HALO - High Acuity, Low Occurrence
When the rare becomes real, and the scalpel becomes a lifeline.
In emergency medicine, we train for the extraordinary.
The cases that happen once a career—if that.
We call them HALO events: High Acuity, Low Occurrence.
Open thoracotomy.
Postmortem C-section.
Surgical airway.
They’re the procedures you hope to never perform but must be ready to execute without hesitation. There’s no room for uncertainty when your patient is circling the drain.
HALO: When There's No Time to Think
An open thoracotomy involves splitting open the chest in the ED to directly access the heart—often in the setting of traumatic arrest. A brutal, last-ditch maneuver. But sometimes it works. Sometimes it’s the only thing that can.
The postmortem C-section is even more surreal: slicing into a dead mother to try to save her baby. It’s grisly. Unnatural. And every second matters. If the baby isn’t out within five minutes, the odds collapse.
Then there’s the surgical airway—when intubation fails and a patient can’t breathe, and there’s no time left to wait. You cut the neck. Find the trachea. Get the tube in. Fast.
These are the things that live in the corners of our training. We rehearse them in simulations. Practice with mannequins. But when the real thing hits? Nothing feels like enough.
Cricothyrotomy
It was a busy night shift.
Crowded waiting room, backed-up stretchers, elderly patients waiting hours. But we were holding the line—my senior resident, Dr. Harris, was managing resus while I cleared urgent care.
That’s when the triage nurse flagged a new arrival: stridor.
Not a good sign.
She transferred the patient to resus. I told her to page Dr. Harris and promised to follow immediately.
When I arrived bedside, he was sitting upright—breathing comfortably and speaking clearly.
“I’ve had trouble breathing for three days,” he said hoarsely.
“It comes and goes. Feels like my throat tightens and I can’t get air.”
There was no obvious swelling. His mouth and pharynx looked normal. Some tenderness near the Adam’s apple, but nothing glaring.
His symptoms had nearly resolved after receiving racemic epinephrine.
Steroids and antibiotics were started. Neck imaging was ordered. ENT was called to perform a bedside scope.
He seemed tired, but stable. His wife—calm but worried—sat quietly beside him.
“He’s stubborn,” she said. “I’ve been trying to get him in for days. Tonight, I just called 911.”
I stayed to chat. Noticed a pinky ring—engraved with a crest.
“Family heirloom,” he said. “Been in the family for generations.”
He smiled. I smiled back. Then I was paged away.
Collapse
ENT scoped him soon after. Mild glottic swelling—nothing alarming.
“Airway appears stable. Hold off on intubation.”
He was admitted promptly to the ENT service for monitoring.
An hour later, he crashed.
The stridor returned—worse.
Gasping. Panicked. Clutching his neck.
We rushed him back to the resuscitation bay.
We prepared for intubation—with a double setup for surgical airway.
Seconds after arriving, he stopped moving air.
Ketamine in.
Dr. Harris attempted intubation. No view. The airway was gone—swollen shut.
The ENT resident stood at the bedside, scalpel in hand. Her fingers trembled.
“Are we really doing this?” she asked.
Yes. We had no choice.
A trauma surgeon once told me:
“The hardest part is the decision, not the incision.”
The Cut
She made the incision. Tentative.
Too shallow.
“Keep going,” I said, guiding her hand.
On the third pass, she broke through. Blood poured. Visibility disappeared.
She plunged her fingers into the neck, searching blindly for the trachea.
The patient arrested.
CPR began.
She kept working—hands slick with blood, anatomy blurred.
At last, the tube slid in. Air moved.
But he’d been without oxygen for at least a minute too long.
It was too late.
His face had swollen grotesquely. His abdomen distended with air. His neck and chest crackled with subcutaneous emphysema.
The man I’d spoken to just minutes earlier was gone.
We worked on him for an hour—compressions, meds, everything we had.
But there was no recovery.
The Hardest Part
I sat beside his wife.
“His airway became so swollen that we couldn’t get a breathing tube in through his mouth.
We had to create an opening in his neck to help him breathe.
Right now, his heart has stopped, and we’re doing CPR to try to bring him back.”
She stared at me, silent.
Trying to understand.
How could she?
I promised to bring her in when we could.
Goodbye
His body was nearly unrecognizable.
Swollen. Bloodied. A tube jutted from his neck.
She sat beside him, took his hand, and whispered goodbye.
“Life is so fragile,” she said.
“I had no idea I’d lose my partner of 48 years today.”
She kissed his face.
Then she walked back to the family room alone, waiting for her children to come say their goodbyes.
Later, I returned with a small bag—his wedding band, and the pinky ring that had sparked our final conversation.
I’ve delivered a lot of bad news over the years. But this one stayed with me.
We acted quickly. We followed the steps. We did everything we could.
But some moments are beyond control—swift, unforgiving, and final.
Sometimes, HALO procedures don’t save lives.
Sometimes, they simply remind us how fragile life is—how quickly things can turn, and how just seconds can separate life from death.
Life is so fragile
How very difficult. Blessings for giving the gift you have.