OBJECTIVE: Prehospital care of stroke and chest pain patients is dependent on adequate emergency medical services (EMS) education and evidence-based protocols. We sought to describe the amount of education offered, community outreach implemented, and protocols established for stroke and for chest pain among North Carolina EMS agencies and personnel. METHODS: A survey was developed to measure EMS system characteristics regarding the prehospital care of stroke and chest pain patients. Each of the 83 primary EMS agencies in North Carolina was asked to participate. RESULTS: Of the 83 agencies surveyed, 72 (87%) responded. Both advanced life support (ALS) and basic life support (BLS) services were provided by 54% of agencies; 44% offered ALS only and 1% offered BLS only. While 89% of the EMS agencies provided stroke education to EMS personnel and 96% chest pain education to EMS personnel in the previous two years, the median hours devoted to stroke was one-half that for chest pain (6.0 vs. 12.0 hours, respectively). In the previous six months, 14% of EMS agencies had conducted community outreach programs for stroke compared with 17% for chest pain. The majority of EMS agencies had protocols specifically for managing stroke (83%) and for managing chest pain (99%). Diagnostic scales to identify stroke patients were used by 54% of agencies (20% Los Angeles Prehospital Stroke Screen, 20% Cincinnati Prehospital Stroke Scale, and 14% a locally developed scale). Thrombolytic checklists were used to identify eligible stroke patients at 37% of the EMS agencies, compared with 28% for eligible chest pain patients. CONCLUSIONS: In North Carolina, primary EMS agencies appear to have stroke and chest pain protocols in approximately the same frequency, yet their personnel receive only one-half as much education about stroke as they do about chest pain. Many stroke protocols were lacking basic components and would benefit from standardization across the state. Community outreach programs for both stroke and chest pain are minimal.