Table 1 Overview of simulation scenarios

Summary

Hypotension secondary to sepsis due to tricuspid valve endocarditis with septic emboli and gram-positive

bacteremia in a person who uses intravenous drugs

Pregnant patient with ischemic chest pain, anterior T-wave inversions, and positive troponin at 34 weeks. The patient developed ventricular

fibrillation and a cardiac arrest. The scenario concludes 4 min after the cardiac arrest.

Presenting information

Becky Jones is a 36-year-old G5 P4 woman who estimates she is about 36 weeks GA. She presented with total body pain, non-productive cough and a fever that has been ongoing for the last day. No known COVID-positive contacts. Lives in shared housing.

HR 110, 89/40 mmHg, RR 22, O2 sat 97% room air, temp 38.5

Fetal heart rate: 150 with moderate variability and no decelerations.

Stephanie Barrow is a 34-year-old G1 P0 woman at 34 weeks GA. She developed crushing, retrosternal chest pain radiating to the left arm about 2 h prior to presentation. Her partner drove her to OB triage for further evaluation. She arrives at OB triage at 1 am.

HR 100, 135/70 mmHg (equal in both extremities), RR 22, O2 sat 99% room air, temp 36.5

FHR 150 with moderate variability and no decelerations.

Synopsis of Scenario

Further history reveals current use of cocaine; no features of active labour.

Physical exam demonstrates closed cervix and holosystolic murmur at the left lower sternal border.

Investigations released upon request from the treating team reveal leukocytosis, elevated creatinine, elevated lactate, toxicology positive for cocaine, negative rapid COVID test, ECG demonstrating sinus tachycardia, chest X-ray demonstrating a right lower lobe infiltrate, and POCUS images demonstrating a large vegetation on the tricuspid valve with severe tricuspid regurgitation.

Initial management includes initiation of intravenous fluidsbroad-spectrum antibiotics including MRSA coverage, consultation from infectious disease and/or cardiac surgery.

If fluids are not given, the patient becomes progressively more hypotensive.

Further history reveals no features concerning pulmonary embolism or neurologic symptoms.

Physical exam reveals closed cervix and normal cardiovascular exam.

Investigations released upon request reveal abnormal ECG with deep anterior T wave inversions.

Expected initial management includes aspirin, initiation of heparin, initiation of nitroglycerin, and consideration of a second antiplatelet agent and coronary angiogram when the pain does not improve with nitroglycerin.

The patient becomes unresponsive with rhythm revealing ventricular fibrillation, necessitating cardiopulmonary resuscitation with modifications for pregnant patients including lateral displacement of the uterus, early intubation, and consideration of resuscitative hysterotomy.

Uncertainty prompts

Patient statements:

Patient asks:

“What is going on?”

“Do I need surgery on my heart?”

“Can you make me feel better?”

“What if I go into labour- do I need a C-section?”

Complexity around diagnosis and management:

Patient initially denies drug use

Presence of murmur and intravenous drug use added complexity to the presentation of sepsis and symptoms of pneumonia

Ambiguity around diagnosis and management:

Investigations are only released when requested

ECG, chest X-ray, and POCUS images needed to be interpreted by the treating team, no interpretation was provided with these tests.

Patient statements:

Patient asks:

“Why are you calling a cardiologist?”

“Are these medications safe during pregnancy?”

Complexity around diagnosis and management:

Scenario occurs overnight

CT angiogram not available if requested to assess for pulmonary embolism

Ambiguity around diagnosis and management:

Investigations are only released when requested

ECG findings could be due to anterior ischemia or pulmonary embolism, requiring prioritization of diagnosis based on clinical features.

Management of spontaneous coronary artery dissection is ambiguous with the role of a second antiplatelet agent and angiography in a non-ST elevation myocardial infarction context debated.