The most difficult transport I have ever encountered was during my pediatric critical care fellowship. I traveled to an outside hospital with a fully equipped pediatric critical care transport team, including a critical care nurse, respiratory therapist, and myself—a third-year pediatric critical care fellow—to pick up a toddler ejected from a vehicle during a high-speed collision. Upon arrival, we found a child who had undergone an open laparotomy, open clamshell thoracotomy, and endotracheal intubation. Surrounding the child was a team of physicians desperately searching for central venous access.

I vividly remember the collective acknowledgment among my transport team members that this was one of the highest-acuity patients we would ever encounter. The critical question was, “Should we attempt this transport?”” We remained in that ER for 12 hours, striving to stabilize the child, place central access, and confer with our medical command officer about the risks. Ultimately, the question boiled down to whether the child could survive the transport and, if so, whether a major quaternary children’s hospital could significantly improve their chances. This case underscored the complexities of pediatric transport medicine, even for the most experienced teams.

A new beginning

Now, as a pediatric intensivist at a rapidly growing quaternary children’s medical center, I am tasked with building a pediatric critical care transport team from nothing in a metropolitan area already served by several well-established transport programs. Immersing myself in this new role has revealed an array of unforeseen challenges.

As a junior faculty member, I sought guidance from experienced mentors who had inherited their transport programs. To my surprise, none had started a program from scratch. While they directed me to valuable resources, the specific wisdom required to build a team from the ground up remained elusive. And so, my journey into the intricate world of pediatric critical care transport began.

The wild west of pediatric critical care transport

One of my earliest discoveries was the lack of standardization in pediatric transport medicine. Oversight is often left to local, regional, or state agencies. While emergency medical systems (EMS) provide guidelines for EMTs and paramedics, they offer little for medical professionals involved in pediatric transports. The American Academy of Pediatrics provides a useful manual, but even this resource leaves significant discretion to individual health systems.

Creating our team’s training curriculum required innovation. We developed a rigorous didactic schedule to address high-yield pediatric critical care scenarios and incorporated high-fidelity simulation training. Fortunately, our institution’s world-class simulation center provided invaluable support. Developing this curriculum has been one of the most rewarding endeavors of my career, as our team strives to match the excellence of more established programs.

Through academic research and discussions with transport professionals, I have become convinced of the need for national standards and certifications in transport medicine. However, these standards should allow for regional and institutional tailoring. While most programs require annual didactic training, not all use high-fidelity simulations, despite their proven benefits in other areas of medicine. Expanding this training approach in transport medicine could enhance team preparedness and patient outcomes.

To fund or not to fund, that is the question.

Stepping into the administrative responsibilities of a transport director, I have become acutely aware of the financial challenges and inequities in health care. Transport teams are high-cost systems requiring significant investment in equipment, vehicles, multidisciplinary staff, training, and accreditation. Justifying this investment is particularly difficult given the ongoing decline in pediatric inpatient resources. Over the past two decades, adult inpatient beds have decreased by 4.4 percent, while pediatric inpatient beds have declined by 30 percent. This consolidation has disproportionately affected vulnerable children, leaving them stranded in overcrowded emergency rooms due to limited transport resources.

Despite operating in a densely populated urban area, the demand for transport services continues to strain available resources. Medically complex children are often caught in a cycle of overcrowded facilities, staffing shortages, and limited transport capacity. These challenges underscore the importance of prioritizing equitable access to pediatric care and ensuring that transport systems are adequately funded.

Challenge metamorphosis

Reflecting on that critically ill child during my fellowship, I saw firsthand the clinical demands of pediatric transport medicine. Now, as a program director, I grapple with the broader system-level challenges: Training a team, setting standards, addressing community needs, managing budgets, and navigating administrative intricacies. While that child’s transport was one of the most difficult clinical cases I have faced, every transport now poses its own challenges because the system must be prepared to support any child, no matter how severe their condition.

If tasked with building a pediatric transport team from scratch, what would your top priorities be?

The next mountain to climb, one riddled with further systematic difficulties—how to grow and sustain a transport system in a diverse and competitive market.

Kyle Willsey is a pediatric critical care physician.