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.
Checklists
Cognitive unloading and guarantee of the performance of critical actions. Use after addressing the boldface
Prioritization of Attention and Tasks
In combat aviation:
- Aviate
- Navigate
- Communicate
In EM & Critical Care:
- Resuscitate
- Differentiate
- Communicate
The Cross-Check
Keep coming back to the global patient picture before diving into any minutiae
Efficient and Unambiguous Communication
- Directive
- Descriptive
- Informative
Briefing
Pre-Brief
Planning: Mission, Defined Roles, and Set the tone
De-brief
Learning happens in the debrief
Perception-Decision-Execution
Pre-Flight Read Files
Can't fly until you have read and signed-off on any new procedures or techniques
Additional New Information
Sterile Cockpit
More on EMCrit
Additional Resources
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Professor
Nassau University Medical Center
No conflicts of interest (coi).
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Definitely a must listen for all resuscitationists: ED, ICU, prehospital, retrieval. Loved it. Have to hear more!
Joe has promised more is coming, my friend.
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?… Read more »
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… Read more »
Amazing! Thats all I can say.
Thank you Russ, very kind of you. Let me know what you’d like to hear more of.
-Joe
Catch 22
Sorry brother, too late and wrong place (G+)
damn timezones……nevermind, great fun and great speak by Joe.
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.
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.
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.
Outstanding stuff…..really looking forward to more!
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.
-Joe
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.
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.
-Joe
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.
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.
-Joe
Really enjoyed this – superb stuff.
Thanks Joe and Scott.
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?
Sincerely,
Joe
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… Read more »
[..and it would have been Tornadoes rather than F-15s for me at that time and place]
:o)
I absolutely agree that the “boldface” is a great way to capture what we end up doing in prioritizing the time critical tasks. Thanks for this concept and how it helps to free our minds.
Joe: Hat tip and thanks for bringing the “Boldface” to resuscitation. Added that to my first blog post at PHARM on the FOAMed Airway Kit Dump Project (with TrackBack)
Solid lecture by Dr Novak!
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… Read more »
Could you post a list of “The Boldface” ?
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… Read more »
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.… Read more »
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…!
-John
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.
Cameron
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!
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)
Be careful what you wish for…
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.
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.
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 when – emergencies are infrequent… Read more »
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… Read more »
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.
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… Read more »
Mike, thanks for that!
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… Read more »
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.
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 podcasts: 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. Examples How to manage information–what makes the cut–how long does the info stay… Read more »