Health care providers, like athletes, need routine and rigorous training to stay on top of their game. But getting that instruction is challenging for those practicing frontier medicine.
One Montana program is now delivering state-of-the-art simulated training to some of the state’s most remote clinics and hospitals. And experts say it’s helping save lives.
A team of obstetrics nurses from Community Hospital of Anaconda who specialize in pregnancy and newborns is working a particularly challenging simulated case: a five-year-old who was found unresponsive on a local school playground.
He has no obvious injuries, but he’s unconscious, and Timmy’s pupils aren’t responding and his breathing is irregular. An attending pediatrician arrives, accesses the situation and makes a recommendation.
“I’m not getting any breath sounds on the left side. Let’s try pushing a little Narcan.”
Narcan, or Naloxone, is used to treat narcotic overdoses. The nursing team quickly prepares two milligrams of the opioid blocker. Within seconds Timmy is regaining consciousness:
"Are you feeling ok? You had a little accident. Can you tell me your name?"
Timmy doesn’t respond because Timmy is a mannequin. The nurses aren’t even inside Community Hospital of Anaconda. They’re in a 45-foot-long custom-built truck in the hospital’s parking lot. It’s a high-tech, mobile training laboratory operated by a non-profit called Simulation in Motion Montana, or SIM-MT.
Project Director Ben King, says, "We have effectively trained our medical providers the same way we treat 14-year-old lifeguards, for the last couple of decades. We’re finally breaking out of that."
SIM-MT operates three of these rolling training labs; one each in Montana’s western, central and Hi-Line regions. Together they annually rack up over 100,000 miles to provide ongoing medical education to the state’s rural health care providers.
Bozeman based Best Practice Medicine has operated the training program along with a volunteer Board of Directors since 2017. Ben King, the company’s CEO, says the program is the first of its kind in the nation to receive accreditation from the Society for Simulation Healthcare.
"It’s a huge honor for us to be awarded that. It makes us first in the nation. So, Montana can be proud that right here in our own state we’re leading the way in mobile simulation."
SIM-MT instructors use computerized medical mannequins programed to simulate various emergencies.
They build that illusion in a variety of ways. For instance, they appear to breathe and have heartbeats and pulse points. When connected to special monitors they display a heart rate, oxygen levels, blood pressure and other vital signs. They have lots more tricks up their silicone sleeves, including subcutaneous lights to simulate changes in skin color and tone. They react to medications. Their eyes blink and move and the pupils react realistically to light. The mannequins can "live" or they can "die" during training sessions. Timmy’s face can make almost 20 expressions, ranging from shock and anger to inquisitiveness.
"And sometimes if I come in to talk to him, he looks at me, which is really fun," says Joe Poole.
Poole is a simulation team leader and co-founder of the for-profit Best Practice Medicine which helps manage the training program. Poole spent 30 years as an emergency room nurse.
At the beginning of every training session, Poole and his colleagues reassure participants they’re in a safe zone. No harsh judgements will be doled out. No professional penalties recorded. Following the session, they debrief to discuss what worked well and, perhaps more importantly, what did not.
SIM-MT’s Ben King appreciates that honesty and understands the nurses' perspective.
"We didn’t have resources like this up until two years ago in Montana. We just didn’t do this kind of training. These folks here we’ve been working with today, if they had an accidental pediatric overdose that came in, they may have missed it. They are good providers and they care about what they’re doing. It’s not a value statement about the clinicians and their knowledge base. It’s a logistics question of what kind of training do they have access to."
Small rural hospitals in Montana can afford to get this kind of intense training because of a multi-million dollar start-up donation from the Leona M. and Harry B. Helmsley Charitable Trust. The Helmsley Trust announced last week it's awarding the program another $2 million to ensure it can continue offering its services in Montana The project also relies on a three-pronged funding approach including fees, initiative-based funding and philanthropic donations to cover the ongoing costs of travel, training and equipment.
"The training opportunities for us are few and far in between," says Brenda Green.
Green is Chief Nursing Officer of Ruby Valley Medical Center in the small, southwest Montana community of Sheridan. It’s one of the state’s 48 Critical Access Hospitals serving rural Montana.
"If we don’t bring it in, we have to send our staff away. Financially it’s extremely expensive and then there’s time lost when the staff have to leave," she says.
The five-bed Ruby Valley Medical Center has received several SIM-MT/Best Practice training sessions over the past couple of years. Green says it’s an impressive teaching tool.
"Anytime you can use something that’s more lifelike, instead of just going through a scenario and talking through it, pretending to do your actions is gonna be a much better training."
SIM-MT/Best Practice’s Ben King agrees.
"The science is pretty robust," King says. "If I can increase your physiologic heart rate by about 20 percent, I will increase your long-term memory retention by over 60 percent. That’s why the military trains under some psychological stress. Because we want your heart rate to go up. If your heart rate goes up, you’re going to be able to perform better under that stressful circumstance."
The Ruby Valley medical team asked SIM-MT to provide a training session last spring on sepsis infections. These are aggressive infections that can rapidly overwhelm the body. Unless quickly diagnosed and treated, sepsis can lead to sudden death.
Small rural hospitals don’t necessarily see many sepsis cases, but the threat always looms. In health care jargon they’re called "high consequence/low frequency" cases.
Ruby Valley Chief Nursing Officer Brenda Green says SIM-MT’s approach was fresh, engaging and particularly effective.
"We’ve had sepsis training before, but we never did get to train with simulation of a patient crashing right before your eyes. It’s like, 'Ok, what are you going to do next? What are your options?' It makes it more real. Everybody was up on the protocol. Everybody was gung-ho and ready to go if that came through our ER."
And shortly after that mandatory all-hands training session, Green says a sepsis case came through the door. The hospital’s clinicians quickly recognized the symptoms and immediately initiated treatment. Green says that patient is alive today thanks to that fast response.
Ben King says he hears these stories all the time. The SIM-MT program isn’t limited to overdose cases. It also offers childbirth simulators, various trauma training sessions and EMS refresher courses among other programs.
King, a career flight medic, says he quit that job in part because he wasn’t satisfied with the quality of medical training in the healthcare industry, especially for those practicing in rural areas.
"I’ve seen patients that didn’t survive because we didn’t do the right thing. Patients have not survived because I didn’t do the right thing. And that sucks. That’s something you take home with you. But being able to listen to the stories of people who say, 'we trained with you and I did better because of that'; that is the achievement of my lifetime."
According to SIM-MT, it’s so far provided 300 training sessions, educating 5,400 Montana health care professionals.