This document contains a report on state and local emergency medical services programs. It discusses the effect of the transition from federal to state leadership under the block grant and identifies the key issues affecting local delivery of services. The report includes an executive summary and five chapters. Chapter 1 discusses emergency medical services (EMS); the evolving federal role in EMS; and the objectives, scope, and methodology of the report. Chapter 2 examines how states use block grant funds to build on federal categorical initiatives. Chapter 3 concerns EMS access and dispatch and notes that a systematic, area-wide approach eludes many areas. Chapter 4 examines EMS systems seeking greater advanced life support coverage. Chapter 5 looks at cardiac and trauma care and notes that more systematic routing of trauma victims is needed. To avert a potentially negative federal effect on the development of specialized trauma care, the report recommends that the Department of Health and Human Services determine whether federal Medicare and state Medicaid reimbursement rates have an adverse financial impact on trauma centers. Further federal actions that could enhance state and local EMS programs are suggested. An annotated bibliography, seven tables, and eight figures are included. (NB)