From sirens to systems: Characterizing EMS and trauma care across America

BACKGROUND: State emergency medical services (EMS) and trauma systems determine prehospital triage, transport, trauma center designation, data reporting, and quality improvement, yet their contemporary organization has not been systematically characterized. We sought to describe state-level EMS and trauma system structures, policies, resources, and perceived gaps across the United States. METHODS: We conducted a cross-sectional survey of EMS and trauma system leaders in all 50 states and the District of Columbia from July 2025 through March 2026. A 56-item instrument utilizing categorical, Likert-type, rank-order, and free-text items assessed oversight, prehospital triage and transport, clinical protocols, trauma center verification, registries, quality improvement, and funding. Respondents were recruited by email and phone. Multiple respondents could contribute complementary domain-level information to a single state profile. Responses were summarized descriptively. RESULTS: All 51 jurisdictions participated. Most states reported a state EMS medical director (84%), statewide trauma triage protocols (84%), and mandatory participation in their state trauma registry (88%). However, operational coordination varied: only 29% had a centralized trauma communications center, only 6% of states reported a single point of contact for helicopter EMS dispatch, and 35% required a certificate of need for new helicopter services. Trauma center verification relied on American College of Surgeons (ACS) verification in 59% of states, while others used state-administered processes. More than half of states rated EMS financial resources in the two lowest adequacy categories, and 55% reported that their trauma system required at least moderate improvement. Rural populations were most frequently identified as underserved (96%) and as experiencing worse outcomes (92%). CONCLUSIONS: State EMS and trauma systems share broad adoption of national clinical standards but differ substantially in governance, coordination, verification, data integration, and funding. LEVEL OF EVIDENCE AND STUDY TYPE: Level V, Prognostic/epidemiological.