• Expired in the ambulance, the injuries were incompatible with life: Some rural trauma patients who receive the very best care don’t make it to the hospital due to uncontrollable complications (internal hemorrhage, uncontrollable airway, etc.) Prevention is the only way to save these patients.

• Unrecoverable shock had set in: These patients may survive in an urban area, but expire in rural districts due to extended response and transport times. Prevention will save many of these patients; EMS won’t save any.
• Mistakes and limitations of the available emergency services: These patients could have survived to the hospital, but the available emergency services just could not handle them. (The ambulance crew was out of position, inadequate back up, lack of advanced care for critical pediatric patients, inadequate specialized equipment, etc.) Prevention will save many of these people; training and upgrading of emergency services will save some.
• Expired in the Emergency department: These patients arrive at the receiving hospital with some vital signs, but expire in the emergency department due to many variables that are beyond the control of field EMS. This group includes pediatric trauma patients who require specialized care and equipment not commonly available at rural primary care facilities. Also included are trauma patients who self admit to the emergency department, bypassing field EMS entirely. Prevention will save many; upgrading EMS will save a few. Patients who self admit can only be helped by prevention or improving the hospital’s emergency services.
• Expired in ER due to delays: Any unstable patient who arrives in an emergency room, far from emergency surgery is in a holding pattern. Every delay in the notification or response of med-evac resources reduces the patient’s chance of survival. This is primarily a policy issue. Review your policies and procedures manual to see if there is any way to reduce the amount of time between the injury and the patient’s arrival at surgical care.
• Expired enroute to surgical care: With extended response times from urban Medical air-evac services and long flight times to trauma centers, unstable patients sometimes destabilize in flight and expire between the primary receiving hospital and surgical care. Even with immediate notification of flight resources, response and transport times are commonly over 2 hours. Pediatric trauma patients are especially vulnerable due to their tendency to rapidly decompensate in shock and the lack of on-call pediatric services at most rural hospitals. There are also fewer Level-I (Pediatric) trauma centers with resultant lengthened response and transport times. Injury prevention will save many of these young patients. Developing protocols for launching and utilizing air resources, pre-designated landing zones, and notifying trauma surgery as soon as possible will reduce delays and improve patient survivability. (See chapter XII: Speeding up Trauma and Pediatric Emergency Care on the EMS Frontier.)
• Expired during or after surgery: Those critical patients who, for whatever reasons, have beaten the odds and made it into surgery, can still expire afterward for many reasons, some preventable and some not. Prevention will save many, upgraded EMS, establishment of local trauma teams and quicker air-evac with faster transport to definitive care will also help, by delivering more stable patients to surgery.

The sad fact is, after all the good efforts of many professionals and endless expenditure of money, resources and time, people will die. Barring vast additional expenditures, there is currently little that rural EMS can do for the already dead and the dying except offer comfort to the patient and their families. Their lives are literally, "In God's hands".