This report explores the current state of rural EMS by interviewing 49 local directors from all-volunteer rural services in 23 states. Respondent agencies were considered to be rural if they were located in a nonmetropolitan county or within a metropolitan county in an area with a Rural Urban Commuting Area (RUCA) code of four or higher. A semi-structured interview format encouraged respondents to speculate on the future viability of their local service, describe the challenges they face and what they need to ensure continuance. The descriptions presented represent the perceptions of those interviewed, but are also likely to resonate with other rural EMS administrators.