Decompensated Toxic Shock in a Gender-Diverse Adolescent: A Pediatric Emergency Medicine Simulation Case

Gender-diverse patients frequently encounter health care discrimination, contributing to delayed care and worse outcomes. Simulation offers a safe environment to integrate trauma-informed, gender-affirming care into high-acuity training. We developed a 1-hour simulation for pediatric emergency medicine (PEM) fellows combining management of toxic shock with affirming communication and trauma-informed practices.

The case features a 13-year-old nonbinary patient presenting with abdominal pain, ultimately diagnosed with toxic shock from a retained tampon. A high-fidelity mannequin capable of intubation and genitourinary exams was used, with a standardized actor voicing the patient. Learners diagnosed and managed toxic shock including progression to decompensated shock requiring intraosseous access and endotracheal intubation. Performance was assessed using a 10-item critical actions checklist. Learners completed a postsimulation survey assessing confidence in providing gender-affirming care, use of trauma-informed communication, and perceived case effectiveness. The simulation was piloted with PEM fellows and is adaptable to pediatric or emergency medicine residents, attendings, and interprofessional teams.

Ten PEM fellows piloted the case. Across 2 sessions, learners completed 9/10 critical actions, with consistent omission of asking pronouns until prompted. All participants correctly diagnosed and managed toxic shock, with surveys indicating increased confidence in providing affirming, trauma-informed care. Seventy percent rated the case very effective and 30% rated it extremely effective in preparing participants to interact with patients using trauma-informed care principles.

This case demonstrates how high-stakes resuscitation training can incorporate equity-focused communication objectives. We offer a complete, educator-facing resource with case materials, script, debriefing guidance, and assessment tools to support adoption.