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The 20-60-20 Rule of Helicopter EMS

—Fly-along day is an exciting time for wannabe flight crews.

If you’re considering an air medical career, fly-along day makes a lot of sense.

See the blood. Feel the turbulence. Smell the fuel.

What better way to figure out if a flight medic, flight nurse or EMS pilot career is for you?

There is no substitute for watching a flight nurse, flight medic or EMS pilot do their jobs inside a trauma helicopter. No way to simulate that unique perspective. It’s not the type career that lends well to “plug and play” imagination. You can’t watch a ground medic or emergency room nurse do their jobs, and then just transfer the images inside a helicopter.

If you do, your perspective is skewed.

The pictures don’t match reality.

Air medical is a profession you learn by doing. Hands on.


There are some important things you can learn about air medical without ever leaving the ground.

That’s what this article is about.

Understanding what I call the 20-60-20 rule of Helicopter EMS.

What is the 20-60-20 Rule of Helicopter EMS?

Let me explain with a story.

Jaime, a local paramedic, was in my office when the tones dropped. Jaime was job-shadowing the flight medic at my base.

It was Jaime’s second fly-along attempt in as many months, and of course she was gushing with excitement.

I could see anticipation swell up in Jamie’s face when the call to transfer a two year old from our parent hospital to a burn center in Allentown, PA, came across the pager.

Patient data isn’t supposed to come across the pilot pager. By design, I’m not supposed to know patient details. The premise being pilots make better (or at least more objective) decisions when patient data is withheld.

All good.

Except this particular time I did see the patient data. Why? Because sometimes wires get crossed, pagers get swapped and people make mistakes.

Before you roll your eyes and blame the wrong person or persons, stop. The reason I knew patient details wasn’t the fault of fight communication specialists. In fact, not even close. Dispatchers and flight communication specialists work very hard and consistently do great work, under conditions that for the most part, suck.

Imagine trying to pass critical information to flight crews while simultaneously listening to angry charge nurses, ER doctor to-do lists, and public complaints. Not an easy job. Plus, the volume of requests these folks juggle is herculean.

Obviously, I feel compelled to stick up for dispatchers and flight communication specialists. I consider them an integral part of the EMS Flight Safety Network team, and that’s the reason for the expanded explanation.

Back to the flight request…

Jaime Is Ready To Fly

In Jaime’s mind, this is the flight request she has been waiting for. The big one…

Me too…from the perspective of sitting around bored out of my skull for two straight days. I really wanted to fly as well.


The weather was not cooperating. Lines of embedded thunderstorms blanketed the entire state. There was no safe way to go from point A, to B, to C, to D.

I turned down the flight and Jaime took the news hard. I showed Jaime the current radar picture and used the opportunity to explain the 20-60-20 Rule of EMS Flying.

Jaime perked up a bit and showed great interest in learning the details of the 20-60-20 rule. Probably because no such rule exists for ground EMTs and paramedics. The expectation for ground medics is to transport patients 100% of the time, with zero (or near zero) exceptions.

I explained how all EMS flights fall into three broad categories:

  • 20% of air medical flights are critical, necessary, and needed
  • 20% of air medical flights are total B.S. and do not need flown at all
  • 60% of air medical flights fall between the two parameters explained above*

*The middle 60% follows a standard bell curve distribution.

What does that all mean in the real world?

Put simply:

Give every flight request your best effort, make a decision, stick to the decision, and move on.

Sounds simple, right?

And it is a simple process (especially with embedded thunderstorms).

But….simple things aren’t always easy –even when they should be.

New pilots and sometimes experienced pilots, carry guilt about flights they turn down. The guilt sometimes magnifies when plots know patient data, like a 2-year old with burns.

That’s one reason understanding the 20-60-20 Rule of EMS Helicopters is important. It gives proper perspective to flight requests. Reminding yourself this patient has the same chance (mathematically) of falling in the top 20% or bottom 20% tiers, keeps everything in its proper perspective.

The point is that if you give every flight request your best effort, there is no reason to feel guilty. None.

The U.S. Coast Guard teaches a similar concept to search and rescue pilots. The concept is included in Coast Guard crew resource management classes. I realize it’s a completely different mission and flight profile, but the goal of everyone going home after every flight, is shared by both the Coast Guard and air medical.

The Science Behind The 20-60-20 Rule

Are you wondering about “the science” behind The 20-60-20 Rule of Helicopter EMS?

I can clear it up for you.

There is no science or proven data.

The rule is based purely on opinions of EMS pilots.

But after two decades of flying, I sincerely believe it’s true.

I queried so many pilots I lost track of the exact number. Note: with hindsight, if I did it again, I would make the survey scientific and meticulously track the results.

The most common answer regarding air medical cases that legitimately needed flown, was actually closer to 16% vice 20%. But that made the math (and name of the rule) difficult to remember. The 16-60-24 rule doesn’t have the same ring to it… And since the data is purely EMS pilot opinions, rounding up to 20% was an easy decision.

What’s your experience with air medical?

Do you agree with the 20-60-20 EMS Helicopter math? Or do you think it’s way off base?

Share your opinion in the comments section.


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Troy Shaffer
Troy Shaffer

About the Author: Troy is an Air Medical Career Expert passionate about a team approach to improving air medical safety from the ground up. Troy is a former Army medic, Army pilot, Coast Guard pilot and EMS pilot. Troy has taught hundreds of wannabe flight medics, flight nurses and EMS pilots the exact steps needed to launch air medical careers.

    2 replies to "The 20-60-20 Rule of Helicopter EMS"

    • Avatar James Boyd

      I understand the weather aspect but, as a 27 year ground Paramedic I understand the space limitations and procedural limitations on board a Helicopter. That being said, If I’m calling for air transport you can bet that’s what’s needed.
      As an aside, I have also called / waved off air transport I felt were unnecessary.
      Some use air transport simply as a time saver rather than attend to a patient for 45 minutes.
      The rule seems fair in the grand scheme of things.

      • Avatar Troy Shaffer


        Thanks for sharing your experience.

        Clear Skies & Tailwinds,

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