By Eric Ferreri
The News & Observer (Raleigh, North Carolina)
Copyright 2006 The News and Observer
County emergency management agencies are hemorrhaging staff and blowing out overtime budgets, trapped in a losing battle to retain paramedics lured away by better pay in emergency rooms and doctors’ offices.
As a result, emergency squads are frequently putting one or two fewer ambulances on the roads each day than they would like, prompting concern over whether paramedics can respond to emergency calls quickly enough.
“If I don’t have a full staff and I can’t get anyone to work overtime, I have to shut down an ambulance for a day,” said Skip Kirkwood, who heads Wake County’s Emergency Management Services agency, where 31 of 91 paramedics left last year. It was the third year in a row of double-digit departures. “As demand goes up and supply stays constant, there’s a decrease in performance.”
Though pay has long been an issue, the problem has worsened in recent years as other understaffed health professions — particularly nursing — poach EMS workers with the promise of better pay.
Starting pay for clinical nurses at Duke Hospital, for example, is nearly $40,000, while a Durham County paramedic starts at less than $28,000. And university nursing programs are making the transition easy for paramedics, often giving them course credit for their work experience.
Across the Triangle, short-handed EMS agencies are struggling. Overtime costs have skyrocketed — in Orange County, the overtime budget more than doubled by the end of the 2005-06 fiscal year — and EMS administrators have had to heap more work on the paramedics they do have.
Although they insist their ability to get to the sick quickly hasn’t suffered, many EMS chiefs acknowledge that they are chronically undermanned. Complicating matters, the paramedics who are working — and gobbling up overtime — are sometimes running on fumes.
“I’m overworking the folks who are here,” said Michael Smith, Durham County’s EMS director. “On some days it’s difficult even for them to get a bite to eat. People just get worn out and get tired.”
Life-and-death issues
Emergency management officials across the state concede that they are overworking their paramedics, but they don’t have a solution.
“We are concerned,” said Drexdal Pratt, chief of the state Office of Emergency Medical Services, the administrative agency that oversees all county EMS squads. “The fatigue, being able to think properly, especially when you’re administering medication — you want them to be fresh.”
And reducing the number of ambulances on the road — by necessity — might prove deadly, said Theodore Delbridge, chairman of the emergency medicine department at East Carolina University.
“In the most dramatic example, the person suffering cardiac arrest may have to wait an extra couple minutes,” said Delbridge, who studied EMS response times several years ago while he was the head of a medical air program at the University of Pittsburgh. “Those minutes may be the difference between life and death.”
Work force shortfalls
Paramedics and emergency medical technicians are the people who appear at your door minutes after you call 9-1-1 with an injury or medical emergency.
Paramedics, who undergo two years of training, provide advanced life-support services, such as shocking hearts back to rhythm and inserting intravenous lines.
EMTs have less training and can only offer more basic care such as taking blood pressure readings and helping stabilize patients in accidents. Large EMS agencies such as Durham’s and Wake’s are staffed mostly by paramedics.
In North Carolina, most paramedics work for county emergency services agencies, although some counties contract out the services to private or nonprofit squads. Johnston County, for example, is covered by eight small, private agencies.
Right now, Durham County EMS is eight paramedics short of filling its 96 full-time positions. In many cases, paramedics work part time while attending school. Another impediment: Durham EMS’ starting paramedic salary is $27,811, significantly lower than that of other area EMS agencies, Smith said.
“We’re a training ground,” said Smith, whose former paramedics have gone on to be nurses, respiratory therapists and physician assistants. “They continue to work for us part time, but they go to where the money is.”
In Wake County, Kirkwood has also struggled. Even though Wake County’s $37,609 average annual salary is almost $3,000 more than Durham’s, it, too, routinely loses paramedics. Some of the 31 paramedics Kirkwood lost in the past year moved on to better-paying careers. Others found EMS jobs in other, more affordable counties. Two years ago, he lost 20 paramedics; the year before that, 15 left.
“Large numbers of the potential work force are young and very mobile people who will move for a couple bucks an hour,” Kirkwood said. "[Wake County] has a great quality of life, but it’s not cheap.”
The Wake County budget for 2006-07 brings a mixed blessing to Kirkwood’s agency. The budget includes money to hire 14 paramedics — bringing Wake’s total to 105 — an acknowledgement of the county’s rapid growth. Now, Kirkwood faces the challenge of filling those jobs.
On the state level, EMS officials are working to find ways to bring young recruits to a field in which the average age is 35, said Pratt, the state EMS chief.
The obstacles are formidable, he acknowledges. Salary issues aside, paramedics work long shifts — Wake County schedules 24-hour shifts that net 20 days off per month — under difficult working conditions. Often, they are called upon when co-workers leave, take vacation, or become ill or injured.
“In nursing, they work a shift and go home,” Pratt said. “Paramedics may work a shift and then be on call because there’s not enough people.”
Generally, a 24-hour shift includes time for paramedics to eat and sleep.
Mushrooming costs
For many counties, overtime costs have been jarring. Durham County budgeted for $900,000 in overtime for emergency services for the 2005-06 year; that estimate was short by about $400,000. In June, the last month of the fiscal year, the county routinely put fewer ambulances on the road because it couldn’t afford the overtime.
Money from vacant positions was used to help offset overtime costs, but it didn’t come close to covering the costs of overtime, which pays time-and-a-half.
In Orange County, EMS Director Jack Ball’s 2005-06 overtime budget of $200,000 was only a starting point. By the end of the fiscal year, overtime costs ballooned to nearly $500,000, he said. Paramedics who ideally would work a 24-hour shift, then have three days off, have been forced to work 24 on, 24 off. Ball acknowledged that is only a short-term solution.
“It puts a lot more pressure on the medics we do have,” he said. “It is very concerning to me.”
To remedy understaffing, administrators have no choice but to heap more work on existing staff, relying in large part on loyalty and job satisfaction.
Take Steve Gooch, who at 44 has worked for Durham County EMS for 25 years. A wisecracking bundle of nervous energy who, like other EMTs, scribbles his next call destination on the palm of his hand, Gooch is addicted to the rush.
“Every day’s different, and every call’s different,” Gooch said. “Everyone who works here is an adrenaline junkie a little bit.”
That rush comes in fits and starts. Being a paramedic means wasting hours watching “The Price is Right,” then jumping into the rig to pinball from call to call. Five or six calls over a 12-hour shift is manageable. Paperwork may even get filed. But when the calls reach double digits, lunch or even a bathroom break might prove elusive.
“It is a stressful job for short bursts,” said Delbridge, the East Carolina doctor. “The more frequent those short bursts come, the more predictable it is that [people] wear down.”
In Wake County, paramedics can work as many as 36 straight hours, after which they must take 12 hours off. The key to an efficient EMS squad is a savvy scheduler who makes sure everyone gets some time off, said Tony Fraccola, a 16-year veteran of Wake County EMS. Still, he acknowledges the grind.
“The burnout is there,” he said. “It’s the nature of the job. You get out there and run 15 or 16 calls in a 24-hour shift, and you don’t know what the next 12 hours will bring.”
At Winston-Salem State University, where a popular “bridge” nursing program gives paramedics course credit for experience, about 12 students in an average graduating class of 100 are paramedics.
But WSSU’s latest enrolled class has 18 paramedics, a large enough increase to indicate that more want a career change, said Charlena Garrison, WSSU’s student affairs director in its nursing division.
“It takes someone who is pretty sharp and aggressive to go into paramedics,” she said. “They come with a work ethic. We have found that they are quite successful in our program.”