You should have administered fluids sooner

H. State: Delay Diagnosis1. History patient gives: The patient's pain is worse and she is very light-headed2. Exam: The abdomen is more distended and there is clear rebound tenderness3. Phys: BP 120 84/844. What Next: Establish IV access and administer fluids5. Transitions:

a. To state: Diagnosis with Fluids

i. If: Intravenous Fluid > 999cc and Intravenous Fluid < 2001ccii. Points: +200 iii. Debrief: You appropriately administered IV fluids

b. To state: Diagnosis with Fluidsi. 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 orderedii. Points: +200iii. Debrief: You appropriately performed surgery to remove the

ectopic pregnancy, but you should have replaced intravenous fluids.

d. To state: Medical Managementi. If: methotrexate administeredii. Points: -600iii. Debrief: You should not have administered methotrexate for this

casee. To state: Critical Delay & Diagnosis

i. If: >300 sec elapseii. Points: -200iii. Debrief: You should have acted on your diagnostic tests,

pregnancy test and pelvic ultrasound exam, sooner.I. 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 testii. Points: +400 iii. Debrief: You appropriately performed pregnancy test and pelvic

ultrasound examb. To state: Fluids with Surgical Management

i. If: salpingectomy/salpingostomy orderedii. Points: +200iii. 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 Managementi. If: Methotrexate administeredii. Points: -600

iii. Debrief: You should not have administered methotrexate for this case

d. To state: Deadi. If: >300 seconds elapseii. Points: -1000iii. Debrief: You should have performed a pregnancy test and pelvic

ultrasound exam and surgery soonerJ. EndState: Fluids with Surgical Management

1. History patient gives: Patient is recovering from anesthesia2. Exam: Patient is recovering from anesthesia3. Phys: BP 110/80 HR 924. What Next: End of case simulation. You met the learning objectives for this case

K. EndState: Surgical Management1. History patient gives: Patient is recovering from anesthesia2. Exam: Patient is recovering from anesthesia3. Phys: BP 90/60 HR 1104. What Next: End of case simulation. You met the learning objectives for this case

but should have administered intravenous fluidsL. EndState: Fluids with Surgical Management

1. History patient gives: Patient is recovering from anesthesia2. Exam: Patient is recovering from anesthesia3. Phys: BP 110/80 HR 924. What Next: End of case simulation. You met the learning objectives for this case

M. State: Critical Delay1. History patient gives: The patient's pain is worse and she very light-headed2. Exam: The abdomen is more distended and there is clear rebound tenderness3. Phys: BP 60/20 HR 1404. What Next: Establish IV access and administer fluids. Perform pregnancy test

and pelvic ultrasound5. Transitions:

a. To state: Critical Delay then Diagnosisi. If: perform pelvic ultrasound and pregnancy testii. Points: +200iii. Debrief: You appropriately performed pregnancy test and pelvic

ultrasound examb. To state: Delay with Fluids

i. If: Intravenous Fluids >999cc and <2001ccii. Points: +200iii. Debrief: You appropriately administered intravenous fluids

c. To state: Delay with Fluidsi. If: Fluids >2000ccii. Points: -100iii. Debrief: You administered a very large initial intravenous fluid

bolusd. To state: Surgical Management

i. If: salpingectomy/salpingostomy ordered

ii. Points: +200iii. Debrief: You appropriately performed surgery to remove the

ectopic pregnancy, but you should have replaced intravenous fluids.

e. To state: Medical Managementi. If: methotrexate administeredii. Points: -600iii. Debrief: You should not have administered methotrexate for this

casef. To state: Dead

i. If: >300 seconds elapseii. Points: -1000iii. Debrief: You failed to act in a timely fashion during this urgent

clinical scenarioN. State: Critical Delay & Diagnosis

1. History patient gives: The patient's pain is worse and she very light-headed2. Exam: The abdomen is more distended and there is clear rebound tenderness3. Phys: BP 60/20 HR 140 4. What Next: Establish IV access and administer fluids5. Transitions:

a. To state: Diagnosis with Fluidsi. If: tFluid > 999 and tFluid < 2001ii. Points: +200iii. Debrief: You appropriately admnistered IV fluids

b. To state: Diagnosis with Fluidsi. If: Fluids > 2000 cc were administeredii. Points: -100iii. Debrief: You admnistered a very large initial IV fluid bolus

c. To state: Surgical Managementi. If: salpingectomy/salpingostomy orderedii. Points: +200iii. Debrief: You appropriately performed surgery to remove the

ectopic pregnancy, but you should have replaced intravenous fluidsd. To state: Medical Management

i. If: methotrexate administeredii. Points: -600iii. Debrief: You should not have administered methotrexate for this

casee. To state: Dead

i. If: >300 seconds elapseii. Points: -1000iii. Debrief: You failed to act in a timely fashion during this urgent

clinical scenario. O. END State: Dead

1. History patient gives: The patient is unresponsive2. Exam: The abdomen is soft. The skin is cyanotic. Heart sounds are absent

3. Phys: BP 0 HR 04. What Next: Notify the family. You should review the learning objectives and try

this case againV. 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. 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.

VI. Debriefing PlanA. 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

VII. Pilot Testing and RevisionsA. 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

Adjacent massEchogenic left ovarian mass Uterus: Normal. No evidence of IUP.

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

Uterus (cm): L: 7.3 W: 3.5 D: 4.4 Volume: 58.8 ccRight Ovary (cm): L: 3.3 W: 1.5 D: 3.8 Volume: 9.8 ccLeft Ovary (cm): L: 2.2 W: 3.8 D: 3.4 Volume: 14.9 ccSize (cm): Mass: Lt adnexal L: 4.7 W: 6.0 D: 2.9 Volume: 42.8 cc

SUMMARYImpression: 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.