You’re standing in that apartment. Elderly male. Head bleeding. Family screaming. Dog barking. TV blaring.
You know every textbook answer. You studied your ass off. You passed your registry. And your brain just locked up completely.
Questions spinning: Why’d he fall? Cardiac rhythm? Blood sugar? Spinal precautions? History? How do we get out of here?
You know everything you want to do. You have zero process for when to do it.
Your tires are spinning. Your mental horsepower isn’t hitting the street.
This isn’t an intelligence problem. More knowledge will not fix this.
The EMS Power Curve- using an analogy from the phases of flight well known in aviation, understanding the power curve framework can help you transforms scattered knowledge into executable action. You’ll learn the six predictable chunks of every 911 call, the if-then statements that reduces cognitive load, and how to reset when calls go sideways. Your attention is a finite resource—stop wasting it on chaos you can control.
The Aviation Origin: Why Pilots Who Don’t Understand Flight Phases Crash
The term “behind the curve” comes from aviation. The power curve describes the complex balance of forces keeping aircraft in the air—lift, thrust, speed, drag.
Different phases of flight demand different pilot responses.
Moving slowly at takeoff? Specific control inputs.
Cruising at altitude? same inputs might produce completely different reactions.
The same control input at different flight phases produces different results. So it’s imperative to understand what phase of the flight you are in in order to know the specific input needed.
Get behind these demands and the aircraft crashes.
Your 911 calls work the same way. Predictable phases. Different requirements. Different priorities.
The Six Phases of the EMS Power Curve
Every call breaks into manageable chunks:
- Initial Contact – Patient interaction on scene
- Moving to Ambulance – Decision and physical movement
- Loaded But Not Rolling – Back doors closed, haven’t started driving
- Wheels Turning – Transporting to hospital
- Preparing To Arrive – Packaging patient and equipment for ED arrival
- Hospital Handoff – Arrival through transfer of care
Each phase has specific priorities, clear goals, and decision points.
Chunking calls this way stops you from trying to do everything at once. Focus on what matters now, then shift to what matters next.
Phase 1: Initial Contact — Build Your Foundation or Crash
Your true priorities:
- Introduce yourself professionally
- Form initial impression (sick or not sick?)
- Obtain focused history and physical exam
- Start differential diagnosis
- Identify how you’re getting out
Notice what’s not on this list: completing a full head-to-toe exam, calling the hospital, deciding every intervention you need to perform.
You’re gathering enough information to steer your decision-making.
At a bare minimum before you depart the scene you want to have answered 4 questions:
- Are we going to the hospital?
- Do I have a differential diagnosis?
- Have I addressed immediate life threats? (Maryland protocol for the critically ill mentioned in the episode: “Cease all efforts of patient movement until treatment is complete.”)
- What information exists here that I can’t get elsewhere?
Phase 2: Moving to the ambulance
This is a natural break in the chaos.
Not much in the way of treatment or interventions can occur while moving the patient to the ambulance.
There is room potentially for more questions / history gathering but often this natural break is a good time to mentally regroup, collect your thoughts, solidify your differentials, and develop a plan for what you want to happen in the next phase.
Recovering When Behind the Curve
CBA Framework
- C – Cue: Have a pre-rehearsed phrase that helps to recenter you – “Reset. Focus on the present. One step at a time.” It is important to make this phrase simple, actionable and true to you. Practice it with mental rehearsal before you need it in reality.
- B – Breathe: Tactical breaths, physiological sigh, box breathing. Your diaphragm is a muscle just like your bicep. It needs training too. Practice your breathing before you need it.
- A – Attach: Ground yourself in the present (5 things I can see, 4 sounds I can here, 3 smells)
Reset between phases. Revert to what you know best. The ABCs are always true.
Phase 3: Loaded But Not Rolling
This is your office, it’s the perfect work environment:
- Doors locked
- Climate controlled
- All lights on
- Every tool at your disposal
- Zero distractions
Veteran rule: At a bare minimum make sure the airway is managed and take your first attempt at an IV before wheels turn. (Does this fit every scenario? No. But it’s a good starting bench mark to compare and justify your decision making.)
Prioritize: What are the most important things? Who’s doing them?
For high-acuity patients, do lifesaving interventions first. Everything else happens during transport.
The WHAT-IF/IF-THEN Framework for Emergency Medical Decision Making
Core Philosophy: Anticipate, Don’t Just React
The goal of emergency medical care is to think ahead—to anticipate scenarios rather than simply respond to them as they unfold. This framework transforms reactive clinicians into proactive decision-makers who mentally rehearse multiple pathways before they’re needed. Ultimately improving both patient care and provider confidence through systematic preparation for the unexpected.
After completing your initial assessment, differentials, and treatment plan, begin the mental rehearsal process:
What-If Scenario Planning
- What if the patient’s condition deteriorates?
- What if my primary diagnosis is wrong? It’s good to develop more or less likely differentials but we should almost never hang our hats on a single diagnosis.
- What if complications arise during transport?
- What if the patient arrests unexpectedly?
If-Then Decision Trees
- IF this happens, THEN I will take these specific actions
- IF that doesn’t happen, THEN I will follow this alternative pathway
- IF complications arise, THEN I have predetermined responses ready
Experts Think Logistics
Knowing what to do ≠ knowing how to execute it.
Ask:
- “What do you want to do?”
- “How will you do that?”
Test each step: equipment, backup, roles, contingency.
Phase 4: Transport
Multi-tasking is a myth. You are task switching, and every time you switch to a new task you have to reorient and precious seconds are lost. Instead- Prioritize and delegate, complete one task at a time before moving to the next.
If you don’t have extra hands in the back the same principle applies, you are just prioritizing and delegating tasks to yourself.
You may not get everything you want done before you need to prepare for arrival to the ED. But if you’ve prioritized and completed one task at a time it will assure that the most important tasks have been completed first.
Phase 5: Preparing for Arrival — Seat back, trays up
Before arrival:
- Final set of vitals
- Switch to the portable oxygen
- IV bag and bloods secured, ready for exiting the ambulance
- Monitor off and put away or secured to the stretcher ready to roll with the patient
- Last dose of pain meds
- Mental rehearsal of report- allows you to more confidently command the room and is a mental checklist to identify any questions you may have forgotten to ask
- Clean up any trash laying around, be ready to turn and burn if the big one suddenly comes in
The goal is for the doors to open and you to be able to immediately exit the ambulance with the patient. There should be little to no cleaning needed so that you can be ready to return to service should their be an immediate need to do so.
Does this happen every time? Of course not. With a critically ill patient who required multiple interventions during a short transport, chances are there will be some cleaning needed at the end of the call.
But none the less this is a good bench mark to aim for on the majority of the calls we run.
Phase 6: Landing the Plane — Hospital Handoff
80% of medical errors trace to miscommunication during handoff. Have a structure to your handoff but allow some flexibility so that you are not burying the lead or forgetting important information. Command the room- be loud, be succinct, allow for questions.
Advocate for your patient, include physician if possible, and organize information clearly.
Build Your Power Curve System Today
Action Steps:
- Map the 6 phases on your next three calls
- Build three if-then statements for common call types
- Create a recentering phrase and practice the CBA
- Master one logistics sequence per shift
- Rehearse handoff mentally before arrival
Your attention is finite. Your mental horsepower is real.
Understanding The EMS Power Curve stops you from spinning on things that don’t matter and start executing what is needed in that current phase of the call.
Build the system. Stay ahead of the curve. Stop crashing in apartments.
