Podcast 99 – Combat Aviation Paradigms for Resuscitationists


Joe Novak, MD was an F-15 Combat Pilot and now is an Emergency Physician. In this fantastic lecture, he brings the concepts of Combat Aviation to the art of Resuscitation.

The Boldface

aka the no-shitters things that must be absolutely incorporated into your memory and available for immediate execution. You should not need to think about what to do in these situations.


Cognitive unloading and guarantee of the performance of critical actions. Use after addressing the boldface

Prioritization of Attention and Tasks

In combat aviation:

  1. Aviate
  2. Navigate
  3. Communicate

In EM & Critical Care:

  1. Resuscitate
  2. Differentiate
  3. Communicate

The Cross-Check

Keep coming back to the global patient picture before diving into any minutiae

Efficient and Unambiguous Communication

  • Directive
  • Descriptive
  • Informative



Planning: Mission, Defined Roles, and Set the tone


Learning happens in the debrief


Pre-Flight Read Files

Can’t fly until you have read and signed-off on any new procedures or techniques

Ultrasound Podcast Guys’ New IBook Kicks Ass!

Screen-0005 5-25-2013 5.36.41 PM

IBUS Volume 2 can be found here

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    • says

      Thank you for the kind words. My thought is to continue with video podcasts for the present. With this initial podcast as the “introduction” to the concept, future podcasts will likely focus on just one fighter pilot paradigm – the boldface, “Chairflying” (visualization), debriefing (a complex sortie), proper checklist usage, simulation utilization, syllabus development, mishap investigations, human factors in fighter mishaps, communication concepts, nurturing morale, established rules of engagement and their roles, etc. etc.

      What would you like to hear about? What length of podcast would you prefer? What challenges do you face in your ED? Individually? With the team? With the hospital?

      Thanks Yen, feel free to email me directly, I’d love to chat more.
      -Joe Novak

      • says

        What would I like to hear about? … all of that!!!!! My first love would be “proper checklist usage” as I am trying to develop such in our group at the prehospital retrieval level and at the ED level. I’ve been bringing the good fight by myself earlier this year but as of twitter last night it sounds like I am getting some front line medics jumping on board much to my heart’s desire!!!!! We are doing airway checklist discussion sessions since April and it is continuing into the fall. I hope to evolve the concepts as feedback and more ideas/learning come. FOAMed and Social Media have been incredibly helpful to me who has never developed a formalized checklist in his life before. I’m told that there are experts at this so perhaps engaging them might be the right solution but right now it is all in my head and I have been driving it (and not much free time to look for experts). Starting to read Checklist Manifesto too now. Anyhow, hearing your perspective and ideas would be amazing! How do we get to e-mail each other? Are you on twitter? Scott has my e-mail too and I am on EMCrit G+ community.

  1. Matt Tabbut says

    Great episode. I think Joe presents a great perspective on effective crew coordination and teamwork. I agree that the traditional commercial aviation paradigm does not fit ED/CC medicine and I think Joe is on to something with the comparison to combat aviation. We definitely have a lot to learn from our military colleagues. Keep it coming, Joe. I think this can be a practice changer and we can set an example for other departments in the hospital.

    • says

      Thanks Matt. Its funny, good medicine is an absolute necessity for the military. Consider all the extremes of the environment and the human condition that our service-members operate in. Good medicine has helped make this possible. Now is a good time for appropriate military paradigms from combat aviation, submarine operations, infantry operations, space operations, etc. to return the favor and help improve medicine.

      • Matt Tabbut says

        I like this concept of cross-discipline collaboration. I think you hit the nail on the head by saying that this concept of combat aviation should not be an opportunity to point fingers at medicine or aviation. Rather it is a good opportunity to learn what works for one industry and see where it applies to make medicine better.

    • says

      Thanks Ryan. What would you like to hear about? What challenges do you face in your ED? Individually? With the team? With the hospital? I am codifying and cataloging the areas where I think combat aviation can help resuscitation and I’d love to hear more of your thoughts.


  2. Darren Moisey says

    More, more, more please.
    For years I have been trying to force the square peg of airline aviation approaches into the round hole of Emergency Medicine. Combat aviation is the round peg. This insightful podcast changed my perspective and will help me refine my approaches in resuscitation. Thanks for the alternate viewpoint. I’m waiting for the next installment.

    • says

      Amen Darren. I’m a bit embarrassed to say, however, that it wasn’t until my 2nd year of residency that I started seeing huge swaths of the EM landscape that could potentially benefit from combat aviation (vice general aviation). And it wasn’t until my 3rd year that I really started implementing some of these ideas.
      What would you like to see more of? What are some challenges you are experiencing in EM? Thanks Darren, more is on the way.

  3. Eric Bean says

    Amazing combination of 2 worlds! As a current flight nurse, I am constantly striving for safety in aviation and medical care. When these two worlds collide, only good can come of it. Thank you to Scott and Joe for getting the message out. I can’t wait to hear more.

    • says

      Thanks Eric. I always feel a kinship with flight nurses and paramedics because you folks live in the flying world and medical world at the same time and hence you see the pros and cons of both. Although I get nervous when you use the word “collide” when referring to aviation [laughing], I agree, these professions can and should maintain a very symbiotic relationship. I’d suggest less “collide” and more “collaborate”. Please keep me honest from an aviation perspective and give me continued feedback with my follow-on podcasts. Thanks.

    • says

      Hello Dr. Reid,
      It’s funny, I had just listened to your podcast “#90, Mind of the Resuscitationist Series: Cliff Reid’s Own the Resus Room” the day before Scott posted my presentation above. I mentioned to Scott that it was uncanny how much overlap your presentation at Essentials, and my podcast have. I’m sure you would have made one hell of a fighter pilot! You have F-18s out your way, why not put in for an age waiver?
      Thank you for the comments, I look forward to meeting you in the future. Perhaps SMACC 2014?

      • says

        That’s good to know, since that was my plan B had I not got into med school (seriously!).

        I built on some of the Own The Resus concepts for my SMACC Talk “Making Things Happen” (http://resus.me/making-things-happen-from-smacc-2013/) but where your stuff helps me is that it adds clarity and a terminology to some of the concepts.

        For example, I recommend a directive leadership style in high stakes scenarios, and now I can add the directive/descriptive/informative structure to how this is done.

        I was speaking to fellow retrieval doc Brian Burns (@HawkmoonHEMS) and we LOVE the boldface concept. A nice example is an elderly seizing patient who came in recently hypoxic despite OPA/BVM, with no iv access. My first interventions were an LMA (connected to ETCO2) and humeral IO and we got instant control of ABC. Some junior colleagues suggested they might not have thought to do that and I was wondering how to teach it, since I didn’t really remember thinking about it. They were “no shitters”.

        Definitely would love to chat more and share a beer – SMACC 2014 would be perfect for that.



  4. Daryl Pudney says

    Dear Joe,
    As a first career fighter pilot and second career doctor from Australia I must admit I cringed a little when I saw the title of this months EMCRIT. Fighter flying paradigms are sometimes offered as slick and sexy methods to improve productivity in the corporate sector and I was thankful that your presentation was so professional and ED focussed. One of the EMRAP presenters made the comment a year or so ago (to paraphrase) ‘I can’t see the similarity between a fighter jet and the septic 76year old with heart failure and copd that I am trying to fly’. I can understand his point and I know which one is easier to fly….. most of the time.

    Your commentary raised many excellent and easily applicable points that span he two professions. As you would expect my main addition would with regard to debriefing…

    It is very rare to debrief in the EDs where I have worked and it can be so effective if done well. Not only does it highlight areas that were not easily recognised in the melee but it also establishes rapport with collegues and sets the scene for next time. A very simple and quick flow for the lead doctor after gathering the team afterwards could be something like this.

    Intro, Domestics, Lessons ABC, Summary

    “I like to gather everyone after we treat a critically ill patient because I think we owe it to our future patients learn everything we can from these presentations. I am going to step through in a logical order and gain input from everyone so please offer your honest opinions when asked.
    Firstly before the patient arrived I allocated roles and briefed everyone. Was there any questions relating to the brief or the plan? (If at this point the lead can offer something which is both an honest critique of his/her performance then this can set the scene for others to offer follow. (This tends to work better than contrived statements such as ‘tell me what went well)
    Secondly – domestic issues. Were there any problems with equipment, drugs or personnel that we need to highlight to the next shift or management?
    Thirdly – Step through AIRWAY, BREATHING, CIRCULATION issues gaining input from relevant players on the goods and not so goods.
    Finally summarise briefly with what went well, what can be improved for next time ending with a positive comment before everyone departs.

    Intro, Domestics, Lessons ABC, Summary

    (I agree with your statement regarding the many things the fighter community could learn from medicine. If I went back to flying jets I would demand ‘evidence’ prior to allowing the squadron to proceed with a range primary targeting plan or new buddy laze pass just prior to a major exercise….it would have also been nice to walk away from the 3 hour BFM debrief like we walk away from a resus but i am sure we wouldn’t have learned as much)

    Thanks for your excellent podcast,

  5. Braden says

    One of the biggest truths in this concept is the idea that we should not be “afraid” to use checklists. Common arguments against checklist use or looking up a drug dosage .etc in the prehospital environment are that it takes too much time. If medical training became similar to aviation, where one is trained to reference a checklist/algorithm (except for the BOLDFACE) medical errors will likely be reduced.
    One BLS first response service in our region can give basic medications (which is unheard of for the FR level, usually due to CYA medicine); they use a checklist integrated into the PCR/ACR for each dose of medication administered (checklists for nitro, asa, epi autoinjector and salbutamol [albuterol for the US providers]). This checklist must be completed prior to each dose of medication, and ensures medication safety for providers who infrequently give drugs.

  6. Matt S says

    Great, great show (especially as someone who has a brother who’s a newly minted Navy helo pilot). I’d love to see an entire show on The Boldface, maybe make it a duo discussion between Joe and Scott or even throw in some other panelists. Pick a dozen or so resus situations and cover The Boldface for each one. Maybe just walk through a few cases and see how The Boldface changes at each decision point or critical action. But really you could dedicate a show to any of the topics Joe discussed in this one and it would be great. Looking forward to hearing more in the future.

  7. John Hinds says

    Great post and lecture Joe!

    Think you’ve sold the EM community on the Boldface concept. Be interesting to see if your former F15 colleagues start using it as well now…!


  8. Cameron says

    Great job Joe!
    I am currently an ED doc and a former submarine officer and nuclear engineer. When operating the nuclear reactor on a submarine in tactical situations, we too have a very similar mindset and method of attacking the problems posed. Falling back on this previous training has truly been a life saver. The process we used is exactly as Joe describes, and applies easily to Emergency Medicine. Thank you, Joe, for taking the time to put this together in a great podcast.

  9. Don Diakow says

    Doctor Novak ……….honest stuff from a honest perspective. The podcast brings to light one of our weaknesses in EMS and that is the lack or absence of checklists. Thank-you for enabling us to bring these proven concepts forward to improve our quest for excellence in the pre-hospital environment. P.S. I found myself quoting a portion of your podcast during an EMS recruit orientation this morning. You made us look at things differently!

  10. xaqu1n says

    Great podcast! “pre-Flight Read Files” should be integrated in ED-IT and pop up with the sign-in of the user and have to be “signed” after reading to continue/ begin with the shift. So everybody could be informed about news and actual changes concerning the department. That would be much better than e-mails.
    Looking forward for the follow up
    Joachim (@xaqu1n)

  11. Mat Goebel says

    The answer to the challenge given by Dr Novak: what’s the other half of the story about William Hammond?

    Turns out he was a medical school dropout that only claimed to be an MD/phD, although he was actually a pilot.

  12. Ray says

    Excellent podcast! I have listened to it more than ten times and learn something each time.

    I am not an ED doctor but rather a SWAT Sgt. (EMT-B). I never write reviews but I can appreciate the work that was put in to clearly teach the learning objectives. Once again good job and please consider doing another one.

  13. says

    Originally emailed direct to Joe, cross-posted at his request as flat out doing CCATT retrieval work, lucky bugger…

    Hi there

    Fricking amazing talk, thanks so much for doing that with Weingart

    You asked about Qs – and lessons from aviation.

    I’m small town rural doctor, but “critical illness doesn’t respect geography”

    Whilst my resus & EM skills are OK, and I do a weekly anaesthetic list to maintain airway skills, the team around us is often junior an comprises myself, and two nurses

    Any tips from aviation on how to perform well as a team

    – emergencies are infrequent
    – team is limited in resources and training
    – there is not ‘institutional buy in’ to adopting checklists, despite individual enthusiasm?

    To my mind, most of the PHARM concepts translate well to either rural practice as well as ED/ICU … that uptake is slow amongst non-FOAMites is a barrier that neds tobe breached.

    Thanks and great talk for FOAMed

    Tim Leeuwenburg
    Kangaroo Island
    South Australia


  14. Michael P says

    Hello Dr. Novak. My name is Michael Poulin. I listened to your presentation on EMCrit podcast, It was totally engaging and inspiring. I am a Paramedic/firefighter. I have been practicing Pre-hospital Medicine for twenty eight years. Previously I work in other states that had very progressive Pre-Hospital systems as well as very supportive and progressive Medical Directors. But I have found things here in my immediate area of operation to be lacking ambition from both my brother and sister BLS and ALS firefighters, as well as our neighboring fire departments, I routinely respond mutual aid to. When I have addressed my opinion on a specific ideas or treatments, for example, stocking our ambulance with an IV infusion pump to administer Amiodarone after conversion of V-Fib. I feel that I am knocked down by the same answer every time “we are only five minutes from the hospital”. I strive to be the best patient advocate I can be, but the lack of enthusiasm, has me stymied. How do you motivate your staff, students, your ground and/or flight crew. Heck even your commanding officers or hospital administration. I am sure you have dwelt with the guys at Chicago Fire Department, do you have any suggestions or advise. May I show your EMCrit presentation to my fellow firefighters?

    • says

      Michael, the podcast is available for you to show to anyone. Extended prehospital practice parameters can usually be found in systems with extended transport times or as a flight medic. From economics alone, you probably are not going to get extended practice in a system with short transport times. If you move to NYC or Seattle, your practice will be extensive despite short transport times. I am sure there are other cites as well.

  15. Mike L says

    As a prior USAF Pararescueman, I was impressed with the podcast and completely agree with Dr. Novak. The development of cognitive abilities using similar decision making tools and checklists has been integral to successful completion of missions in the tactical environment. This includes paradigms like Dr. Novak’s “resuscitate-differentiate-communicate” method, as well as Boyd’s OODA Loop and navigation checklists. Novel approaches to resuscitation science are important to solving some of the challenges we continue to face. Applying some of these tried and true mantras and tools to the world of resuscitation can help us enhance our abilities and improve care in a variety of environments. Great stuff Joe and Scott!

  16. Seth Trueger says

    I was thinking about how to make a pre-shift binder in a reasonable manner.

    There’s no way for me to make it happen for the entire Department, so I’ve been kicking around some ideas on half-measures that would make it work.

    What I have so far is really not a huge step, I made a gmail label called “Binder” and every time I get an email notifying me of a process change, I add the label, and look through the rest to make sure no obsolete labels on the same topic are left. I’ve been doing it for <3 weeks and have 16 emails in there so far.

    For people who work at multiple sites, it would be easy to use nested labels, with a nested folder for each site.

    Any thoughts?

    • says

      I think the intranets that the business world has been using forever are ideal, but they have not moved down to medicine. I would love evernote for business, but too expensive right now.

  17. Matt says

    Loved the podcast on emcrit. I’m an ER doc and have a number of interests that tie in to this (private pilot, medical director for EMS including flight, tactical physician, ER medical director, etc.).
    Thought your presentation was right on and I want more.

    Initial questions that came up for me that I hope you’ll cover in future

    Boldface topics–I know others have asked for this also

    Pre-shift read–I think this is right on. I’ve been struggling with how to communicate constantly moving parts to docs.
    How to manage information–what makes the cut–how long does the info stay in, etc.
    How to get buy-in/compliance from physicians


    Great stuff. Hope you keep it coming.

    Matthew Sutter, MD FACEP FAAEM


  1. […] Please add your ideas and suggestions on version 3.3 of the Kit Dump Sheet in the comments below. The “BOLDFACE” are the minimum “immediate-execution” items for time sensitive and critical situations (see EMCrit episode 99: Combat Aviation Paradigms for Resuscitationists). […]

  2. […] this fantastic lecture, Jo Novak brings the concepts of Combat Aviation to the art of Resuscitation. Aviation Paradigms for Resuscitationists – brilliant and awe inspiring guaranteed to challenge your current approach to the resus […]

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