To empowers each team member in resuscitation .
(Adapted from Boyd’s model — redesigned for resuscitation teams under pressure)
By Dr.Abdolghader Pakniyat
Emergency departments already have a wealth of protocols — ACLS, ATLS, PALS, sepsis bundles. Experienced team leaders often lead resuscitations based on pattern recognition, rapid decision-making, and intuition. But beneath the surface, our current approach relies on unspoken mental models, variable team dynamics, and ad hoc communication. It often works — when the team is experienced, the case is typical, and the environment is calm. Yet it tends to unravel during complex, ambiguous, or high-stakes scenarios: crashing toxic trauma patients, undifferentiated shock, unfamiliar teams, or cognitive overload.
So why hasn’t a cognitive framework like the OODA Loop — originally developed for fighter pilots in life-or-death situations — been formalized in emergency medicine?
Partly because medicine favors algorithmic thinking over adaptive thinking. Partly because many excellent leaders use such mental models intuitively, without making them visible or teachable to the rest of the team. And partly because introducing a new model can seem unnecessary — until things go wrong.
The ER-OODA Loop doesn’t replace clinical protocols. Instead, it provides a shared cognitive structure to help teams observe accurately, orient effectively, decide intentionally, act clearly, and reassess continuously. It turns leadership from an individual skill into a collective system. And in doing so, it helps teams respond better — not just when things go right, but especially when they don’t.
🔄 What is the ER-OODA Loop?
Observe → Orient → Decide → Assign & Act → Reassess & Iterate
An enhanced version of the original OODA Loop — this five-phase model is built for high-stakes, fast-paced emergency care, where lives hinge on clear thinking, rapid coordination, and decisive action.
🩺 Why Use the ER-OODA Loop in Resus?
✔️ Resuscitations are unpredictable. Patients crash. Plans change.
✔️ EM isn’t just about following ACLS — it’s about thinking, adapting, and leading under fire.
✔️ This framework creates a shared language for decision-making, helping every team member stay aligned and effective.
🔍 1. OBSERVE — “What’s happening right now?”
🔸 Gather real-time data 🔸 Be intentional and comprehensive 🔸 Include people, patient, and environment
🔹 Everyone Can:
- Listen to EMS or family handoff
- Look at the monitor, the patient, the room
- Note vitals: HR, BP, RR, SpO₂, temp, EtCO₂
- Watch for red flags: cyanosis, altered LOC, bleeding
- Check for hazards: tangled wires, missing equipment, wet floor
🔹 Role-Based Examples:
| Role | Observation |
|---|---|
| Physician | “HR 150, BP dropping, GCS 10, pupils unequal — neuro + shock.” |
| Nurse | “No IV access yet. O₂ sat low. Patient diaphoretic.” |
| RT | “SpO₂ still falling on NRB — preparing BVM support.” |
| Tech | “Pads on, defib charged to 200 joules.” |
| Student | “Vomiting noted — airway at risk. Can I prep suction?” |
🔹 Tools:
- Monitors
- POCUS
- ABCDE exam
- EMS/family history
- Environment scan checklist
🧭 2. ORIENT — “What does this mean?”
🔸 Interpret inputs → build a shared mental model 🔸 Think “why is this happening?” 🔸 Predict what’s next if we don’t act
🔹 Everyone Can:
- Ask: “Does this look like sepsis? PE? OD?”
- Share insight: “It’s looking like hemorrhagic shock to me.”
- Spot trends: worsening EtCO₂, rising HR, falling GCS
🔹 Clinician Thinking:
- Type of shock?
- Airway secure or deteriorating?
- Does this require immediate intervention (e.g., chest tube)?
- Should we activate massive transfusion?
🔹 Team Technique:
Quick team orientation pause: “Here’s what I see: HR rising, BP dropping, looks like septic shock. Agreed?”
⚠️ Pitfalls:
- Anchoring bias (e.g., assuming it’s asthma — missing PE)
- Premature closure (diagnosing without full input)
🧠 3. DECIDE — “What should we do next?”
🔸 Choose the next most critical move 🔸 Frame each step as a working hypothesis
🔹 Everyone Can:
- Suggest actions: “Do we need to intubate now?”
- Help prep: “I’ll draw RSI meds.”
- Ask: “Are we thinking tension pneumothorax?”
🔹 Leader Moves:
- Say: “We’re intubating. Drugs, equipment, suction. Let’s go.”
- Frame logic: “If it’s tamponade, we need bedside ECHO + pericardiocentesis ready.”
- Make backup plan: “If this fails, Plan B is…”
🧠 Tips:
- Avoid overthinking — act on best next step, not full diagnosis
- Balance risk: “What’s the risk of waiting?”
⚡ 4. ASSIGN & ACT — “Let’s move.”
🔸 Execute with clarity, precision, and speed 🔸 Use closed-loop communication 🔸 Assign tasks by name and job
🔹 Everyone Can:
- Take initiative: “I’ll get IO access.”
- Say it loud: “Epinephrine 1 mg IV push, given.”
- Repeat tasks back: “Drawing 300 mg amiodarone now.”
🔹 Team Flow:
| Task | Directive | Confirmation |
| Meds | “Laura, 1 mg epi IV now.” | “Giving 1 mg epi IV now.” |
| Defib | “John, charge to 200 joules.” | “Charged. Ready.” |
| Airway | “RT, bag 10/min till RSI ready.” | “Bagging at 10/min.” |
⚠️ Pitfalls:
- Vague orders: “Somebody give…”
- Missing confirmation: “Was epi given?”
- Single-task overload: one person trying to do it all
🔁 5. REASSESS & ITERATE — “Did it work?”
🔸 Watch for effect of intervention 🔸 Use that feedback to refine your plan
🔹 Everyone Can:
- Report effect: “BP now 90/50, EtCO₂ rising.”
- Raise concern: “No change after 2 shocks — what else?”
- Request check: “Shall we ultrasound again?”
🔹 Leader Prompts:
- “ROSC achieved. Let’s secure airway + prep for transfer.”
- “Still PEA. Let’s scan for tamponade. Ready with probe.”
🔁 Cycle It:
- Observe → Orient → Decide → Assign & Act → Reassess → repeat as needed
🧠 Final Summary Table
| Phase | What You Do | Examples |
| Observe | Scan patient, team, room | “HR 150, no IV, monitor showing VT.” |
| Orient | Make sense of data | “Looks like hypovolemic shock from GI bleed.” |
| Decide | Form hypothesis + plan | “Fluids + pressors. RSI if mental status worsens.” |
| Assign & Act | Task execution + communication | “Nurse X, give 1 mg epi. RT, bag @ 10/min.” |
| Reassess/Iterate | Check response + refine next step | “EtCO₂ rising, good. Now, secure airway.” |
What Is CRM?
Crisis Resource Management (CRM) is a set of team-based safety principles adapted from aviation, designed to improve performance in high-risk, high-pressure settings like resuscitation.
CRM focuses on:
- Situational awareness
- Clear leadership
- Effective communication
- Task delegation
- Mutual support and speaking up
In short, CRM is about how teams work together — under pressure — to avoid errors, manage resources, and save lives.
CRM doesn’t replace clinical skill — it amplifies it by making teams safer, more efficient, and more resilient.
🔄 Merging ER-OODA with CRM: Why It Works
While ER-OODA and CRM were born in different worlds — military strategy vs aviation medicine — they thrive together in the chaos of the resuscitation room. Each fills a gap the other leaves:
- ER-OODA is about how we think and adapt.
- CRM is about how we communicate and collaborate.
When merged:
- OODA gives the cognitive loop — observing, orienting, deciding, and acting.
- CRM ensures each phase is executed safely and communicated clearly.
🧠 ER-OODA guides decision flow
🗣️ CRM ensures nothing gets lost in translation
Together, they turn isolated decision-making into team-wide shared cognition — boosting speed, safety, and adaptability.
This combined model (ER-OODA+) helps your team:
- Avoid cognitive overload
- Reduce errors from miscommunication
- Anticipate failure points
- React with clarity under pressure
💬 Think smart. Act safe. That’s the power of ER-OODA+.
🧭 Leadership in the ER-OODA+ Model: Who Owns the Loop?
Even in a cognitively fluent team, there must always be a clearly identified team leader — especially in high-stakes resuscitation. The leader:
- Sets the tempo of the OODA cycle
- Owns the clinical decisions, even when others contribute input
- Ensures assignments are made and CRM behaviors are followed
- Keeps the team in sync by saying things like:“Let’s pause to orient — do we agree this looks like hemorrhagic shock?”
“Decision made: we’re intubating. Laura, get the RSI meds.”
So even though everyone participates in Observe, Orient, and Reassess, the Decide and Assign & Act phases must be led.
Think of it like a conductor with a jazz band:
- The leader is the conductor — setting direction, tempo, flow
- The team plays their parts — and improvises within a shared structure
- Everyone speaks the same language (ER-OODA), but someone leads the tune
ER-OODA+ empowers everyone to think and speak — but still depends on clear leadership for execution.
🔚 Final Thoughts
✔️ The OODA Loop in resus is not just for physicians — every team member plays a role in each phase.
✔️ It trains the whole team to stay adaptive, focused, and aligned during the storm of critical illness.
✔️ When everyone cycles together — you outperform the illness.
✔️ ER-OODA gives you mental agility — CRM gives you team safety.
✔️ Together, they make resuscitations smarter, smoother, and safer.
✔️ When you cycle both models in sync — you build a high-performance culture in your ED.
❓ FAQ & Criticisms
“Is ER-OODA just another layer of complexity?”
Not at all. It’s a clarifier — not an extra task. The model maps the natural cognitive flow that great resus leaders already use — just made visible and sharable across the team.
“We already have ACLS/ATLS. Why add more?”
ACLS tells you what to do. ER-OODA helps you decide how and when to act — especially when protocols fall short or cases become atypical.
“Will this slow us down?”
The opposite — it helps eliminate confusion, delays, and duplicated efforts. ER-OODA isn’t a checklist — it’s a mindset loop that speeds up clarity and coordination.
“Do junior team members really need to think like this?”
Yes — in fact, this model teaches them how to think in high-stakes moments. It gives a structure to grow into and a common mental language to contribute meaningfully.
“But isn’t this just common sense?”
It is — but common sense isn’t always common practice. By making the invisible process visible, we help more people perform like the best leaders do — especially under pressure.
❓ “Where’s the evidence?”
The original OODA Loop is a proven military and aviation model, adopted by fields like critical care, trauma surgery, and crisis leadership .
In EM, we already teach parts of it in CRM (Crisis Resource Management) and simulation —
ER-OODA simply packages it into a usable, bedside-friendly framework.
🧪 ER-OODA+ in Theory… But What About in Practice?
While the ER-OODA+ model offers a promising fusion of decision-making and safety behaviors, we must acknowledge: it’s still a conceptual framework, not yet validated through large-scale research in emergency departments. Its strengths are clear in theory — improved cognitive clarity, team synchronization, and adaptability under pressure — but translating that into measurable clinical outcomes requires formal study.
Just like CRM had to be studied, tested, and adapted to medicine, ER-OODA+ deserves the same process.
Until then, its best use may be as a training scaffold, a mental checklist, or a team debriefing tool. The next step? Encourage simulation-based trials, pilot team huddles using this model, and build real-world feedback from the resus room.
References :
- Boyd J. A Discourse on Winning and Losing. 1987.
- Gaba DM. “Crisis Resource Management and Team Training.” Anesthesiology Clinics, 2010;28(2):233–250.
- Klein G. Sources of Power: How People Make Decisions. MIT Press, 1999.
- Soar J, et al. European Resuscitation Council Guidelines for Resuscitation 2021. Resuscitation, 2021.
- Weinger MB, Slagle JM. “Human Factors and Ergonomics in the Operating Room: Applications to Patient Safety.” Anesthesiology Clinics, 2002.
- Eppich W, Cheng A. “Promoting Excellence and Reflective Learning in Simulation (PEARLS).” Simulation in Healthcare, 2015;10(2):106–115.
- Hunziker S, et al. “Teamwork and Leadership in Cardiopulmonary Resuscitation.” J Am Coll Cardiol, 2011;57(24):2381–2388.
- Gawande A. The Checklist Manifesto: How to Get Things Right. Metropolitan Books, 2010.
- Berg RA, et al. “Systems of Care and Continuous Quality Improvement.” 2020 AHA Guidelines for CPR and ECC.
