Simulation Scenario Pack - MOH

Western Sussex Hospitals Trust Simulation Centre

Created by: Julie Turner - Clinical Skills and Simulation Manager

Edited by:Dr Keri Ashpole - Anaesthetic Consultant

Sarah Bolger - Practice Development Midwife

Miss Alison Crocker - Consultant Obstetrician

This document is designed to assist you inyour scenario in the simulation suite. By reading all sections in this document, you will have all the relevant information to run your station.

This scenario was originally designed to be used with SimMom as an immersion simulation in a dedicated sim lab. However, it has been rewritten to allow it to be used in a setting with no access to any specialised simulation kit.

Contents

Rules for simulation4

Curricular information5

  • Education Rationale
  • Learning objectives

Demographics6

  • Scenario details
  • Simulation plan
  • Patient details

Preparation7

  • Station kit requirements

Handover8

Scenario route card9

Debrief points specific to this scenario 10

Debrief points for all simulation 11

Rules

Participant Guidelines for Simulation

  1. Whether there is a mannequin or a patient actor for your station, treat them with respect as you would a real patient, and treat the scenario as a real patient interaction as much as possible.
  2. Actively participate in the simulation and provide respect, support and encouragement for those around you. This is a team learning experience in a safe, non-threatening environment.
  1. Remember that mistakes are puzzles to be solved, not crimes to be punished.
  1. Do not discuss the patient’s situation or anyone’s performance outside this room. “What happens in simulation stays in simulation.”
  1. Follow safety, quality of life, and infection control standards.
  2. Time is limited. Be prepared to change activities as directed.
  1. Use the telephone in the scenario to call required help if needed. DO NOT use your hospital’s real emergency number

Precautions for Simulation Mannequins

  1. All mannequins are to be operated by trained personnel only.
  1. Any special instructions for using the mannequins will be explained to you by the faculty beforehand.
  1. Wash hands prior to using the mannequins and use gloves as appropriate when working with the mannequins.
  1. Do not perform mouth-to-mouth respirations on the mannequins.
  1. Do not place felt tipped markers, ink pens, acetone, iodine, or other staining medications, newsprint or inked lines of any kind on or near the mannequins, as it will stain them.
  1. Do not bring food or drink anywhere close to the mannequin.
  1. Do not introduce fluids into the torso area without advanced training. At no time are fluids to be introduced into the left (BP) arm.
  1. Do not use sharps on mannequins.

Curricular Information

Educational Rationale:

Learning Objectives:

Demographics

Case Title:Major Obstetric Haemorrhage (Postpartum Haemorrhage)

Patient Name:Tamsin

Simulation Team:

Lead faculty: normally an obstetric or obstetric anaesthetic consultant or senior registrar

Role: Manage clinical picture, take notes for debrief, lead debrief.

Supporting faculty: could be any senior doctor/midwife

Role: Midwife giving handover, extra support in station scenario is needed, help facilitate debrief

Patient actor: could be any member of the MDT team

Role: Patient (with PROMPT pelvis attached if kit available)

Simulation Plan

Time Line:

1-2 minutes: Handover/scenario brief

2-15 minutes: simulation

15-30 minutes: Debrief and discussion

Patient Details

Patient Age:43

Normal BMI

Patient Allergies: nil

Past medical History:nil

Current Obstetric History:P3NVD 4.2kg male infant (30 min ago)

Current Medication:nil

Preparation

The following props and kit should be available for this station:

Equipment / Alternatives if no specialised kit available
Patient Actorsitting with PROMPT pelvis under a gown / Can manage without PROMPT pelvis if necessary
‘Blood’ soaked incontinence sheets (IS)* / Approx. 2 litres ‘clot’ and ‘blood’
Fluid bag in pelvis to simulate atonic uterus / Fluid bag on actor’s abdomen if no sim pelvis available
Bed with head rest /pillows
Baby doll wrapped in a towel
Wall oxygen , oxygen mask (selection), oxygen tubing / Does not need to be connected to anything
BP cuff / Does not need to be connected to anything
Oxygen saturation probe / Does not need to be connected to anything
Emergency buzzer / Can just be a photo stuck to the wall
Drip stand
PPH Emergency Box**
Syntocinon infusion pump / Can just be a photo stuck to the wall
Laminated photos of O Neg Blood / With hole punched to allow it to be hung up on drip stand
Prescription Chart for patient
Blood Prescription Chart
Anaesthetic Chart
Maternity Notes
Haemacue / Can just be a photo
ABG syringes

*Undiluted Ribena works well as blood, and strawberry jelly makes lovely clots!

**contains laminated PPH protocol from local unit

-Laminated PPH proforma/checklist with dry wipe marker

-Cannulae with sharps removed

-Blood bottles and forms

-Syringes and blunt drawing up needles

-IV crystalloids

-Blood giving sets

-Simulated drugs as per local protocols (use vials of water)

-Catheter and urometer

-Anything else in your local PPH box

Handover

“This is Tamsin. She is a 42 year old woman who has just given birth to her third baby Joseph who was 4.2 kg.

It was a very quick normal birth - but we had time to get an epidural in which worked well but sadly Dad has missed it but he’s on his way in. It’s been 30 minutes since delivery so he should be here soon.

I gave her 10 units of syntocinon by IM injection following the birth of Joseph. The placenta appears complete but the membranes were ragged - it’s still in the sluice.

I estimated blood loss to be about 300ml, although there has been a constant trickling of blood. I think the perineum is intact, although I haven’t had a chance to fully inspect it yet.

I’m sorry to rush off but I really need to get a cup of tea –I’m gasping!! But I am around for the next 30 minutes if you need me.

(Possibility of a PPH may be considered by the member of staff taking over the patient’s care - be non-committal ‘I suppose she may have bled a bit’ and insist on leaving)

Scenario Outline

At handover the patient is talking but looking wan /tired and starts yawning. At about 1 minute she says she feels strange/ woozy then she becomes drowsy for the rest of the scenario.

Expectations

  • Staff member taking over would call for help/ emergency buzzer
  • Ask for obstetric emergency call to be put out
  • Initiate basics - baby safely into cot, lower head of the bed, oxygen
  • Examine patient
  • Diagnose PPH
  • Ask for obstetric haemorrhage call to be put out
  • PPH Trolley
  • IV Access x 2
  • Blood taken - G&S/ FBC/ Clotting/ Fibrinogen/ +/-haemacue
  • Drugs – Syntometrine /Syntocinon Infusion / Hemabate
  • Estimate blood loss -? Massive Haemorrhage
  • Order O negative blood and administer safely

Drill End

The patient is stabilised and the decision to go to theatre is made.

1

This document remains the property of Western Sussex Hospitals Trust PGMC Simulation Centre

Created by Julie Turner, Clinical Skills and Simulation lead.

Scenario route card

Below is the running program of the scenario. By entering the information it will allow the simulation controller to run the scenario in the planned sequence.

Monitor settings
(actions) / Patient/mannequin
(actions) / Patient voice / Other info
0-30 seconds / Initial State:
RR:20
HR:120
BP:90/60 / Patient sitting up in bed holding baby, but look tired and start yawning
(white face paint to make you look pale /clots of blood under gown / bag of fluid in pelvis to indicate boggy uterus) / ‘Oh! he is so lovely’ (about baby)
‘I wish my husband was here I feel a bit strange, a bit light headed’
30-90 seconds / RR:25
HR:140
BP:80/60 / Flop back and gradually release grip on the baby / ‘Oh! -I feel woozy! –I feel’ –(then just stop talking) -few groans / Expect OBS EMERGENCY call from attending midwife
If not calling for help original midwife to come back in
90 seconds -
3 mins / RR: 25
HR: 150
BP: 70/40 / Remain semi-conscious, making groans and responding with OW! To any cannulation attempts i.e. GCS > 8 / ‘Groans only or Ow!’ But no words
But towards end of scenario if 2 x IV in situ fluid/blood given start to say –what’s happening? ‘My baby’ etc. / Observations are not affected by drugs given only by resus with fluids/blood.
3 minutes – end of scenario / RR/HR/BP
Respond to what is done
1 x IV =110 90/60
2 x IV = 100 90/60
Blood = 100 110/70 / Start moving arms, lifting head from pillow / ‘What’s happening –where is my baby’ / The plan is for her to be stabilised before being moved to theatre.
Consider epidural top up or GA?

You will notice that the plan is broken into 3 with the start, middle, end. This is used to guide the controller during the scenario.

Debrief Points Specific for this Scenario:

General:

  • The importance of recognising haemorrhage before the blood pressure falls! (RR/agitation, then raised HR, then raised diastolic BP, then low SBP)
  • Call for help – MAJOR OBS HAEM Bleep – Who is contacted? Who isn’t? When to upgrade to Massive Obstetric Haemorrhage.
  • Difficulties in estimating blood loss
  • Always check responses to treatment – look at patient, measure vital signs

Specific Responsibilities /dilemmas for each staff Group:

Staff group / Potential problem
Anaesthetists /
  • Resuscitation - How much? To normal BP or wait till cause of bleeding treated?
  • In theatre would you use epidural or give GA?
  • When would you remove epidural?
  • Cell salvage?? Currently not for vaginal blood loss

OPDs /
  • Communicate with anaesthetists and assist resuscitation
  • Suggest fluid warmer
  • Get theatre ready
  • GA Drugs/ vasopressors ready?

Obstetricians /
  • Causes of bleeding –this history –retained placenta + /- cervical tear
  • Leadership/ communication with MDT
  • Stabilisation of patient
  • Treatment plan -theatre

Midwife /
  • Call for help
  • Obstetric emergency initially
  • Management of ABC
  • Baby to place of safety
  • Look at placenta?

1

This document remains the property of Western Sussex Hospitals Trust PGMC Simulation Centre

Created by Julie Turner, Clinical Skills and Simulation lead.

Debrief Points (for all simulation)

This is a generic pathway we suggest you use as a template when facilitating a debrief.

Debriefing is a vital part of simulation training. We recommend you use the ALSG and Resuscitation councils guidelines prepared by Kate Denning, for debrief.

  1. Make opening gambit (phrases)
  1. Jointly explore any issues that emerge
  1. Include impressions / suggestions from the rest of the group
  1. Share your thoughts using advocacy with inquiry
  1. Check whether anyone has any other issues that they want to discuss
  1. Summarize

Underlying principles

Credibility

Authenticity

Empathy

Mutual dialogue

Techniques

Advocacy with inquiry

Listening and responding

Using the group to solve puzzle

Highlighting genuine strengths

Being precise rather then general about what you have observed

Making / sharing concrete suggestions for improvement

Impediments

Easing in and the use of leading questions or tag question

Relentless optimism

Repetition (can be avoided by dealing with issues as they emerge rather then shelving them)

Listing (“You did this, then this, then this…”)

Mechanistic approaches to feedback

More detail to go with the structure

  1. Make opening gambit (phrases). You are looking to start the conversation here. The opening gambit is something of a hurdle you have to get over in order to get the discussion started. Below are some suggestions; their strength however is in being individualized so see them as examples waiting to be tailored.
  • What did you feel were your specific challenges there?
  • Can you tell me what your plan was and to what extent that went according to plan?
  • Can you describe to me what was going on in the group during your discussion?
  • Let’s talk
  • That looked pretty tough. Shall we see if we can work out together what was going on there so that you can avoid that situation in the future?
  • That seemed to me to go smoothly, what was your impression?
  • Can you describe to me what was happening to the patient during that scenario?
  1. Jointly explore issues that emerge.

This will require listening to what the candidate says and picking up on what appears to be the key issue for them. You will probably need to ask additional questions to deepen their thinking and may need to give your own opinion. Where solutions are to be sought your immediate resources include yourself, the practice candidate, the group and other instructors.

Here your role as the facilitator is to deepen and widen the conversation (see the bigger picture); introduce new concepts; challenge perceptions; listen and build on what has been said.

  1. Include impressions / suggestions from the rest of the group e.g.
  2. Let’s check with the rest of the group how they reacted to you saying that.
  3. What did you [members of the group] want from [the facilitator] at that point?
  4. What ideas suggestions has anyone else got for how to deal with that situation?
  1. Share your thoughts using advocacy with inquiry
  2. These can be both strengths and areas for change
  3. Consider the whole group’s learning without overloading the practice candidate: Some points can be left until later
  4. Use advocacy with inquiry to share your observations and explore perception

5. Check whether anyone has any other issues they want to discuss

  • Avoid asking the practice candidate what they would have done differently given another chance. This will already have been covered
  • See whether any other group members or instructors have additional points to discuss.
  1. Summarise
  • Keep this brief

1

This document remains the property of Western Sussex Hospitals Trust PGMC Simulation Centre

Created by Julie Turner, Clinical Skills and Simulation lead.