Training for HALO procedures. Part 3: The Team.

This is the third post on the preparation and training of HALO procedures, These are high acuity, low occurrence procedures that we may face in emergency medicine and prehospital care. The first two posts focused on personal preparation and psychomotor skills. Both of these are clearly important but without a team to support you in delivering the procedure it will be sub-optimal and may well fail. That’s why we believe that preparation for HALO is a triumvirate of training and skills.

One of my concerns about HALO procedure training is the focus on the person who is actually performing the skill at the exclusion of training and supporting those who are supporting or witnessing what’s going on. Paradoxically, these procedures are prone to ‘draw a crowd’ and so whilst we have previously discussed the stresses upon the operator, these are arguably compounded by the audience and other clinicians who may similarly be stressed.

Many years ago and as a senior registrar (yes – THAT long ago) I was preparing to RSI a head injured patient with max fax injuries. It looked to be relatively straightforward, but there were stressors and difficulties about the case. I prepped the patient and was about to proceed when the consultant asked me to pause a second. They left the room to return with another consultant, 3 junior doctors and 6 med students. With the audience assembled in a large curve around the bottom end of the trolley they said to me….. ‘no pressure SImon, carry on’….. In truth it significantly added to my stress levels and although not a HALO procedure I see similar behaviours today that add to the difficulties operators face.

Similarly, in the prehospital setting I am sometimes dumbfounded to find members of the public approaching seriously injured patients with phone cameras videoing the event.

The point is that the environment, team, observers, assistants and colleagues can become additional stressors if poorly managed.

It’s also worth remembering that any HALO procedure will be optimised by having an assistant or team who can assist in the preparation, situational awareness and safety of the event. As the proceduralist it is highly likely that you will become task focused. This is fair enough as the procedures will require a lot of thought and skill. However, the patient and the wider scene still needs management and this needs support.

Training your team.

It is very, very difficult to simultaneously conduct a teaching event and a perform real life HALO technique. This means that we need to train in other ways, and although at first thought you might think about going on a course, you will find that very few of those train teams. They are focused on the individual. For teams we need to be a bit more creative and arguably a bit more local. It’s tricky, but it can be done through mental and physical rehearsal.

  • Mental rehearsal: Just as with personal preparation we can prepare as a team using a shared mental model and a team talk through. It’s quite easy to discuss a real or imagined situation with your team. Talk through who does what, where you stand, what kit is needed, what checklists are used, where are they, what might happen and what complications might arise. This can be done in formal training, in M&M sessions or even as part of the zero point survey on the way to a job, or whilst awaiting a standby in the ED. This kind of team mental rehearsal is an expansion of the techniques describing personal mental rehearsal discussed in the first HALO blog.
  • Physical rehearsal: Simulation sessions are an excellent medium to train for HALO procedures. These can work well, but there are a few complexities and I would make the following suggestions.
    • It’s very tricky to have high fidelity sim of the actual procedure at the same time as simulating the wider team working and environment. I find it better to separate these such that when doing a team sim the actual procedure is relatively low-fi or notional. This also means that you can still train your team on something like thoracotomy without a specific mannequin. Pretty much all aspects of team training in terms of leadership, organisation, equipment, placement, communication etc. can be achieved without putting knife to plastic/skin/mannequin. Arguably this approach also focuses the session on exactly what is needed from the ‘team’.
    • Many people come to these sort of simulation sessions with relatively prior experience of what is needed. We have found that a stop:start approach to the simulation sessions helps learners ask questions sequentially and constructivist way. In practice this means that we might run through a thoracotomy simulation stopping every few minutes to review what has happened, what the team is thinking, how we might optimise and then move on to the next phase. This stop start teaching approach allows teams to learn as they simulate. It allows any errors to be corrected and discussed before any major consequence. Once comfortable a more real-time run through can be attempted, but don’t try that first up. This is formally called RCDP (Rapid Cycle Deliberate Practice), thanks to Chris Ericsson for pointing this out.
    • For teams that are well rehearsed and practiced then a more traditional approach to simulation with or without video playback can be adopted. This is something we can do in PHEM teams, where regular practice is often performed. For other teams be sequential and build up to a real time run-through. The point is that we should not ask teams to perform very unfamiliar skills without first teaching them about them first.
    • Teams that are well practiced can effectively combine team training with skill specific training with the right sort of mannequin. This is shown in the picture below using the THOR thoractomy trainer from the ATACC group.
    • Avoid additional noise/problems/tricks etc. When training for these sort of situations there is enough going on with already without introducing additional complexity such as bizarre equipment failure or associates with abnormal reactions/behaviours. If you want to read more on this there is a great paper by Vic Brazil, Eve Purdy and colleagues from Bond university in the references below. Some of this could be summarised as ‘when training for HALO techniques there is enough stress already, you don’t need to add more as an educator’.
    • Debrief, debrief, debrief. In our experience these rehearsals/simulations generate a lot of questions. Make sure you leave lots of time to get a good debrief done.
THOR trainer
What about real events?

It’s also worth mentioning that when a real situation occurs then it is very likely that there will be people there who have not been to your training session and who have never seen anything quite like this before. Whilst you will not have planned this as a ‘teaching’ event, it will undoubtedly be a ‘learning’ event for those that are present. It therefore makes sense to use this as an opportunity, and to help them learn positive/useful knowledge. Clearly you must make sure they get a good debrief, and make sure they are OK. Consider how you can help those present learn about what just happened in a supportive and positive way.

It’s highly likely *(well they should) that these cases will go to your M&M meetings. Use those events for learning but do remember that they are stressful for those involved. Be mindful of how to support colleagues through the M&M process which they may find difficult.

One element not often considered is that fact that some team members may find themselves in the middle of a procedure without any preparation at all. One of our colleagues recently commented that at one point they were trying to get IV access, the next they looked left and there was a heart on display. This can be very traumatic. One of the things that we do in HEMS, and I’ve increasingly started doing a version of this in-hospital, is to do a declaration of intent before we proceed with a HALO procedure to avoid this sort of thing happening. It does not have to be read by the lead clinician. These cards are kept in the surgical pack as a reminder, a similar plan could be adopted in emergency departments.

Final thoughts

The bottom line when it comes to HALO procedures and teams is that without a functioning team it really does not matter if you are personally expertly prepared and skilled, as you will always need a team around you to optimise the event. Therefore you must train with your teams, so that they can similarly think about how you can all optimise your environment, equipment, procedures and SOPs etc.. That said, you also need to be prepared to manage those team members who may have very little training or exposure to what you are about to do. That’s not easy, but it is something that you can prepare for.

If you’ve not already done so then please read parts 1&2. Also check out the links below for more information on training teams for high pressure situations.

Good luck



References and further reading
  1. Brazil V, Orr R, Canetti EFD, Isaacson W, Stevenson N, Purdy E. Exploring participant experience to optimize the design and delivery of stress exposure simulations in emergency medicine. AEM Educ Train. 2023 Mar 30;7(2):e10852. doi: 10.1002/aet2.10852. PMID: 37008650; PMCID: PMC10061575.
  2. Morgenstern, J. Performance Under Pressure (how to manage stress), First10EM, March 13, 2017. Available at:
  4. Hick C. team work, managing teams – chris hicks
  5. Simon Carley, “Training for HALO procedures. Part 1: Background and psychomotor skills. St Emlyn’s,” in St.Emlyn’s, April 2, 2023,
  6. Simon Carley, “Training for HALO procedures. Part 2: Personal Preparation. St Emlyn’s,” in St.Emlyn’s, May 11, 2023,
  7. EMCrit RACC Podcast 220 – Beat the Stress Fool (BtSF) with Mike Lauria — Just In Time Performance-Enhancing Psychological Skills.
  8. Performance Under Pressure (how to manage stress). First10EM
  9. Enhancing Human Performance and Flow in Resuscitation Part 2: The Tao of Resuscitation Performance
  10. Zero Point Survey.
  11. Michael J Lauria, Isabelle A Gallo, Stephen Rush, Jason Brooks, Rory Spiegel, Scott D Weingart. Psychological Skills to Improve Emergency Care Providers’ Performance Under Stress. Ann Emerg Med. . 2017 Dec;70(6):884-890. doi: 10.1016/j.annemergmed.2017.03.018. Epub 2017 Apr 29.
  12. MATT: Manchester Advanced Trauma Training.
  13. ATACC: Anaesthesia Trauma and Critical Care group.
  14. NWAA: North West Air Ambulance Charity.
  15. NWPCCC: North West Prehospital Critical Care Charity.
  16. Thoracotomy on St Emlyn’s :
  17. Ng C, Primiani N, Orchanian-Cheff A. Rapid Cycle Deliberate Practice in Healthcare Simulation: a Scoping Review. Med Sci Educ. 2021 Nov 2;31(6):2105-2120. doi: 10.1007/s40670-021-01446-0. PMID: 34950533; PMCID: PMC8651942.

Cite this article as: Simon Carley, "Training for HALO procedures. Part 3: The Team.," in St.Emlyn's, July 29, 2023,

1 thought on “Training for HALO procedures. Part 3: The Team.”

  1. Good summary and I’m glad to say that we have evolved similar structure on our PHEC course here in Australia (prehospital emergency care course run by Australian College of Rural and Remote Medicine). Thanks for reinforcing the essentials.

Thanks so much for following. Viva la #FOAMed

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