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John Glasheen discusses the importance and challenges of trade-offs in prehospital critical care. Every Pre Hospital and Retrieval Medicine (PHARM) mission involves a series of complex decisions. These are made rapidly in a high-pressure environment. Excellent PHARM clinicians are invariably expert decision makers. The ability to identify, accept and manage trade-offs is a key skill in prehospital and retrieval medicine. Some of these trade-offs are obvious, and the best options are clear. For example, aircraft and crew safety cannot be compromised regardless of the clinical situation on scene. Other choices are far more complex. These require rapid and accurate cognitive appraisal of a dynamic and often incomplete information set. Moreover, interventions performed on scene, involve a balance of the patient’s immediate requirements against time and risk. During a mission, each decision to do something leads to how and where it should be done. This often results in a trade off between principle and preference.