EMS systems are designed to provide a quick, coordinated response of emergency medical care resources for traumatic incidents and medical emergencies. Persons who need such a response may need help for a variety of medical conditions, such as cardiac arrest, diabetes, seizures, or behavioral disorders, or they may have injuries such as burns, wounds, or severe head or spinal damage. The major components of an emergency medical system often include the following: A public access system. This is generally a 911 emergency telephone line used to contact and dispatch emergency medical personnel. Emergency medical response. The goal for the initial response is to have medically trained personnel available to the patient as quickly as possible and to provide early stabilizing care. The level of care provided can be either basic life support or advanced life support. Because most EMS agencies operate independently of other medical facilities and have relatively few physicians among their providers, the ability of field personnel to talk with a physician is important in ensuring appropriate medical care. Such a link to “medical oversight” ensures that field personnel at the scene or during transport have immediately available expert direction that can authorize and guide the care of their patients. Emergency medical transport or transfer. This involves getting the patient to a hospital or other medical facility. Although an important component of the system, emergency transport does not apply in all cases. Officials responding to a recent survey of urban EMS systems indicated, for example, that an average of 37 percent of emergency requests do not result in emergency transport. EMS systems are typically managed and operated by local communities and jurisdictions, such as counties or fire districts. Entities involved in providing EMS for a particular community may include fire departments with paid or volunteer personnel trained in both fire suppression and EMS or EMS alone, for-profit or not-for-profit ambulance companies, volunteer ambulance services or rescue squads, hospitals, and government-based EMS organizations. The extent of involvement of each type of entity in local EMS systems nationwide is not fully known. While some systems provide both emergency response and emergency transportation within the same agency or organization, others may use multiple organizations. For example, a fire department may provide the first emergency response while a private ambulance company provides most emergency transport. Varied sources of EMS funding also exist, such as local taxes, billing for services provided, private-sector donations, subscription services, and government grants. At the state level, EMS agencies generally do not provide direct services but rather regulate and oversee local and regional EMS systems and EMS personnel. In most states, state laws and regulations govern the scope, authority, and operations of local EMS systems. While the state’s authority and role varies from state to state, the agencies typically license and certify EMS personnel and ambulance providers and establish testing and training requirements. Some establish standard protocols for treatment, triage, and transfer of patients. State EMS agencies may also be responsible for approving statewide EMS plans, allocating federal EMS resources, and monitoring performance. At the local level, the needs reported by EMS systems are wide-ranging and diverse, reflecting the different environments in which they operate. However, the available data allow a better understanding about the kinds of problems reported than about their effects. At the state level, the reported needs centered on the lack of information and systems for evaluating the performance of EMS systems and deciding how best to make improvements. At the local level, the challenges faced by individual systems are often associated with variations in such factors as the characteristics of the population served and the geography of the area. The area served by an EMS system can range from isolated rural settings in mountainous terrain to sprawling and densely populated urban settings with high-rise buildings and traffic gridlock. Such differences tend to be reflected in certain aspects of the EMS system itself. For example, according to officials, rural areas are less likely than urban areas to have 911 emergency dialing (requiring callers to use a 7- or 10-digit number instead), and their communication between dispatchers or medical facilities and emergency vehicles are more likely to suffer from “dead spots”—areas where messages cannot be heard. Rural areas are also more likely to rely on volunteers rather than paid staff, and these volunteers may have fewer opportunities to maintain skills or upgrade their skills with training. These differing characteristics affect what officials perceive and report as key needs. For example, officials from national associations representing EMS physicians have indicated that long distances and potentially harsh weather conditions in rural areas can accelerate vehicle wear and put vehicles out of service more often. By contrast, an urban area may be less concerned with vehicle wear and more concerned with traffic problems. A 1994 study, for example, compared New York City’s EMS response time for cardiac arrest patients with response times reported from other locations. In New York City, the time interval from patient collapse to arrival of EMS personnel at the patient’s side was about 11.4 minutes, nearly half of which (5.5 minutes) was spent negotiating city traffic. This interval was similar to ambulance driving time reported in another large city, Chicago, but was significantly longer than the 3.3 minutes of driving time required in a suburban county in the state of Washington. The variety of EMS needs can be seen in the various categories of needs reported by EMS officials. Far-reaching needs were identified in a March 2000 national survey on rural EMS needs, from our own fieldwork involving urban and rural EMS systems, from our review of the professional literature, and in our conversations with EMS experts. Recruitment and retention of EMS personnel. In rural systems, personnel needs reflected these systems’ heavy dependence on volunteers. Rural systems reported that it was getting more difficult to recruit volunteers, especially for daytime shifts, and that inadequate staffing was a major problem affecting the ability to quickly respond to emergencies. For example, one predominantly volunteer EMS squad reported having difficulty responding to early-morning calls because most of its volunteers also had full-time jobs. Officials reported that in the past year, the service had been unable to immediately respond to two early-morning calls involving critically ill patients. Rural EMS systems also report encountering problems with staff attrition due to increased demand on personal time for training and calls, stress from treating relatives and neighbors, and poor working conditions. For example, in one instance, closure of a local hospital increased demands on staff by doubling the amount of time personnel had to spend transporting patients. In another example, a state reported concerns about the ability to retain volunteer staff because they had to use antiquated and unreliable equipment, such as ambulances that frequently stranded them in remote areas or that had unreliable lighting, requiring them to provide care by flashlight. In urban systems, where there is less reliance on volunteers, experts report that job stresses may involve very different concerns, such as a higher possibility of encounters with violent situations. Training and Education. Rural systems reported training and education needs that focus on retention of infrequently used medical skills, as well as training in management, budgeting, personnel, and organizational issues. EMS officials said that in rural areas, the sparsity of staff and distances were major impediments to providing in-person training. One local system reported that some personnel certified to provide advanced care had never performed certain advanced procedures, such as airway intubation. This system is currently trying to partner with a local hospital to provide the necessary clinical experience. By contrast, some urban systems we consulted reported needing specially trained staff to respond to patients with mental disorders and personnel trained in different languages so they could better communicate with the diverse populations they serve. Equipment. In the March 2000 survey, a wide range of equipment needs was reported for rural systems, including communication equipment (73 percent of respondents), medical equipment (68 percent of respondents), ambulances (54 percent of respondents), and buildings (34 percent of respondents). For example, one survey respondent cited a rural county that had one operational ambulance for 6,500 residents (the state average was 1 per 4,600 residents) and only three hand-held portable radios were available for the six medical personnel on call. Asked to estimate the costs of addressing the capital needs for rural EMS systems in their states, only 28 of the 41 state EMS directors responding to the survey said they had enough information to provide an estimate. The average state cost, based on the figures from 27 of these states, was $12.2 million. For urban systems, no similar survey or set of estimates is available. Officials we spoke with indicated that urban systems also face equipment needs. Financing. Both urban and rural systems reported examples of tenuous financing. In rural areas, officials reported that it is difficult to fully support the high fixed cost of operating around-the-clock EMS services because the number of calls is generally smaller in sparsely populated areas, limiting the opportunities to bill for services. This difficulty has resulted in some communities going without local EMS coverage. For example, one county reported going without the services of a dedicated EMS provider for the past several years and instead relied on ambulance response from other communities that may be located as far as 20 miles away. According to officials, this county—with a population less than 3,000, no industry, and a relatively small number of businesses—has an insufficient tax base to support such services. Other states have reported increased response times in their rural areas due to lack of funds to maintain greater capacity. Urban systems reported financing problems caused by a growing demand for services combined with tight community budgets. Officials of systems that relied heavily on local government funds and levies to support their operations said they were considering billing health insurers to supplement the income of their EMS services. At the same time, some systems that were relying on income from billing health insurers reported concerns about declining reimbursement levels from these sources due to possible changes in reimbursement rules. Medical oversight. Both rural and urban EMS officials we spoke with expressed a need for improved medical oversight, but this need took different forms. Officials from two urban systems pointed to the need to centralize and standardize medical direction.