EMS has long been a function of emergency service organizations (ESOs) in many parts of the U.S. In other areas EMS is just becoming an ESO service. Issues regarding scope of practice, deployment, response workload, funding and others create challenges for ESOs that must be addressed in a proactive manner. Consequences of inattention to the challenges can include declines in volunteer retention rates. Additionally ESOs must ensure it is providing significant input into EMS system design and provider regulations.