In rural EMS systems, transport is often the most critical phase of care, with definitive treatment an hour or more away. This session focuses on managing critically ill and injured patients during prolonged transport, where early decisions, reassessment, and anticipating deterioration are essential. Drawing from real-world rural EMS and critical access experience, participants will learn practical strategies for ventilation, hemodynamic support, packaging and positioning, and recognizing early signs of decline. Through case-based discussion, this talk equips providers to maintain stability and make high-stakes decisions when help is far away.