Training for HALO procedures. Part 2: Personal Preparation. St Emlyn’s

In part one of the Halo Procedures blogs, we talked about the various types of Halo procedures, the high acuity: low occurrence type procedures that we occasionally face in emergency medicine and pre hospital care. In that first blog, we talked about acquiring the psychomotor skills required to actually physically complete the task.

However, this is not enough. Even having trained for the psychomotor tasks is not enough for you to be successful in practice. When you’re actually faced with having to do one of these very difficult skills, it’s vital that you are in the right mental state as well. A practitioner who is overly stressed or distracted will not perform at their best. So in this blog, we look at some of the techniques you can use to prepare yourself.

In my experience you can be very, very competent at a procedure test in the lab, maybe you even teach the procedure to others, but if you can’t get your ‘self’ preparation correct (and in later blogs the team too) then you may well fail.

So, what are the elements we can address? There are a number of themes and procedures described, but in this blog, we will focus on IFTT decision-making, the use of the intracranial simulator, and refocusing in circumstances where we feel overly stressed/stimulated.

Is This Then That (IFTT)

The decision to commit to a HALO procedure is often challenging. In the first blog, we talked about the optimal time to perform a procedure. Too soon, and without enough information or without exploring alternative treatments we might commit ‘too early’ and a patient might get a procedure they do not need. Too late and we may miss the optimal time to save their life or correct potentially reversible pathology. Whilst there may well be complexities and variation between patients and circumstances it is probably not wise to be having debates about this in the moment. Rather it is better to have a good sense of actions before the event arises. This is something we can do for all HALO procedures and I invite you to do it today.

The model you might use is IFTT, which stands for If This Then That; for all HALO procedures, we can agree on a set of circumstances that if they arise then we will proceed to the HALO procedure. An example of perimortem hysterotomy is shown below. The point is that in your head you should have a very clear set of circumstances for all of the HALO procedures. For example, if there’s a pregnant patient in recent cardiac arrest, and the fundus is at the umbilicus then they are a third-trimester pregnancy. If these set of circumstances arise, then I am going to do this (perimortem hysterotomy).
So; the learning point from this part of the blog is that really you should have that list of IFTT circumstances in your head, and ideally also write them down in the SOPs of your organisation.

Beat The Stress Fool (BTSF)

IFTT is great at preparing for HALO procedures, but what happens when we get cognitively overloaded just before or during our procedural attempt? This is more common than you might think and can affect clinicians at all levels of seniority. The difference for those who handle situations well may be that they have a strategy to deal with the stress/stimulus. Those people you know who are ‘good’ at this sort of thing are rarely born that way; rather, they have reflected, learned and trained to optimise their performance under stress.

A bit of stress is, of course, a good thing. Optimal performance needs a bit of stress, but too much can lead to inertia and the loss of fine motor and then gross motor skills: not something that is going to help with your technique.

There are many techniques described, but I like the Beat The Stress Fool method (BTSF) as championed by Mike Lauria, Scott Weingart and many other resuscitation luminaries.

The B is for ‘breathing’ techniques to regain control of your physiology. Practise a yoga-type approach to breathing: breathe in for four seconds, hold for four seconds, breathe out for four seconds, hold for seconds. Repeat that a few times and it’s remarkable how it can control the physiological impact of stress.
The T is for talk and is about ‘self-talk’. Tell yourself that you’re going to do this now because the circumstances demand it. Tell yourself that it’s something you are trained for, tell yourself that this is something that can be done. Tell yourself that you are the right person to do it. These approaches are commonly used in sport where you often see athletes preparing in this way. They talk themselves through the process, give themselves some self-reassurance that they are competent and the best people to do it, and then proceed. It’s a really powerful technique that may feel a bit weird to you, but give it a try.
The S is for ‘see’ (mental rehearsal). We can all visualise a HALO procedure that might go ahead (after you’ve been trained on the psychomotor elements), and you can do this prior to performing the task. This could be as late as on the way to a job, or just before you put needle/knife to skin. You can also do it regularly as part of your routine preparation. As Cliff Reid taught me years ago, the human brain is by far the best simulator available to us all. It’s so much better than any plastic mannequin in your sim lab, assuming that you have enough experience to be able to simulate a scene and procedure (and is therefore especially useful to those with prior lived experience of HALO procedures). This is something we should probably do on a regular basis as part of our training routines.
And finally, the F is about ‘focus‘ using a keyword. Many individuals involved in high-pressure situations will have one word or one phrase that tells them that, OK, this is now the time to proceed, this is how it’s going to work and I am confident and competent to do this now. That phrase or word can be a model for how you trigger yourself to start and deliver the procedure as best you can (or to continue if you’ve taken a time out).

The intracranial simulator

Every single one of us has access to the most powerful simulation system known to man. It’s much better than any plastic mannequin and much better than any computer program. As mentioned above, it is your own mind and imagination. You can and should use this incredible tool to imagine and prepare for all the HALO procedures. Think about how you will feel, and how you will act, imagine the procedure itself and the decisions around it.

Two minutes on your brain as the world's most powerful simulator (and how it helped me with a surgical airway)

Excerpt from a video interview I did with @hypoxicchicken for the University of Melbournehttps://t.co/tSwRJYVD7W
— Cliff Reid (@cliffreid) March 10, 2023

This becomes easy over time and experience. For novice learners, it might be quite difficult to imagine the circumstances as they may never have seen it before. For experienced operatives it becomes easier to simulate a complete picture and then inject nuance and complexity, all within the confines of your own imagination. As we will discover later this is something that you can also do in pairs, or teams if all members are able to imagine and articulate a common scenario.

Final thoughts

The key point in this blog is that individual preparation for HALO procedures is a deliberate act that requires effort and time. Those people who are ‘good’ at this sort of thing were not born that way. They learned the routines and techniques to improve their personal performance. There is no reason why you cannot do the same.

In part three we’re going to look at team preparation for HALO procedures.