Dr. Winders’ article does an excellent job of summarizing many of the challenges facing those working to create, mature, and/or bolster EMS systems in LMICs. In the US and other nations like it, where we tinker with the order of procedures and exactly which piece of equipment to use to fine tune desired outcomes, it is easy to fail to comprehend the task facing developing systems. Even ignoring the obvious elephant in the room, funding and administrative support, which nearly all systems must overcome, each system finds its own unique morass of difficulties. Attempts to apply European and US EMS models to a heavily water transport based chain of islands in the south pacific requires an entirely different set of adaptations than doing so to mountainous Bhutan. Solving these sorts of problems requires strong collaboration between expertise developed through involvement with “traditional ems” and expertise held only by local parties. On the other hand, solving problems such as EMS training in areas with limited literacy or the complexity of EMS response with unmarked roads with no addresses and long-distance transports without the luxury of HEMS, often requires the development of an entirely new knowledge base. Additionally, while certainly much benefit can be produced by philanthropic involvement from developed nations, we must always keep an eye toward an ultimate goal of local independence.