The patient has been entrapped for almost thirty minutes. An unrestrained driver going 50 mph who lost control and struck a tree, he is now unresponsive, bleeding profusely, and has the outline of a steering wheel tattooed across his chest.


His face was crushed on impact. You’ve managed to insert an OPA, and you are suctioning his airway and providing ventilations, but his condition is deteriorating with each passing minute. At last, his legs are free, and the patient is packaged. The next critical juncture in patient care arrives: How and where will the patient be transported?

With every emergency call, a paramedic must make transport decisions that will impact the patient’s outcome. Excellent care in the field is diminished if it is followed by poor decisions concerning transport. Here are a few considerations. 


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How Should the Patient Be Transported?

With the rise of helicopter EMS transport (HEMS), you may be faced with the decision of ground versus air. The growth of HEMS has made transport via helicopter a common occurrence, but just because it is an option doesn’t mean it should be considered a standard mode.


HEMS is inherently dangerous–not only for the patient but for the HEMS crew. So its use should be restricted to only those patients who meet HEMS guidelines, which generally include:


  • Patients requiring a higher level of care not available through ground transport.
  • Patients whose treatment is time critical, where HEMS can deliver the patient much faster than transport via ground.
  • Scenes located in geographically isolated areas, making ground transport difficult, if not impossible.
  • Situations when local EMS resources are overextended, such as disasters or mass casualty incidents. 


When considering transport by air, be sure your patient meets the criteria. Just because a patient needs a trauma center does not mean he or she must go by air. Use good judgment when making the decision to drive or fly. 


Where Should the Patient Be Transported?

Once you’ve decided on the best mode of transport, you then must decide where the patient should go. On routine calls, the patient typically decides based on their preference or insurance needs. The closest facility is always a reasonable choice. But certain patients require specialized facilities; none more so than trauma.


Here is a quick review of the guidelines that dictate which patients require the highest level of trauma care available (preferably a Level I trauma center). The criteria are broken down into two categories: physiological and anatomical.


 Mental status and vital signs

  • All Patients
      • Unable to follow commands (motor GCS < 6)
      • RR < 10 or > 29 breaths/min
      • Respiratory distress or need for respiratory support
      • Room-air pulse oximetry < 90%
    •  Age 0–9 years
      • SBP < 70mm Hg + (2 x age in years)
  • Age 10–64 years
      • SBP < 90 mmHg 
      • HR > SBP
  • Age  ≥ 65 years
    • SBP < 110 mmHg or
    • HR > SBP 


Anatomical Criteria

  • Penetrating injuries to head, neck, torso, and proximal extremities
  • Skull deformity, suspected skull fracture
  • Suspected spinal injury with new motor or sensory loss
  • Chest wall instability, deformity, or suspected flail chest
  • Suspected pelvic fracture
  • Suspected fracture of two or more proximal long bones
  • Crushed, degloved, mangled, or pulseless extremity
  • Amputation proximal to wrist or ankle
  • Active bleeding requiring a tourniquet or wound packing with continuous pressure 


It’s up to you as the paramedic to decide the most appropriate destination for your patient, so know the criteria and follow your instinct and agency protocols.


Finally, some patients may require special transport considerations based not only on their etiology but on their demeanor.


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Special Transport Considerations

Finally, some patients may require special transport considerations based not only on their etiology but on their demeanor.


  • Neonates and pediatrics – consider a special facility if one is available.
  • High-risk pregnancies – also consider a special facility, if available.
  • Combative patients – have law enforcement accompany the patient to the hospital (crew safety is priority one!).
  • Intoxicated patients – determine whether the emergency room or a detox facility is most appropriate.


 When deciding the best transport alternatives for your patients, know your protocols, follow those protocols, and most importantly, use good judgment.


Editor's Note: This blog was originally published in September 2015. It has been re-published with additional up to date content.