Key considerations when planning a pediatric critical care transport include, but are not limited to patient condition, distance to definitive subspecialty care, weather condition, and the level of care needed during transport. In many cases like this, a pediatric specialty transport from a hospital will be on board the helicopter to supplement the normal crew configuration. In a simple adult interfaculty transport the sending hospital is primarily responsible for transport decisions. However, in this case, the hospital (or pediatric ED/division of mixed tertiary care center) likely played a role in the decision. The HEMS agency would also either choose to accept or decline the call. It is important in this case to determine who the part 135 holder (FAA regulations) is, as that will affect who ultimately has control of the aircraft. During the transport itself, there is typically a base station physician who would be overseeing the flight (direct medical control). In some cases, they are called on 100% of IFT calls, in others, it is limited based on the situation. Even though a medical operation, it is the pilot who ultimately is responsible for the aircraft. In HEMS cases, FAA regulations trump state EMS regulations. It would be interesting to know if the pilot had truly timed out based on FAA regulation or simply had exceeded their normal shift (which is typically less than then the maximum allowable by the FAA). The Part 135 holder typically has policies in place governing this.