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“Combat Aviation Paradigms” Bogeys, Bandits, & Fighter Tactics in the ED?

joseph novakAdvances in science, industry and thought often come from unexpected places far removed from the discipline which needs that "advancement.” Consider the microwave oven.  This did not come from the world's foremost oven engineers.  It never could have.  Rather, it was invented by a radar technician who noted that a candy bar in his pocket melted away (probably at the same time as his fertility) while he walked in the radar antenna fields.  He wasn't constrained by "oven maker" paradigms and was able to adapt his knowledge to the field of food preparation.  Clever examples like this abound in history and thankfully this hasn't been lost on the House of Medicine.  Medicine has begun looking at other industries as a way to improve itself.  This is a fantastic step in the right direction and is our duty as quality and safety professionals.  Three prominent industries that have been studied are the automotive industry, the nuclear industry, and commercial aviation.  These are variably accepted by medical professionals.  Now, it should be said that there is no panacea.  No industry will solve all of medicine's problems.  The intent of these analogies is to take what is applicable and apply it.  What isn't applicable… isn't applicable!  In the literature when rebuking the idea of using other industry's lessons for medicine, there are examples where authors take concepts out of context and revert to issues of semantics, pettiness, and frankly, machismo.  In my opinion, looking at medicine through the lens of any other industry or body of knowledge is fair game.  If another industry's paradigms or processes are relevant, we learn.  If they aren't relevant, we still learn.  Win - win. 

So what is a field of human knowledge and experience that is an untapped resource for medicine?  Combat aviation.  Combat aviation is incredibly relevant to the emergency room and quite different from commercial aviation.  Combat flying is a very dangerous and difficult venture, with little to no margin for error, yet adverse outcomes for our pilots are startlingly low.  Why?  Because of the practices, paradigms, and processes that are drilled into the heads of every fighter pilot.  Let’s look at one concept as an example: "the Boldface."  The boldface are those procedures that MUST be accomplished immediately and correctly while under incredible duress to survive a given situation in the air.  Some examples are stall recoveries, engine fire on takeoff, and ejection.  For every jet there are usually about 6 to 10 boldface procedures.  Pilots know these boldface procedures inside and out and are tested on them repeatedly.  Can we use the concept of the boldface in medicine?  Definitely. In truth, how many things do we do in the ED that really and truly need to be done in seconds for a patient to survive?  I would submit a hand full: shocking pulseless V-fib/V-tach being one example.  Creating a list of the boldface in Emergency Medicine could do several things as a teaching, quality, and safety tool.  The ED boldface can be a concept that we can rely on when the situation is dire and we can barely think, just like in the air.  But more on this to come in the next article…

The world of the Fighter Pilot is the world of the ED physician.  For both worlds we take an individual and put them through an excruciating selection process.  We then train them for years and years just to attain a minimal level of competence and safety.  We incorporate them into teams, organizations, and systems as members and leaders.  We expect them to utilize their knowledge, tools, teams, and systems to solve complex problems in complex and rapidly changing environments.  Combat aviation is a beautiful example that medicine can learn from on the individual, the team, and the organizational level in the vast areas of selection, training, and operations. 

In future articles, I will present tangible and focused examples from the fighter pilot world that we can use in emergency medicine.  We will discuss:

- "The Boldface" - we will go into more detail regarding how fighter pilots deal with very complex and dangerous situations quickly and how we can use
    this technique in the ED

-  Checklists - the proper use and mindset for this incredible tool in the air and in our EDs

-  Task prioritization - fighter pilots have a mantra that focuses their minds while under incredible distress, the resuscitationist should too

-  The instrument Crosscheck - keep your plane in the air and keep your patient alive

-  4-ship dogfight communication - the fog of war made less foggy, how to lead your team in a chaotic resuscitation

-  The hallowed concept of fighter pilot briefing and debriefing - how to effectively do this in the ED with your team

-  Pre-flight situational awareness - a simple system to set you up for organizational and logistical success on every shift

We can take these and other lessons learned and refined after years of combat aviation experience and translate them to our EDs to improve the quality and safety of the care we provide.  Next issue we will do a deep dive into the concept of the boldface and create a set of boldface procedures for Emergency Medicine.  See you then.

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