Rural and retrieval trauma

The rural and the retrieval trauma is the trauma managed away from the definitive trauma centre — in the small rural hospital, the remote clinic, or the pre-hospital setting where the resources, the expertise and the time-to-definitive-care are all limited. The Fellowship candidate must know the principles of the rural damage control, the aeromedical retrieval physiology, the clinical decision-making that determines who stays, who goes, and how, and the system design that supports the rural provider.[1][1]

The challenges of the rural setting

The rural trauma differs from the urban in the time (the prolonged pre-hospital time, the long transfer to the definitive care), the resources (the limited staff, the equipment, the blood products, the surgical capability), the expertise (the generalist rather than the specialist), the communication (the limited connectivity, the distance), and the environment (the weather, the terrain, the evacuation difficulty). The rural provider manages the patient for hours longer than the urban ED, with fewer hands and fewer tools, and the quality of the initial management determines the outcome.[1][1]

The delayed discovery and the prolonged transport

The first and most distinctive feature of the rural trauma is the time. The injury may not be discovered for hours — the farmer alone in a paddock, the tourist off a remote track, the motorist on an empty highway at night — and the time from injury to first responder contact is measured in hours rather than minutes. The activation chain is long: the bystander (if any) raises the alarm, the volunteer ambulance navigates the unsealed road, the patient reaches the small hospital, the retrieval is tasked, the aircraft flies — each step consuming time that the urban system compresses into minutes. The golden hour — the concept that the seriously injured patient reaches definitive surgical care within 60 minutes — is unattainable in much of the rural and remote setting, and the rural system is designed around the recognition that the patient will be in the pre-hospital and the rural-hospital phase for several hours. The rural provider therefore becomes the definitive caregiver for a period that would be unthinkable in the city, and the standard of care delivered in that window — the airway, the breathing, the circulation, the warmth — is the principal determinant of survival.[1][6]

[1]

The limited resources and the limited staff

The rural hospital has fewer of everything. The staff may be a single doctor and two nurses at night, the equipment may lack the ventilator, the ultrasound, the blood warmer or the cell-salvage device, and the blood products may be limited to a few units of O-negative red cells in the refrigerator (or none at all). The surgical capability is variable: some rural hospitals have an operating theatre and a GP surgeon with anaesthetic support, while others have none and cannot perform even the damage-control laparotomy. The imaging is typically a plain radiograph and a basic CT; the laboratory is limited to the basic biochemistry and haematology, with the crossmatch sent to a distant laboratory. The pharmacy carries a narrow formulary. The rural provider works with what is available, and the Fellowship candidate must be able to construct a resuscitation plan around the resources that actually exist — not the resources the textbook assumes.[1]

The weather, the terrain and the evacuation difficulty

The weather is a recurrent and unpredictable adversary in the rural and the remote setting. The fog, the low cloud, the high wind, the thunderstorm and the dust storm ground the aircraft and convert a 90-minute helicopter retrieval into a six-hour road journey — or no journey at all until the weather clears. The terrain — the mountains, the gullies, the flooded creeks, the unsealed roads that become impassable in the rain — affects both the ground and the air access: the helicopter cannot land in the dense canopy or the steep slope, and the ambulance cannot cross the washed-out bridge. The distance multiplies every decision: the retrieval that is 'just a quick flight' in the city is a multi-hour mission with weather, fuel and crew-duty considerations. The Fellowship candidate must understand that the weather and the terrain are not inconveniences but clinical variables — they determine the platform, the timing, and sometimes whether the patient can be moved at all, and the rural provider may need to hold and resuscitate the patient for longer than planned because the aircraft cannot fly.[1]

[1]

The communication and the connectivity

The communication is the invisible infrastructure of the rural trauma system, and it is frequently the weakest link. The mobile-phone coverage is patchy or absent across much of the rural and the remote area; the radio and the satellite phone are the fallback. The clinical communication — the tasking of the retrieval, the consultation with the trauma centre, the handover to the receiving team — must traverse this unreliable network, and the failure of any link delays the tasking, the advice and the preparation. The telemedicine — the video link, the image transfer, the remote ultrasound guidance — is increasingly valuable but depends on the bandwidth that the rural site may not have. The Fellowship candidate must know the structured communication tools (the ISBAR for the clinical handover, the ATMIST for the pre-hospital and the retrieval handover) and the discipline of the concise, the structured and the repeated communication that compensates for the unreliable channel.[1][2]

The rural damage control

The rural provider applies the damage-control principles from the first contact: the catastrophic haemorrhage control (the tourniquet, the pressure dressing), the airway management (the basic and the advanced), the oxygen, the IV access, the warmed fluids or the blood products (if available), the splinting, and the preparation for the transfer. The limited surgical capability (the rural GP surgeon) may perform the life-saving intervention (the chest drain, the emergency caesarean, the damage-control laparotomy) if the transfer is not feasible in the time available. The telemedicine and the telephone consultation with the trauma centre guide the management and the decision-making.[1][1]

The early definitive airway in the rural setting

The early intubation is one of the most important and most decision-heavy interventions in the rural trauma. The rural provider will not have the anaesthetist at the bedside within minutes, and the patient who is borderline for the airway in the city is the patient who needs the definitive airway in the country — because the deterioration in the ambulance or the aircraft is far harder to manage than the deterioration in the resus bay. The physiologically difficult airway (the hypoxia, the hypotension, the acidosis, the right-heart failure) is the patient in whom the rapid-sequence induction precipitates the cardiovascular collapse, and the rural provider must prepare for it: the fluid or the blood bolus before the induction, the vasopressor drawn up, the reduced dose of the induction agent (the ketamine at 1 to 1.5 mg per kg rather than the 2 mg per kg, or the halved etomidate), the full pre-oxygenation, and the back-up plan (the surgical airway, the second-generation supraglottic) ready before the drug is given. The anatomically difficult airway (the facial trauma, the blood, the obesity, the limited neck movement) compounds the difficulty, and the rural provider should err on the side of the early, the planned and the well-resourced intubation over the late, the rushed and the improvised one.[5][8]

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The chest tube before the transfer

The chest tube (the intercostal drain) is placed for the pneumothorax, the haemothorax and the suspected pneumothorax before the aeromedical or the prolonged road transfer, because a small or an occult pneumothorax will expand at the altitude and may convert to a tension pneumothorax in the cabin — where the noise, the vibration and the limited access make the needle decompression and the tube thoracostomy far more difficult. The conservative management of the small pneumothorax (the 'watch and wait' appropriate in the well-monitored urban ED) is not appropriate for the patient about to fly. The chest drain is connected to the Heimlich valve or the underwater seal that will function in the aircraft, and the drain is secured for the turbulence. A prophylactic chest drain is considered for the patient with the rib fractures and the subcutaneous emphysema even without a clear pneumothorax on the limited rural imaging, because the cost of an undrained tension pneumothorax at altitude is death.[2][3]

[1]

The splint, the pelvic binder and the haemorrhage control

The haemorrhage control is the first priority in the rural as in the urban setting: the catastrophic external haemorrhage is controlled with the direct pressure, the tourniquet (the limb), and the pelvic binder (the pelvic fracture). The pelvic binder is applied early and broadly in the rural setting — the clinical suspicion of the pelvic fracture (the high-energy mechanism, the unstable pelvis on the springing, the perineal bruising, the blood at the urethral meatus) is enough, because the rural imaging may not confirm the fracture and the undetected pelvic-volume bleed is a frequent cause of the preventable rural death. The long-bone splinting (the traction splint for the femoral fracture) reduces the pain, the blood loss and the fat embolism risk, and the fracture reduction and splinting before the transfer prevents the neurovascular deterioration in transit. The rural provider applies the binder, the splint and the dressing before the retrieval team arrives — the retrieval should not be delayed to do what the rural provider can do now.[1][3]

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The blood products and the rural transfusion

The blood products may be available in the larger rural hospital (a few units of O-negative red cells, occasionally the thawed plasma) but are frequently absent in the remote clinic. The rural provider must know what is available and what is not. The O-negative red cells are the universal donor product for the haemorrhaging patient of unknown group; the limited supply is reserved for the women of childbearing potential (to avoid the Rh sensitisation) and the severely shocked patient, while the O-positive may be used for the men and the post-menopausal women when the O-negative is scarce. The balanced resuscitation (the ratio of the red cells to the plasma approaching 1:1) is the urban standard from the trauma centre, but in the rural setting the provider works with what is available — and the warmed crystalloid (the balanced crystalloid, the Hartmann's or the Plasma-Lyte) remains the pragmatic bridge when the blood is not available or is en route. The tranexamic acid (the 1 gram IV over 10 minutes, then the 1 gram over 8 hours) is given within the first three hours of the injury and is the single cheap, portable, evidence-based haemostatic drug that the rural provider can always give.[1]

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The retrieval decision

The decision to retrieve (vs to treat locally) depends on the injury (the need for the definitive surgery, the intensive care, the specialist), the time (the time-sensitive intervention — the STEM, the GCS below 9, the shocked patient), the resources (the rural capability, the retrieval availability, the weather), and the patient (the comorbidity, the stability for the transfer). The retrieval is by the fixed-wing (the long distance, the stable patient) or the rotary-wing (the shorter distance, the scene retrieval), with the flight crew (the doctor, the nurse, the paramedic) and the equipment. The decision is made jointly with the receiving trauma centre and the retrieval service.[1]

The tasking and the appropriate platform

The tasking is the process by which the retrieval service allocates the right resource to the right patient at the right time. The retrieval coordinator — typically a senior retrieval clinician at the trauma centre or the dedicated retrieval service — takes the call, applies the tasking criteria, and dispatches the platform and the crew. The tasking decision weighs the clinical urgency (the time-critical injury — the haemorrhagic shock, the severe TBI, the time-sensitive ischaemia), the distance and the geography (the helicopter for the short to medium range and the scene, the fixed-wing for the long distance and the inter-hospital transfer), the weather (the cloud base, the wind, the visibility, the temperature), and the crew availability (the duty hours, the fatigue, the concurrent taskings). The Fellowship candidate must understand that the tasking is a clinical decision, not a logistical one — the coordinator is matching the patient's physiological need to the platform's capability, and the wrong platform (the road ambulance for the patient who needed the doctor-led helicopter) is a clinical error with consequences.[1][2]

The doctor-led versus the paramedic-staffed retrieval

The crew composition is a critical and frequently examined variable. The doctor-led crew (the retrieval physician, typically with the critical-care paramedic or the nurse) brings the advanced procedural capability — the rapid-sequence intubation, the chest drain, the arterial line, the vasoactive infusion, the procedural sedation, the paediatric and the obstetric expertise — and the clinical decision-making to upgrade the care beyond the protocol. The paramedic-staffed crew (the critical-care paramedic) brings the standardised, the protocol-driven care (the airway adjuncts, the supraglottic device, the needle decompression, the fluid and the drug administration) that is sufficient for the majority of the stable and the moderately unwell transfers. The evidence suggests that the doctor-led pre-hospital care is associated with the improved survival for the severely injured patient (the trauma with the severe physiological derangement), and the tasking system is designed to dispatch the doctor to the patient who needs the doctor — the shocked, the intubated, the multi-trauma and the paediatric — while the paramedic crew manages the stable transfer. The Fellowship candidate must know the triage logic and the evidence, and must be able to articulate the trade-off: the doctor-led crew is the scarcer resource, the longer to mobilise, and the higher cost, and is not sent to every patient.[4][8]

The telemedicine and the remote support

The telemedicine is the lifeline of the rural provider. The video consultation, the image transfer (the radiograph, the CT, the wound photograph) and the remote ultrasound guidance connect the solo rural clinician to the specialist at the trauma centre — the trauma surgeon who reviews the FAST clip, the intensivist who guides the ventilator setting, the neurosurgeon who advises on the TBI management and the transfer priority. The telemedicine does not replace the retrieval but it bridges the gap: it improves the accuracy of the rural assessment, the appropriateness of the intervention, and the priority of the tasking. The Fellowship candidate must value the telemedicine as a clinical tool — the early call for the advice is the mark of the competent rural provider, not the sign of the inadequacy — and must be able to conduct the structured, the concise and the purposeful tele-consultation (the ISBAR handover, the specific question, the agreed plan, the documented outcome).[2]

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The aeromedical physiology

The aeromedical retrieval adds the physiological stress to the already compromised patient. The altitude (the cabin pressure equivalent to 1500 to 2400 metres) expands the gas volumes (the pneumothorax expands, the bowel obstructs, the ETT cuff inflates) — the pneumothorax is drained before the flight, the cuff pressure is adjusted. The temperature (the cold cabin) causes the hypothermia — the patient is wrapped, the fluids are warmed. The vibration and the noise cause the discomfort, the agitation and the difficulty of the monitoring. The acceleration and the deceleration affect the haemodynamics. The limited space constrains the interventions (the limited access to the airway, the chest, the IV lines). The flight crew anticipates and pre-empts these stresses: the pneumothorax is drained, the cuff is adjusted, the patient is warmed, the sedation is adequate, and the lines and the tubes are secured for the turbulence. The candidate must know the gas laws that govern the flight physiology — the Boyle law (the gas volumes expand at the altitude), the Dalton law (the partial pressure of the oxygen falls, and the hypoxia worsens unless the supplemental oxygen is increased), and the Henry law (the dissolved gas tensions shift) — and the practical consequences of each for the intubated, the shocked and the head-injured patient.[1]

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The acceleration, the deceleration and the haemodynamics

The acceleration and the deceleration phases — the take-off, the climb, the bank, the descent and the landing — shift the blood volume within the patient. The head-up position during the climb pools the blood in the legs and may precipitate the hypotension in the hypovolaemic patient; the head-down position during the descent engorges the venous return and may worsen the intracranial pressure in the TBI patient. The retrieval crew positions the patient for the phase of the flight: the head toward the front (or the back, depending on the aircraft and the phase), the careful turning, and the anticipation of the haemodynamic shift with the fluid or the vasopressor. The candidate must know that the patient who is 'stable' on the tarmac may transiently destabilise during the manoeuvres, and the pre-flight resuscitation target is a margin of safety, not a bare minimum. [1]

The transfer preparation

The transfer is not the end of the rural care — it is the continuation of it, under harder conditions. The patient who is under-resuscitated on the tarmac will deteriorate in the cabin, and the patient who is not packaged will lose the airway, the line or the tube in the turbulence. The transfer preparation is the deliberate, the structured and the complete packaging of the patient — the ABCDE stabilised, the monitoring established, the oxygen and the blood calculated for the journey, the drugs drawn up, the handover prepared — before the patient leaves the rural resus bay. The Fellowship candidate must be able to run the pre-transfer checklist from memory and must understand that every omission is amplified by the distance and the limited access of the transfer.[1][2]

The ABCDE stabilisation before the transfer

The patient is not transferred until the ABCDE is stabilised to the transfer standard — a higher standard than the 'stable enough for the ward' but a pragmatic standard short of the 'fully resuscitated in the ICU.' The airway is definitive (the intubated and the sedated patient with the secured tube) for any patient who might lose the airway in transit — the GCS of 8 or below, the facial trauma, the anticipated swelling, the hypoxaemic patient. The breathing is supported (the oxygen for all, the ventilator for the intubated) with the adequate oxygenation and the controlled ventilation; the pneumothorax is drained, the chest drain is to the Heimlich valve. The circulation is stabilised — two IV lines (preferably one large-bore and one central or intraosseous), the haemorrhage controlled, the blood or the fluid running, the systolic blood pressure at or above 90 mmHg (or the permissive hypotension at 80 to 90 mmHg in the uncontrolled haemorrhage until the surgical control). The disability is assessed — the GCS, the pupils, the sedation adequate for the intubated patient (the analgesia and the sedation to prevent the awareness and the coughing on the tube), the blood glucose checked. The exposure is complete — the patient is wrapped and warmed, the hypothermia prevented (the blanket, the bubble wrap, the warmed fluids, the hat), the log-roll completed and the back examined before the transfer.[1][3]

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The ISBAR handover

The ISBAR (the Identify, the Situation, the Background, the Assessment, the Recommendation) is the structured handover tool that ensures the receiving team receives the complete and the relevant information in the order they need it. The handover is practised at three points in the rural retrieval: the rural provider to the retrieval team on arrival, the retrieval team to the receiving trauma centre on the approach, and the formal bedside handover on the arrival. The ISBAR is concise — the whole handover fits in two to three minutes — and the candidate must be able to deliver it under the time pressure without the omission of the critical detail (the mechanism, the injuries, the interventions, the vital-sign trend, the time of the last assessment). The recommendation — the explicit statement of what the rural provider or the retrieval team thinks the patient needs next (the theatre, the CT, the angiography, the ICU) — is the element most often omitted and most often the source of the miscommunication.[2]

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The monitoring, the oxygen and the blood for the journey

The monitoring for the transfer is the minimum of the continuous ECG, the pulse oximetry, the non-invasive blood pressure (the cycle every 3 to 5 minutes, or the continuous invasive arterial line for the haemodynamically unstable), the end-tidal CO₂ for the intubated patient, and the temperature. The oxygen is calculated for the journey plus a margin: the cylinder duration (the cylinder size, the flow rate, the reserve) must cover the loading, the flight, the unloading and the unexpected delay (the diversion, the weather hold, the road traffic). The blood and the fluid are packed for the journey — the units of the crossmatched or the O-negative blood in the validated cool box, the warmed fluid if possible, and the plan for the ongoing transfusion or the vasopressor in transit. The drugs are drawn up and labelled: the sedation and the analgesia (the fentanyl, the midazolam, the ketamine infusion), the muscle relaxant (the rocuronium infusion for the intubated patient), the vasopressor (the noradrenaline, the metaraminol), the resuscitation drugs (the adrenaline, the atropine, the sugammadex), and the IV fluids. The backup equipment — the airway kit (the supraglottic, the bougie, the scalpel for the surgical airway), the chest-drain kit, the intraosseous driver — travels with the patient.[1][3]

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The national retrieval networks

The rural and the retrieval trauma is not managed in isolation — it is embedded in the regional and the national trauma system that links the rural hospital, the retrieval service and the major trauma centre into a single chain of care. In Australia and New Zealand, the retrieval is coordinated through the state-based retrieval services (the Royal Flying Doctor Service, the state aeromedical services, the hospital-based retrieval teams) and the major trauma centres, with the tasking coordinated through the single point of contact (the retrieval coordination centre). The trauma system triages the patient to the right facility — the major trauma centre for the severe injury (the bypass of the lower-level facility when the time and the geography allow), the regional hospital for the moderate injury, and the local stabilisation and the transfer for the rural facility. The Fellowship candidate must know the structure of the trauma system in their region, the referral pathways, the tasking criteria, and the principle that the system is designed to minimise the time to the definitive care — the patient flows through the system, not stuck at the weakest link.[1][6]

The special populations in the rural trauma

The paediatric trauma

The paediatric trauma in the rural setting amplifies every challenge — the smaller reserve, the narrower physiological margin, the unfamiliarity of the rural provider with the sick child, the weight-based dosing, the limited paediatric equipment. The rural provider should use the length-based or the weight-based tape (the Broselow or the equivalent) for the rapid estimation of the weight and the drug and the equipment sizes. The early intubation is even more critical (the child desaturates faster, the smaller functional residual capacity), and the doctor-led retrieval crew is preferentially tasked to the paediatric patient. The family is part of the care — the communication, the consent, the presence during the resuscitation where appropriate — and the retrieval of the child is often the retrieval of the family (the parent accompanying the child in the aircraft where the weight and the space allow).[9]

The pregnant trauma patient

The pregnant trauma patient in the rural setting demands the simultaneous care of two patients — the mother and the fetus — with the altered physiology (the increased blood volume masking the haemorrhage, the supine hypotension from the aortocaval compression relieved by the left lateral tilt or the manual uterine displacement), the risk of the placental abruption and the uterine rupture, and the need for the fetal monitoring (the cardiotocography, if available) and the obstetric consultation. The pregnant patient is intubated early (the difficult airway, the reduced functional residual capacity, the rapid desaturation, the increased aspiration risk) and resuscitated aggressively (the fetus is the most sensitive to the maternal hypotension). The major trauma in pregnancy is a mandatory transfer to the trauma centre with the obstetric service.[1]

The elderly trauma patient

The elderly trauma patient in the rural setting is the high-risk patient — the comorbidities, the anticoagulation (the warfarin, the direct oral anticoagulants), the frailty, the reduced physiological reserve, and the frequent under-triage (the 'minor' fall from the standing height that produces the significant injury). The rural provider has the low threshold for the CT, the early reversal of the anticoagulation (the idarucizumab for the dabigatran, the andexanet alfa or the prothrombin complex concentrate for the apixaban and the rivaroxaban, the vitamin K and the prothrombin complex concentrate for the warfarin), the aggressive resuscitation (the elderly do not tolerate the hypotension — the single episode doubles the mortality), and the early transfer to the trauma centre for the comprehensive assessment. The geriatric trauma is the under-recognised rural killer.[1]

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The rural provider — the skills, the mindset and the system

The rural trauma care is delivered by the generalist — the rural GP with the emergency medicine training, the rural nurse, the remote-area nurse — who is the trauma team, the airway doctor, the proceduralist and the coordinator. The rural provider maintains the skills through the regular training (the ATLS, the EMST, the REST — the Rural Emergency Skills Training), the simulation, the case review, and the telemedicine-supported practice. The mindset is the preparation, the anticipation and the early escalation — the rural provider who prepares for the worst (the difficult airway, the deteriorating patient, the weather delay), who anticipates the problems (the intubation before the deterioration, the chest drain before the flight, the early call for the retrieval), and who escalates early (the telemedicine consultation, the retrieval tasking, the advice) is the provider who delivers the damage-control standard. The Fellowship candidate must value the rural provider, understand the system that supports them, and be able to design and to improve the rural trauma care at the system level.[1][1]

Common pitfalls

The recurring errors are: under-resuscitating before the transfer; not draining the pneumothorax before the flight; not adjusting the ETT cuff pressure for the altitude; the hypothermia in the cold cabin; the delayed decision to retrieve; and the failure to communicate with the receiving centre about the patient's status and the expected arrival. [1]

The full list of the recurring and the exam-relevant errors: [1]

• The under-resuscitation before the transfer — the patient is moved 'because the helicopter is here' before the airway is secured, the haemorrhage is controlled and the blood pressure is adequate; the deterioration happens in the cabin where it cannot be managed.
• The missed or the undrained pneumothorax before the flight — the small pneumothorax on the limited rural imaging (or the occult pneumothorax not seen at all) expands at the altitude and converts to the tension pneumothorax in the cabin.
• The unadjusted ETT cuff pressure — the cuff inflated with the air at the sea level over-expands at the altitude, causing the tracheal injury or the cuff rupture.
• The hypothermia in the cold cabin — the under-wrapped patient cools during the flight, the hypothermia worsens the coagulopathy and the acidosis, and the trauma triad of death claims another.
• The delayed decision to retrieve — the 'wait and see' that allows the weather to close, the crew to stand down, and the patient to deteriorate beyond the rescue.
• The failure to communicate — the receiving centre is not told the patient is coming, the wrong bed is prepared, the trauma team is not activated, and the patient arrives to the unprepared resus bay.
• The inadequate oxygen for the journey — the cylinder runs out mid-flight, the hypoxic patient has no backup, and the retrieval team improvises.
• The inadequate analgesia and sedation — the intubated patient who is under-sedated coughs on the tube, displaces it, and loses the airway; the non-intubated patient in pain is agitated and difficult to manage.
• The dislodged tube or line in transit — the poorly secured endotracheal tube, chest drain or IV line that is pulled out in the loading, the turbulence or the unloading.
• The under-triage of the elderly and the anticoagulated — the 'minor' fall and the 'normal' GCS that conceal the intracranial haemorrhage in the patient on the blood thinner.
• The failure to involve the telemedicine early — the solo decision that delays the tasking, the advice and the preparation; the late call when the weather has closed and the crew is unavailable.
• The unsafe cervical-spine clearance in the rural setting — the premature removal of the collar in the patient who cannot be properly assessed or imaged, leading to the missed unstable injury and the secondary cord damage. [1]

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Exam practice

[1] [1]

Red flags

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References

1. [1]Rossaint R, Bouillon B, Cerny V, et al. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition Crit Care, 2023.PMID 36859355
2. [2]Pavlu F, Könsgen N, Bieler D, et al. Transport and destination hospital for patients with suspected multiple and/or severe injuries - a systematic review and clinical practice guideline update Eur J Trauma Emerg Surg, 2026.PMID 42295404
3. [3]Klimek O, Dudek J, Czesyk A, et al. The Importance of the Damage Control Strategy in Multiple Organ Injuries, Pathophysiology and Principles of Hemorrhage Control J Clin Med, 2026.PMID 41976850
4. [4]Hansen PM, Nielsen MS, Rehn M, et al. Association of ambulance and helicopter response times with patient survival: A systematic literature review and meta-analysis PLoS One, 2025.PMID 41248153
5. [5]Morton S, Crooks R, Woodman-Bailey A, et al. Emergency anaesthetic management in critically ill and injured patients: the STEPS approach (self, team, environment, patient and system) Scand J Trauma Resusc Emerg Med, 2026.PMID 41484789
6. [6]Smith A, Moosa S, Christey G. Urban-rural disparities of all severity trauma in a region of Aotearoa New Zealand N Z Med J, 2026.PMID 42275653
7. [7]Rutter G, Joseph M, Ferch R, et al. Mortality From Rural Traumatic Brain Injury Are Underestimated Without Inclusion of Prehospital Deaths ANZ J Surg, 2026.PMID 42244446
8. [8]Broms J, Günther M, Svensén C, et al. The impact of airway assistants on prehospital endotracheal intubations - a subgroup analysis of data from anaesthesiologist-staffed helicopter critical care teams Scand J Trauma Resusc Emerg Med, 2025.PMID 41291842
9. [9]Krinock DJ, Walker S, Edington M, et al. Preventable pediatric trauma transfers in a rural state J Pediatr Surg, 2026.PMID 42331311