Addition of a physician or advanced care provider may increase the level of available medical care within the ALS environment, but that impact may be limited by the particular service’s use of protocols and offline medical direction CCT services can increase the medical sophistication of ALS providers by ensuring the presence of a CCT nurse or paramedic, but these providers may be lacking significant pediatric training, experience, expertise, and/or skills Pediatric CCT systems with pediatric-specialized equipment such as ventilators, infusion pumps, and appropriately sized monitoring equipment which include critical care providers with pediatric experience and expertise have been shown to be associated with fewer transport-related adverse events, reduced mortality, and better patient outcomes These providers may include nurses, physicians, respiratory therapists, paramedics, and advanced practice providers When transport services are needed, the modalities to be considered include ground ambulance, rotor-wing (RW) (helicopter), and fixed-wing (FW) (jet or prop plane) aircraft ( Figs 11.4 and 11.5 ) Often, the decision is straightforward For example, the available transport system may be ground only, or inclement weather may prevent air transport Alternatively, the distance may be so great or traffic issues significant enough that ground ambulance transport is impractical Several important issues should be considered when mode of transport is discussed The first is skilled personnel availability If the transport mode require or offer different personnel configurations, the mode with the most appropriate personnel should be strongly considered Choosing between the most readily available, shortest out-of-hospital time, and most appropriate medical personnel can be difficult, although they are not necessarily mutually exclusive Ideally, a pediatric transport service with the capability for both air and ground transport is available, so comparative personnel issues are not the major deciding factor Often, the referral hospitals or physicians want to have a patient taken to the receiving hospital as quickly as possible They are sometimes willing to accept a transport process with limited pediatric sophistication based solely on speed of transport Occasionally this may be appropriate, but caution needs to be exercised to ensure the transport system is capable of handling issues that can occur during the transport process The referral physicians must be proactive in the mode of transport decision This includes being aware of the transport systems that are available and evaluating those systems before requiring their use In areas without tertiary care pediatric transport options, local pediatric providers and receiving physicians should be available to provide expertise to the general transport services to help bridge the gap between the general (primarily adult) and pediatric providers