The room has gone quiet as a team of three health care workers steps into the hospital room to care for a 32-year-old woman who just delivered her baby at home. The woman is still bleeding and requires immediate help. 
"Can we put her on vitals and get an IV started?" orders Kat Brummell, who, acting in the role of the physician, is directing a crew of three as she attempts to stop the bleeding that is quickly filling a pad.
“Molly, I want you to check to see if we can see the placenta there is intact,” she calls to Molly Witting, who’s taken the role of a nurse, before quickly turning her attention to the patient. “I’m sorry Christina, this might feel painful. I’m going to insert my hand in your uterus,” she says, as she massages the top of the stomach while doing a uterus sweep, pulling out the remaining placenta to stop the bleeding on the manikin.
The exercise — taking part in the high-definition simulation lab at Fort Lewis College’s Nursing Hall — was part of a two-day symposium geared toward providing Four Corners health care workers with training on high-acuity, low-occurrence events.
The event was organized by the University of Colorado Anschutz College of Nursing and Fort Lewis College Nursing Collaborative.
Networking to save lives
More than 45 health care workers from the region, including Pagosa Springs, Farmington, Shiprock and Cortez, participated in the event.
The first day included sessions led by experts on substance withdrawal across care settings, preparing critical patients for transfer, emergency assessment of pregnant and postpartum patients, youth suicide prevention, and a show-and-tell of successful programming taking place in the Four Corners region.
The second day focused on hands-on training for events that rural health care workers might not see often, but for which preparation is key to a successful outcome.
This training included an escape room scenario, in which attendees were separated into three groups and given four OBGYN cases that progressively grew in complexity. Teams had to triage, provide assessments, order tests, and prepare for the worst while ensuring adequate care for current conditions.
The exercise then moved to FLC's high-fidelity simulation lab, a high-tech environment used for clinical simulations in the CU/FLC Collaborative nurse training program. In the lab, attendees worked through three cases, including the postpartum woman, a woman with preeclampsia, and the successful delivery of a newborn.
Fara Bowler, associate professor at the University of Colorado Anschutz College of Nursing and assistant dean of Clinical Simulation Science, said simulation gives rural providers a rare chance to practice high-stakes scenarios without risk to a real patient.
“Simulation lets you make the mistakes here, in a safe space, so you don’t make them at the bedside,” Bowler said. “For rural providers especially, who might only see an event like this once every few years, that repetition builds the muscle memory to act quickly and correctly when it really happens.”
After each scenario, participants debriefed, focusing on their decisions, missed opportunities and correct calls made during the intense scenarios.
Abundance of community
Kelly Stamp, associate dean of academic programs and associate professor at CU Anschutz Nursing, said the event was the result of conversations with clinical partners and leaders and started with a simple question: What would be most meaningful for us to contribute as part of this partnership?
“The answer was remarkably consistent,” she said. “We heard a desire for professional development opportunities, continued learning, and more chances to connect with colleagues across the Four Corners.”
Stamp said the event was also an opportunity for everyone to learn.
"I think we are learning probably more from the rural region than the rural region learns from us. And I think part of the symposium is bringing some perspectives from the metro area, but it’s also highlighting the great work that’s being done here in the rural communities, how the experts in these communities deal with everything that could possibly occur within any given time.”
That abundance was a recurrent theme during the event.
In his keynote speech, Joe Theine, CEO of Southwest Health System, encouraged participants to draw inspiration from the strength of the people in the room, their community, and the partnerships that exist across the state of Colorado and the Four Corners region. 
"When you put all of those experiences together in one room, there's really an abundance of knowledge and resources, and it’s great to see that all coming together in a couple of days of education,” Theine said.
Sara Price, assistant professor of clinical practice at CU Anschutz Nursing and director of Midwifery & Women's Health Services, organized the escape room scenarios and worked with the teams as the patients’ conditions escalated.
“Working with you guys in the rural context has made me think about doing some updates to some of these cases,” said Price during the debriefing, when participants get to discuss how they communicated, how decisions were made and what mistakes took place and how to avoid them in the future. “It’s really interesting to hear all of your perspectives around resourcing, and what do we have, and what we do not have. You’re thinking like three steps ahead already. You were very quick to go to the worst-case potential situation, because you have to.”
Dilan Jones, who, along with Brummell, leads the nursing professional development program at San Juan Regional Medical Center, agreed.
“When you’re in rural health care, you have to follow protocols, and you have to be able to deliver it, and to collaborate really quickly, and you have to build a full new resources so quickly and do all of those things simultaneously to save this life,” she said, adding later that getting to work and learn from Price made the experience especially valuable.
“I really, really loved the networking opportunities,” said Jones.
Zachary Kermitz, a clinical transport supervisor and flight nurse with Intermountain Flight and Ambulance Services, said the company will be doing high-risk OB transports, so he attended the event to make sure his skills are up to date as that process gets underway.
“I wanted to get exposure to both the education side for myself as someone who still works clinically and as a leader for our team,” he said. “What we did was great. We need the repetition because I have done high OB transport in the past, but it’s pushing two years probably since I’ve done one. Just getting the refresher and realizing these are the things that I need to refresh on personally. Super helpful. Super helpful.”
“And to get exposure to a lot of folks who just do OB and getting to spend time with them and learning lingo that I’m not as familiar with because it’s not lingo that we use in an adult trauma patient routinely, it really helped me identify points where I need to study.”
Participants said having the opportunity to share knowledge and learn from other practitioners who work in different settings helped them understand how best to prepare patients for those environments and gave them a sense of empowerment that they’re doing everything they can to help their patients where they are.
April Sandman, public health training associate at Southwestern Colorado AHEC, said she was impressed by how the group, strangers that morning, had developed into teams throughout the exercises, each building off the other and complementing each other's expertise.
“It was really neat to see,” said Sandman, who already was brainstorming was to bring cultural trainings to the group next year.
Bringing training close to home
Megan Higman, director of inpatient services and education and staff development at Southwest Health System, collaborated on the event.
“The interesting thing around healthcare in rural settings is that you got to know a little bit about everything,” she said, adding depending on staffing, people will be moved around to different units depending on need and staffing availability.
“How do you prepare your staff to be able to care for any patient that they may be asked to step in and help with? I think the symposium is helping bridge those gaps.”
Higman said having the opportunity to provide professional development in the area is key. For an employer, she said, sending someone to training in the Front Range for a day-long event might mean paying for flights, hotel, multiple days off and finding the staff to cover during that period.
“If we can bring the training here and provide the education here, you know, it’s financially mindful for organizations, but it's also a great way to network within our own organizations.”
Building community
Back in the high-fidelity sim room, there’s excitement as the third team prepares to deliver a baby. After some screaming from the mother, the baby’s head, followed by his body, crosses through the birth canal.
Excitement is palpable as people converse animatedly about the birth, discuss potential future opportunities and lessons from the event, and swap personal stories before heading back to their communities.
“I think it was amazing,” said FLC Director of Nursing Maggie LaRose, who along with CU Anschutz Nursing’s Fara Bowler organized the event.
“Health care is a hard job and knowing there are people out there doing the same thing, and having someone to reach out to, makes a real difference.
“We hope this is the first of many training opportunities for our region,” she added. “As an educational partner, Fort Lewis College is well-positioned to be a convener in the Four Corners region, a place where health care organizations and their workers can engage outside of individual institutions to share, connect and grow together.”