Startups don’t die from starvation. They choke.
On premature infrastructure. Bloated teams. Overbuilt features solving problems that weren’t real.
Everyone says “move fast and break things.” But speed without structure is waste.
The goal isn’t raw velocity. It’s structured speed.
Across startups and Big Tech, I kept seeing the same pattern:
Teams either over-engineered before they had signal, or polished prototypes that should’ve been thrown away. The issue wasn’t execution. It was misaligned certainty.
So I started using a model I now call:
Paramedics, ER, and Surgeons.
The Problem: The Linear Illusion of “MVP → PMF → Scale”
Most product roadmaps pretend the journey is neat:
Build MVP → Find PMF → Scale.
But in the real world, PMF isn’t a moment. It’s a moving target.
Customer needs evolve. Competitors emerge. Your own product enters new segments.
What fits today may not fit tomorrow.
The risk isn’t just building the wrong thing, it’s scaling it with confidence you didn’t earn.
You need an org system that doesn’t just find fit, but continuously manages it.
A system that matches engineering investment to certainty level, while operating at multiple speeds simultaneously.
The Model: Paramedics, ER, and Surgeons
The Lean Startup model treats product organizations like a Toyota factory; however, I treat it as a hospital emergency system:
- Paramedics (Discovery & Ops): These are your first responders, operating in the chaos and constantly seeking signal. At Kormo, our Paramedics were an on-the-ground team in Dhaka running Google Forms, SMS surveys, and WhatsApp workflows… basically, anything to simulate a solution fast. Their job: find signal in the noise.
- ER (Rapid-Response Engineering): When a Paramedic’s hack breaks, or a workflow shows repeat value, it graduates to the ER. Think of these as forward-deployed engineers who have the job of not building for scale, but stabilizing. Their job: operationalize validated insights just enough to keep learning and support real usage, at the next tier of scale.
- Surgeons (Core Engineering): Once a solution has proven to be critical, recurring, and fundamental to a growing user base, it goes to the Surgeons. This is your elite team. They build the robust, reliable, extensible systems your business will depend on. Their job: build leverage.
This is a Continuous System
This is the crucial shift. This model isn’t a one-and-done lifecycle for a single product. It’s a continuous, parallel operating model for the organization.
A healthy org runs all of these at once:
- Paramedics test a new premium upsell with a handful of users.
- ER builds out the job-matching feature that worked last month.
- Surgeons scale payments and identity infra now core to the platform.
This structure ensures we don’t waste top engineering talent on unvalidated problems, nor do we bottleneck learning by waiting for perfect code. We build in layers: validate fast, build smart, scale deliberately…all at the same time.
Putting it into Practice
We used this model to launch Kormo, a jobs marketplace for emerging markets, taking it from an idea to over 2 million job placements across three countries in under a year.
- Paramedics constantly tested new job seeker and employer flows in the field using printouts, WhatsApp messages, and surveys.
- ER built lightweight, operational tools like OCR resume scanners and basic intake portals to handle the initial wave of validated demand.
- Surgeons built the backend systems, recommendation engines, and data infrastructure in parallel, progressively taking over components as they became proven.
The result? We scaled rapidly without waste. There were no massive rewrites and no premature over-engineering. We managed our evolving product-market fit across multiple fronts, deliberately and without drama.
Why It Works: Learning Velocity > Feature Velocity
Most teams optimize for feature velocity. This model optimizes for learning velocity and scalable impact, which is what you truly need in any new market.
It also puts people with roles that match their mindsets. Your scrappy, experimental ops folks aren’t slowed down by formal ticketing systems. Your core engineers aren’t bogged down fixing one-off, manual edge cases. Everyone plays to their strengths, and the entire system is designed for the continuous evolution of product-market fit.
Where / When to Use This
If you’re:
- Building a new product in an uncertain market
- Leading an innovation team inside a large company
- Trying to avoid the classic trap of premature scaling
It’ll keep you fast, focused, and ruthlessly customer-aligned not just at the start, but continuously.
Bonus: What’s the PM’s role?
So where does the role of the Product Manager fit in all of this?
- For Paramedics, synthesis is the PM’s key job.
- For the ER Team, prioritization is the PM’s key job.
- For Surgeons, clear design and scope are the PM’s key job.
Every team should have customer empathy, but the PM’s shape must evolve with the certainty level.
It’s not about process, it’s about surfacing truth and compounding conviction.