The disease process must also be considered in this decision The patient with developing petechiae, fever, and hypotension should not be transported several hours by ground if a quicker method of transport is available Thomas et al reported an association between helicopter transport and increased survival in blunt trauma patients (adult and pediatric) However, short air transport for a relatively stable patient may not be an appropriate use of resources or be in the patient’s or team’s best interest Eckstein et al and Arfken et al suggested that helicopter services may be overused and may not influence outcomes when compared with alternative modes of transport One must be cognizant of the many issues surrounding the mode of transport choices; these choices should be individualized for each patient Although appropriate medical care should never be withheld for financial reasons, a cost comparison of air and ground transports is often useful In general, RW (helicopter) transport costs two to three times more than ground transport for local transfers However, the savings may potentially offset the cost in time saved A helicopter, which can land directly at the patient’s location, is much quicker than an ambulance, which takes a less direct route If the helicopter cannot land directly at the referring or receiving center, however, the potential time savings by air transport may be limited In that situation, in addition to the decreased time savings, the patient may be placed at greater risk due to the multiple transfers involved, as the patient must first be loaded onto a stretcher for an additional ambulance ride to a remote helicopter landing zone, then unloaded from the EMS stretcher to into the helicopter The riskiest time for the patient is often during transfer from stretcher to stretcher or vehicle to vehicle ( Fig 11.6 ) These transfers increase opportunities for dislodgement of endotracheal tubes, central venous catheters, chest tubes, and other lifesaving equipment Communication center personnel, transport team members, and medical control (command) physicians should all be aware of times, distances, and particular medical and logistical nuances of each referring institution and location MEDICAL OVERSIGHT There are two types of medical oversight—direct (online) and indirect (offline) Both models require initial and ongoing input by physicians, and each model has its own risks and benefits Direct Medical Control Direct medical oversight refers to the real-time provision of supervision or authorization of care activities by physicians who are either on-site, or, more commonly, using radio or phone communication with the transport team at the