A 1-year prospective review of 78 multiply injured patients initially treated at local community hospitals and subsequently transported more than 25 miles to a referral trauma center was completed. Injury mechanisms were blunt in 74 (95%) patients and penetrating in four. Patient ages ranged from 6 to 88 years (mean, 33 years). Trauma Scores ranged from 6 to 16 (mean, 13.9) and Injury Severity Scores ranged from 4 to 54 (mean, 21.5). The quality of care during initial stabilization and transport was evaluated by ATLS guidelines for airway management, treatment of shock, spine and fracture immobilization, neurologic evaluation, secondary assessment, and chart documentation. Most frequent departures from these standards involved failure to place a nasogastric tube before transport (72%), failure to document neurologic status (47%), inadequate cervical spine immobilization (32%), inadequate intravenous access (29%), inadequate oxygen delivery (28%), and incomplete or absent records (22%). Life-threatening deficiencies were identified in four (5%) patients and serious deficiencies in 62 (80%). This study demonstrates the need for further education of rural physicians about priorities in trauma management. Increased emphasis on stabilization and transport should be added to ATLS training courses. Established transport protocols between institutions would enhance the quality of care and engender improved interhospital communication. The implementation of trauma systems designed specifically for rural areas must be supported.