riers pose significant problems, both for EMS personnel arriving on scene and for 9-1-1 communicators and emergency medical dispatchers. As a result, patients may be unable to convey their situation adequately to these emergency responders. In addition, EMS providers often struggle to address the challenges presented by severely obese patients (Greenwood, 2004). Standard-issue equipment may be incapable of bearing the weight of these patients, and responses may require multiple personnel.

Children present special challenges to EMS personnel as well. Studies indicate that many prehospital providers are less comfortable caring for pediatric patients, particularly infants, than for adult patients. For example, paramedics have reported being very comfortable about terminating CPR on adults, but very uncomfortable about doing so on children (Hall et al., 2004). A study that looked at job satisfaction among paramedics found that they view pediatric calls as among the most stressful because of the low volume of such cases they typically encounter (Federiuk et al., 1993). For these and other special populations, EMS systems often struggle to provide adequate care.

In addition, while EMS systems are frequently organized to address major traumas and serious medical emergencies, the overwhelming majority of EMS patients have relatively minor complaints. Focusing on this broader spectrum of complaints could make the system more patient-centered.

Timeliness

Response times vary widely depending on the location where an incident occurs. Across the large, sparsely populated terrain of rural areas, EMS response times—from the medically instigating event to arrival at the hospital—are significantly increased compared with those in urban areas. These prolonged response times occur at each step in EMS activation and response, including time to EMS notification, time from EMS notification to arrival at the scene, and time from EMS arrival on the scene to hospital arrival.

Even across cities, however, there are substantial differences in EMS response times (Davis et al., 2003). As a result, a person who suffers a traumatic injury or acute illness in one city may be far more likely to die than the same person in another city. One important factor contributing to slow response times in some areas is the frequency of ED crowding and ambulance diversion. When EDs are crowded, as is frequently the case, EMS personnel wait with the transported patient until space becomes available in the ED. This wait reduces the time during which the ambulance could be servicing the community, thus increasing response times. When hospitals go on diversion status, ambulances may have to drive longer distances and take patients to less appropriate facilities. Again, definitive patient care is



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