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One of the most important roles of emergency medical services (EMS) is in-transit medical care for patients. It has transformed the role of the EMS provider from the “ambulance driver” in the early days of the specialty to the modern professional with varying scopes of practice and protocols. It has helped to reduce morbidity and mortality and extended the reach of medical care out away from the hospital setting. However, there are many situations when traditional medical evacuation is not feasible, possible, or ideal. Casualty evacuation can be defined as the movement of the sick or injured by means other than those designed for medical transport and in which in-transit medical treatment is limited or unavailable. Recognizing the advantages and disadvantages of casualty evacuation, along with when it may be utilized, is essential for the EMS professional in planning for, moving, or receiving patients and implementing proper policies and training for its optimization.