Septic Abortion Complicated by Disseminated Intravascular Coagulation.

Learner Audience: Interns, Junior Residents, Senior Residents Time Required for Implementation: Instructor Preparation: 30 minutes Time for case: 20 minutes Time for debriefing: 40 minutes Recommended Number of Learners per Instructor: 3–4 Topics: Medical simulation, septic abortion, pregnancy complications, hematology emergencies, obstetric emergencies, disseminated intravascular coagulation, emergency medicine. Objectives: By the end of this simulation session, the learner will be able to: Obtain a relevant focused history, including pregnancy history, medication use, and past medical history. Develop a differential for fever and vaginal bleeding in a pregnant patient. Discuss management of septic abortion, including empiric broad spectrum antibiotics and obstetric consultation for source control with dilation and curettage (D&C). Discuss expected laboratory findings of disseminated intravascular coagulation (DIC). Discuss management of DIC, including identification of underlying etiology and supportive resuscitation with blood products. Review the components of blood products. Identify appropriate disposition of the patient to the intensive care unit (ICU). Patients with septic abortion require prompt recognition, treatment, and transfer to an operating room for D&C once initially stabilized. In this scenario, providers will review how to clinically diagnose septic abortion related to retained products of conception with an appropriately focused history and physical exam (objective 1) while still considering and ruling out other differentials that may present similarly (objective 2). Participants should recognize the importance of early resuscitation of sepsis with intravenous fluids and administer broad-spectrum antibiotics (objective 3). Labs and blood cultures should be promptly obtained. In this scenario, participants will also review that DIC may complicate the clinical picture and that their treatment regimen must be expanded to address the need of blood product transfusion (objectives 4, 5, 6). Once the patient has been resuscitated, she should be taken to the operating room (OR) by obstetrics-gynecology (OB-GYN) for a D&C (objective 3) before being admitted in the ICU for further management (objective 7). This simulation scenario allows learners to reinforce septic abortion and DIC management skills in a psychologically-safe learning environment, and then receive formative feedback on their performance. We recommend that instructors review literature regarding septic abortion and disseminated intravascular coagulation (DIC), including presenting signs/symptoms, diagnosis, and management. Suggested readings include materials listed under the “References/suggestions for further reading” section below. This simulation was written for emergency medicine residents to be performed as a high-fidelity simulation scenario. It also may be used as a mock oral board case, or as a case for learners in other specialties. We ran this case with nine small groups of emergency medicine residents over three days. This session received all six and seven scores (consistently effective/very good and extremely effective/outstanding, respectively) other than two isolated 4 scores. The lowest average score was tied at 6.53 for “Before the simulation, the instructor set the stage for an engaging learning experience,” and “The instructor identified what I did well or poorly - and why.” The highest average score was tied at 6.84 for “During the simulation, the instructor maintained an engaging context for learning,” and “The instructor provoked in-depth discussions that led me to reflect on my performance.” The form also includes an area for general feedback about the case at the end. Illustrative examples of feedback include: “Always feel these are great thinking problems, love being in a low-risk situation first,” and “Great review of this less frequent presentation.” Before the simulation, the instructor set the stage for an engaging learning experience. (scores 4–7; 4 comment: “came late.” Mean: 6.54, median: 7) During the simulation, the instructor maintained an engaging context for learning. (scores 6–7. Mean: 6.85, median: 7) The instructor structured the debriefing in an organized way. (scores 6–7. Mean: 6.77, median: 7) The instructor provoked in-depth discussions that led me to reflect on my performance. (scores 6–7. Mean: 6.85, median: 7) The instructor identified what I did well or poorly - and why. (scores 4–7; 4 comment: “No specific feedback.” Mean: 6.54, median: 7) The instructor helped me see how to improve or how to sustain good performance. (scores 6–7. Mean: 6.77, median: 7) One recurring theme that we noticed was that the learners didn’t notice the moulage placed at the intravenous (IV) catheter site to represent ongoing bleeding. Nursing often had to prompt the learners by pointing out the “blood.” In several instances, learners did not recognize this as a trigger to order DIC labs. In these cases, nursing would comment how the IV site was “requiring a lot of pressure to stop bleeding.” Alternatively, moulage depicting petechiae may be used as an additional visual prompt.