severely injured and that they often did not deliver patients to the hospital more rapidly than ground ambulances (Levin and Davis, 2005).

On the other hand, a number of other studies suggest benefits of air ambulance service relative to ground transport. Davis and colleagues (2005) found that patients with moderate to severe traumatic brain injury who received care through air ambulance had improved outcomes. In addition, the study found that out-of-hospital intubation among air-transported patients resulted in better outcomes than ED intubation among ground-transported patients. Patients with more severe injuries appeared to derive the greatest benefit from air medical transport. And Gearhart and colleagues (1997) reviewed the literature and reported 1–12 additional survivors per 100 patients flown.

EMS in Rural Areas

According to the 2000 U.S. Census, 21 percent of the nation’s population lives in rural and frontier areas. Residents of these areas experience significant health disparities relative to their urban counterparts (Pollock, 2001). A large portion of these disparities results from the distinctive cultural, social, economic, and geographic characteristics that define rural America, but the situation also reflects the difficulty of applying medical systems designed for urban environments to rural and frontier communities.

Rural EMS Challenges

Rural EMS systems face a multitude of challenges. A particularly daunting challenge is providing adequate access to care given the distances involved and the limited assets available. Ensuring the delivery of quality EMS to rural populations is also complicated by the makeup and skill level of prehospital EMS personnel and associated issues of management, funding, and medical direction for rural EMS systems. In 1989, the Office of Technology Assessment estimated that three-quarters of rural prehospital EMS personnel were volunteers (U.S. Congress, Office of Technology Assessment, 1989). A more recent national assessment found that 77 percent of EMS personnel in rural areas were volunteers, compared with 33 percent in urban areas (Minnesota Department of Health, Office of Rural Health Primary Care, 2003).

State health directors list access to quality EMS care as a major rural health concern (O’Grady et al., 2002). In a 2003 survey of national and state rural health experts, 73 percent identified access to health care as a priority issue, and EMS access was cited as a primary concern (Gamm et al., 2003; Rawlinson and Crewes, 2003). In its 2004 report Quality Through

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