Skilled and trained paramedical teams should be able to provide ongoing stabilization and resuscitative measures as a trauma patient is transported onto a waiting trauma team directly from the scene. Established protocols will allow both BLS (basic life support) and ALS (advanced life support) teams to care for this patient population and expedite them onto appropriate care. Minimal on scene time is considered the standard of care. As a result, the direct to trauma center population should have any procedures required done en route to hospital and not on scene. Patient packaging is often rudimentary as it is likely that one EMS caregiver is driving the ambulance and another one remains at the back of an ambulance unsecured trying to manage the trauma priorities—ABCs. Prenotification of the receiving center is paramount to facilitate preparation at the trauma center, and if the patient’s condition deteriorates in transit, a plan to consider ongoing physician stabilization at a health facility en route should be considered to allow for advanced procedures beyond the capabilities of the paramedical personnel and early administration of blood products.

The reality of many countries’ geography is that direct transport into a level 1 trauma center is sometimes impossible or not best for patient safety. Distances may be too great and inclement weather may impair or delay ground transport. Other mitigating steps may be that hospital facilities are present closer en route, and it is perceived that definitive or higher levels of care can be brought to bear; more aggressive resuscitation can be offered; the need for some technical procedures or skills is required more urgently (endotracheal intubation, tube thoracostomy). In such cases, EMS transports to a non-trauma designated hospital where some initial investigations and resuscitative efforts are carried out by hospital teams.

Trauma systems have evolved a classification system of hospitals and healthcare facilities that categorize the trauma management capabilities. Level 1, the highest, has all resuscitative, surgical, diagnostic imaging (interventional radiology), critical care capabilities. A Level 5 center accounts for the small rural community hospital with no immediate access to level 1, 2 and 3 trauma centers. The expectation would be that patients are stabilized and rapidly transferred onto higher level of care (Table 7.1) [2].

While trauma systems continue to strive toward all peripheral hospitals applying consistent principles to caring for trauma patients, using approaches like that identified in Advanced Trauma Life Support, patients ultimately need to be moved onto centers capable of managing their definitive medical issues. The transfer of care process should be initiated at the earliest opportunity. Most physicians will appreciate very early in the patient encounter that the patient needs a higher level of care and will require inter-facility transport. However, the decision to initiate the transfer of care process is often done after lengthy investigations and time has lapsed. This additional time until definitive surgical care will influence patient temperature, end organ perfusion, and coagulopathy. Early initiation of the transfer of care process will start a cascade of events that will get an appropriate transport team to the sending site concurrently with the ongoing investigations and resuscitative efforts at the sending facility. Early transfer onto definitive care will mitigate increasing morbidity and mortality.

Inter-facility transport of the trauma patient can be inherently difficult in many countries. The varying geography, great distances, and diverse weather patterns complicate safe and rapid patient transport. The issues and principles that have to be juggled include establishing the fastest pathway on to the relevant trauma center—i.e., ground ambulance, fixed-wing transport or rotary-wing transport; availability of transport modality; capabilities of transport modality; and available personnel depending on the patient’s needs. Each of the transport modalities has advantages and disadvantages. Prolonged ground transport is inherently dangerous for EMS crews and the community as a whole when driving “lights and sirens” over a significant distance [3]. Rotary-wing transport allows direct site-to-site service when both have air transportation regulatory body-approved landing sites but has a record, especially in highly populated areas in the United States, of significant accidents resulting in injury. The Federal Aviation Agency (FAA) issued a “black box” warning against helicopter EMS (HEMS) systems in the past and insisted on the widespread implementation of safety systems to mitigate the identified risks. These recommendations are in the process of implementation worldwide. The challenge of fixed-wing transport is the need for multiple patient transfers into and out of the aircraft and subsequent ground transport between airfields. This process does delay out-of-hospital time. However, the range of operations offered by fixed-wing transport facilitates trauma care over large distances.

The EMS ethos has always been that the level of care delivery should not decrease while a patient is transferred from one site onto higher levels of care. The inter-facility transport capabilities should be able to maintain or continue effective resuscitative strategies en route. Ultimately, attempts should be made to minimize out-of-hospital times; as the EMS environment is austere, clinical monitoring and continued delivery of care can be limited due to space and human resources. In the hospital, caregivers must appreciate that during transport, care delivery must be limited. Psychomotor skills are difficult to perform (endotracheal intubation, intravenous initiation, splinting) in a closed space with limited resources. Due to noise and vibration (sirens, helicopter rotor, radios), auscultation and continuous monitoring is also challenging.

The medicolegal risk during the patient transportation process is equally shared between the receiving and sending physician. It is imperative that the consultation process covers the resuscitation expectations, patient preparation for transport, and transport medicine issues. Some trauma systems have access to Transport Medicine Consultants that join the consultative process and provide advice on these issues. If we are to ensure that patient level of care is not to decrease during the vulnerable interhospital transport period, it is important that we all consider these issues.