In order to introduce EMS problems in large urban communities, I will first tell you the parable of the County of Smog. It covers an area of about 4,000 square miles and includes areas of mountain wilderness, dense urban population, coastal ocean communities and a peculiar blend of heat, foul air, and residential and industrial communities known simply as “The Valley.” About ten years ago, Smog County health officials established a pilot program to train a handful of firemen in reading electrocardiograms, the pharmacology of emergency cardiac drugs, intravenous infusions, and defibrillation. The firemen responded in a station wagon from a hospital. It was readily learned that these paramedical personnel could impact positively on the outcome of patients with cardiac conditions.