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Both.
The US never had a comprehensive EMS system as it was never seen as an essential service, both because EMS is expensive to run (especially in the healthcare/insurance/taxation environment the US has) and because there was significant lobbying against it (there is money in EMS on a large scale if you operate it in a very cut-throat way).
But the recent downturn in healthcare availability and county-tax-income in rural regions and the dwindling volunteer numbers and enshitification of medicine have all done their part in making the whole situation so much worse.
There is actually a good study showing “ambulance deserts”. (Just as a reminder: That does not mean that no Advanced life support provider comes…it means that no Ambulance is available at all. So not even one staffed by an EMT-B and an emergency medical responder. And we’re not talking about "what happens if we need two ambulances at the same time)
Great Filter Events come to my mind first.
Then Gamma Ray Bursts.
And from a professional standpoint: Haemolytic fevers(Ebola,Marburg,etc.). I am trained to handle patients infected with them. But boy am I scared by them, especially on a global perspective. And for that reason also fuck everything that lives in Kitum cave or similar caves.