Borrowing aviation’s “aviate, navigate, communicate” framework, Luke Knoble and Dr. Joshua Stilley explain how EMS clinicians can prioritize immediate stabilization, next-step decision-making, and team communication when cognitive bandwidth is limited.
Article by Luke Knoble, MS3, NRP; Joshua Stilley, MD, FAEMS
Edited by Alexander Blau, DO, EMS Faculty, ChristianaCare
In emergency medicine and EMS, we use many cognitive tools to enhance decision-making. One of the most prominent frameworks, Crew Resource Management, has been adopted from the aviation industry. However, pilots use numerous other mental models to conduct flights safely, and these models can also apply to emergency care. In this series, we continue to explore fundamental aviation principles and discuss how they apply to healthcare through specific case examples.
Aviation and EMS share a common challenge: making high-consequence decisions with incomplete information while managing complex systems and human limitations. Aviation has spent decades developing methods to reduce error and improve performance under stress. EMS can learn from these same principles. In particularly stressful, high-risk, or emergent situations, the priorities of aviation can be summarized by the phrase “aviate, navigate, communicate.”
The Priority Sequence
In a stressful situation, pilots and clinicians may not have enough mental capacity to manage everything at once. Especially for developing clinicians at every level, a reminder to think or act, one step at a time, can help focus attention. A pilot experiencing an in-flight emergency should first focus on the fundamentals of flying the airplane.
For the clinician, the equivalent is the primary survey. When overwhelmed or unsure of the best next step, start again with the primary survey. Identify critical abnormalities, correct those that require emergent intervention, and ensure that the patient is stable enough to pause briefly. Then, think about the patient’s clinical picture and what needs to happen next (navigate), and identify the resources and clinicians who can help (communicate).
Emergency medicine and EMS are team sports, but the clinician’s first responsibility is immediate patient care. A patient with a STEMI needs the cardiac catheterization laboratory alerted, but the primary survey, aspirin administration, and 12-lead ECG acquisition remain the initial priorities.
Aviation Example: Inadvertent Instrument Meteorological Conditions
Consider an all-too-common example from aviation: inadvertent instrument meteorological conditions (IIMC). Most private pilots fly under visual flight rules (VFR). VFR flight is conducted by looking outside the aircraft to maintain level flight and travel in the correct direction. Much like driving a car, you need to see the lines on the road to stay between them. Too many pilots get into trouble each year when they inadvertently enter clouds, fog, or other view-limiting conditions. Flight into IIMC has claimed helicopter EMS aircraft over the years, as well as general aviation airplanes.
The pilot’s first priority, reinforced through repeated training, is to keep the wings level, maintain the current altitude, and adjust engine power to maintain airspeed. The pilot should not rush to the next step until the aircraft is under control. Next comes navigate: know where you are, determine where you need to go, and begin maneuvering the aircraft to get there. Only after those priority tasks are complete should the pilot communicate with air traffic control.
Communication remains essential, but it cannot replace immediate action to correct a threat to the people on board. A pilot who focuses on the radio but fails to keep the airplane flying straight and level has the priorities out of order.
Healthcare Application: The Primary Survey
Clinicians likewise get into trouble when their priorities are out of order. The primary survey is a clear example. The XABCDE sequence is listed in that order for a reason: when you find a problem, you fix it. One common error among developing clinicians is confusing recognition with management. Identifying a problem is only the first step. A clinician who recognizes an obstructed airway but continues the assessment without intervening has identified the emergency without treating it.
As the patient’s physiology deteriorates, we need to “fly the plane”: correct the patient’s physiology, navigate the next steps, and then communicate the plan to the team.
Clinical Example: Hypoventilation
As you approach a 40-year-old patient with altered mental status, you notice that the patient is breathing too slowly and too shallowly for adequate ventilation. Your first actions are to position the airway, begin bag-mask ventilation, and assess perfusion. After a few deep breaths for both the patient and the clinician, you see good chest rise and fall and some improvement in skin color. Aviate? Check.
You hand off bag-mask ventilation to another clinician, complete the primary survey, check a glucose level, and initiate IV access. Navigate? Check. Recognizing that the patient is much more ill than initially thought, you request additional resources. Communicate? Check.
Tactical EMS Application
Tactical EMS provides another example of how good medicine at the wrong time can create problems. Tactics take precedence over medicine. Poor tactics create the need for medical care, while good tactics often help avoid it.
Consider care under fire. A law enforcement officer sustains a gunshot wound to the lower extremity with arterial bleeding while an active threat remains. The wrong action is hemorrhage control that distracts from stopping the threat. The correct action is to eliminate or contain the threat, then move to tactical field care, even when our clinical instincts pull us in the other direction.
Conclusion
Learning the priorities of our environment is essential, whether responding to an engine failure in flight or organizing care for a critically ill patient. Aviate, navigate, then communicate.
