By Rachel Crumpler and Clarissa Donnelly-DeRoven

About 10:30 a.m. on April 20, an 84-year-old Forsyth County resident tripped and fell to the floor in her kitchen. She laid there, unable to get up. Her husband quickly called 911. 

The dispatcher on the other end asked about the woman’s breathing. “Fine,” her husband said. 

And her pain? “An eight,” said the woman.

The dispatcher told the couple, who did not want their names to be used by NC Health News because of privacy concerns, that an ambulance would arrive as soon as possible but it might take a while. 

Confused, the husband asked if there had been a big accident, or something else, that was causing delays? 

The answer: “No, this is just normal traffic.” 

A half hour later, the woman was still stuck on the floor — with a broken hip, she’d later learn. Her husband called for an update.

Unfortunately, the dispatcher said, they’d need to wait a while longer. 

“They could not have been nicer or more concerned but they didn’t have anybody to send,” he said.

Time dragged on and the two grew more anxious. During the wait, the dispatcher did call back to check on her status.

But it took over two hours before the ambulance finally arrived.

“If I had told him that she wasn’t breathing or answered any of his triage questions negatively, I guess it would have gotten somebody there sooner,” the husband said. “But you can’t complain when that’s everybody that they have got.”

Staffing shortages

The post-pandemic labor shortage has hit nearly every position of every industry, and emergency services is no exception. To get a scope of how the labor shortage is hitting EMS offices in North Carolina, NC Health News sent inquiries to 22 county EMS offices, a mix of rural, suburban and urban areas. We asked about the current number of filled and vacant positions, any monthly reports or analyses the office had compiled about shortages since the start of the pandemic, and data on the county’s 911 call volume and response time. 

About half of the counties responded and provided the data. Nearly all of them were experiencing a shortage or had been in the recent past.

“[Staffing] is the number one issue that we have been working on for the past, really, year and a half as an association,” William Kehler said in June. He’s the chairman of the North Carolina Association of EMS Administrators and the director of emergency services in rural McDowell County.

For months, his local office struggled with high vacancy rates —  between 10 percent and 20 percent at any given time. The same has been true a couple of hours east in Mecklenburg County, one of North Carolina’s most populated regions. Jonathan Studnek, the deputy director of that county’s EMS agency, Medic, said the pandemic brought on the worst vacancy rates he’d seen in his 15 years there. 

Medic is budgeted for a mix of 374 EMT and paramedic positions. In June, 71 of those positions were unfilled — a vacancy rate of about 19 percent. Studnek said that’s about as high as the vacancy rate has ever been over the past two and a half years.

Studnek said the staffing crisis began for his county about six months into the pandemic. 

Two Mecklenburg EMS workers on the way to help a patient. Credit: Courtesy of Mecklenburg EMS Agency (Medic)

“People were getting tired of working in health care just in general and we started to see a little bit higher turnover, and with that higher turnover, we saw lower numbers in new hire classes,” he said. “One of the precipitating factors early on was that a lot of the education institutions had to take a pause, and so new EMTs and new paramedics weren’t necessarily right in the pipeline.”

Across the state, EMS staffing was so strained that the North Carolina Department of Public Safety requested the support of 50 ambulances and crews from the Federal Emergency Management Agency, or FEMA. Twenty-five ambulances, each with a two-person crew, arrived in September 2021 to temporarily help nine counties. In early 2022, with the labor shortage persisting and cases surging due to widespread infection with the coronavirus Omicron variant, the federal agency dispatched more ambulances around the state. 

“That really provided relief to our team,” said Studnek, whose EMS agency benefitted from the assistance of FEMA ambulances.

“It lowered their daily demand just a little bit and allowed us to maintain some protection on responding quickly to our sickest patients.” 

Increased call volumes

Alongside the historic vacancy rates, emergency services officials say they’ve also been busier than ever.

Daren Ziglar, the director of Forsyth County EMS, told NC Health News in July that the first months of the pandemic in 2020 caused an “extreme drop-off in calls,” since people were afraid to leave home and possibly be exposed to the coronavirus.

“Once it opened back up, it came back with a vengeance,” Ziglar said. “We still run COVID calls but we’re running more shootings, we’re running more heart attacks, we’re running more of everything.”

From 2020 to 2021, Ziglar said his department saw an 11 percent increase in call volume, amounting to about 52,000 calls last year, a number the department seems on pace to meet again this year. Historically, he said they’ve seen a rise of about 3 percent each year.

Two Buncombe County EMS workers. Credit: Courtesy of Buncombe County EMS

In Buncombe County, EMS Division Manager Jamie Judd said each ambulance in the department would ideally respond to about 2,400 calls per year. Now, ambulances are running an average of 3,000 calls, which can lead to longer wait times. 

Durham also saw a large increase in its call volume last year at 14 percent. The county’s chief paramedic, Mark Lockhart, said August 2021 was the department’s busiest month since the organization began in 1975.

“When we get really busy, and that happens now almost on a daily basis, we’ll hold the Alpha and Omega calls,” Lockhart said, referring to lower acuity emergencies. Those calls get put into a queue so the agency can save its resources for any potentially life threatening calls that might come in. 

But we’ve had a number of days where we’ve just flat out run out of units and so we rely on mutual aid from our surrounding counties — mostly Orange, Wake and Person county.”

Prior to the staff shortages, Lockhart said an ambulance ran about six to eight calls per shift. Now, they may run 10 or 11. Sometimes, he said, the emergency responders will be out continuously responding to calls for the entirety of their 12-hour shift. 

“It’s not that I’m advocating for folks to have time to sit in a recliner and enjoy a cold beverage and watch the news,” Lockhart said. “But I’d at least like them to be able to get a meal.”

EMT recruits “a trickle” 

Even before the pandemic, EMS agencies struggled with staff burnout and high turnover rates. 

EMS workers are some of the lowest paid workers in health care, followed by nursing assistants and direct support professionals. May 2021 salary data from the Bureau of Labor Statistics show that nationally EMTs make an average wage of $17 per hour, or about $41,000 for the year. Paramedics, who provide the highest level of care in the profession, make slightly more, at an average of $22 per hour, or $49,000 per year.

On top of the low pay, these workers have struggled for years under stressful working conditions, which only worsened during the pandemic. But many who spoke with NC Health News said the pandemic alone shouldn’t be thought of as the main reason for the labor crisis, as there are longer standing issues that’ve likely led here.

In a letter sent to Congress in October 2021, leaders of the American Ambulance Association said that their industry faced a “crippling workforce shortage, a long-term problem that has been building for more than a decade.” The organization called for Congressional action.

Judd, from Buncombe County, said that on average, even before the pandemic, a person only spends about five years with an EMS agency. Then, they might move to a different agency or transition to a different career path. The pandemic only amplified the industry’s already high turnover and these vacancies became more stubborn to fill.

Mecklenburg EMS workers respond to a call. Credit: Courtesy of Mecklenburg EMS Agency (Medic)

In Mecklenburg, Studnek said his new-hire orientation classes have been in the single digits for months. Also, EMTs — not paramedics — have made up the majority of the new hires. 

“EMTs are a trickle,” Studnek said. “The paramedic faucet is almost turned off. Recruiting and identifying trained paramedics is a desert out there.”

EMS agencies across the state have been and are still competing for the same limited labor pool — a pool that shrunk considerably during the pandemic.

“As administrators, we’re basically shepherds who are sneaking into other people’s fields and trying to steal their sheep and increase our flocks,” Judd said. “How do we keep our folks from going to other places? And then how do we get people to want to come to us?”

Pay creeps up, but only goes so far

Recently, Buncombe has started to see an influx of applications — volume aided by county commissioners’ approval of significant salary adjustments. In July, starting pay for paramedics increased from $18.05 an hour to $24.02 an hour, and pay for advanced EMTs rose from $16.10 an hour to $19.86 an hour.

Other counties have also boosted pay and seen that it can help them fill vacancies. In McDowell County, aided in part by funding from the American Rescue Plan, the county commissioners approved at least a 10 percent increase in pay for all county workers with paramedics seeing an increase in starting salaries of nearly 15 percent

“It’s not all about money but at the same time you got to make a living,” Ziglar, from Forsyth, said. “EMS in general has been underpaid for the entire time it’s been out there compared to the ability and responsibility they have.”

With community colleges resuming in-person training, EMS officials hope there will soon be new graduates to fill vacancies. Judd said it’s promising that the local community college had more applicants than positions to its paramedic program.

Rather than waiting to recruit upon completion of the program, some county EMS departments, such as Buncombe and Forsyth, are working to attract people as they begin these training programs. Judd said he hopes a connection sooner will reduce attrition rates. He said that often about half the students who start a paramedic training program don’t finish.

In Buncombe County they’re also planning to launch a program where students starting the paramedic portion of their training can also begin working on an ambulance, gaining experience as an EMT, and getting paid. That way, hopefully, students don’t have to work as a restaurant server or other job to make ends meet. Plus, they’ll leave their course with almost a year of experience in the job they want to do.

“And they’re first in line for a permanent position,” Judd said.

Forsyth County EMS has also taken a more proactive approach to recruitment by encouraging community members into the profession — even paying for people to complete their certification. 

But Ziglar emphasized retention is also key.

“The people I have that are out there in the field who are trained and doing the job are worth their weight in gold,” he said. 

A Forsyth County ambulance responds to an accident. Credit: Rachel Crumpler

Alternatives to working in an ambulance

Some in the field say North Carolina’s shortage might also trace back to changes in state health policy.

In 2007, the state office of Emergency Medical Services and the NC Board of Nursing offered their support to a rule change that allowed EMS professionals to work in “alternative practice settings.” Whereas before, the only place paramedics could expect to do their jobs was inside an ambulance, following the change they could pretty much work anywhere: doctor’s offices, urgent care, sports medicine clinics, emergency rooms. 

In a 2019 joint letter, the state’s chief paramedic and the CEO of the board of nursing reaffirmed their support for the program. They wrote, “This expansion has since created the dual advantage of providing alternative career paths for EMS personnel and helping to alleviate shortages of properly trained and credential personnel in various roles in the heath care system.”

The scope of practice for these workers isn’t any different in these locations than it would be in an ambulance, but for many, the work can feel far less stressful. Alex Belanovich, who’s been a paramedic for 16 years and is currently the chief of emergency services in Harnett County, rattled off the benefits of working somewhere other than a county EMS department with ease: a climate-controlled work environment, higher salary, a set schedule with the ability to choose a day or night shift — maybe even a rare 9-5 schedule.

“They started seeing some challenges getting nursing staff, so the thought process was ‘Well we can start this non-traditional practice setting and allow you to hire paramedics. They can essentially do close to the same thing that a nurse can do, with less pay,’” Belanovich said. 

Now that EMS departments are experiencing a shortage, the calculus becomes more complicated, he said. While the Office of EMS has to try and “help pre-hospital providers, they don’t want to hurt the non-traditional practice settings either because they know they have a staffing shortage as well.”

The North Carolina Department of Health and Human Services said it could not arrange an interview between NC Health News and anybody from the Office of Emergency Medical Services, but wrote in an email, “EMS professionals are part of the overall healthcare community. They have a wide skill set that can be beneficial in a number of settings including ERs, urgent cares, physician offices, Community Paramedic programs, opioid response teams as well as traditional ambulances.”

Critical policy change set to expire October 13

In May 2020, Governor Roy Cooper signed an executive order that allowed some temporary changes to health care delivery during the pandemic. In turn, the North Carolina Office of EMS issued a waiver that changed how many credentialed EMS providers needed to be in an ambulance at any given time. Usually, two providers are required, but with anticipated staff shortages due to COVID-19 infections or quarantines, the rule changed to require just one EMS professional and one non-credentialed driver in each ambulance. 

A telehealth collaboration between Wilkes County EMS, Wake Forest Baptist health and the county health department helps care for rural cardiac patients faster. Photo credit: Wilkes County EMS.

While the executive order expired on August 14, the most recent budget contained a provision that allowed the waiver to stay in effect until the federal public health emergency ends, now scheduled to be Oct.13, though it’s expected to be extended again

Many in the field are asking that the change remain in place until the staffing shortage has eased — though given the low wages and the shortage of students in the EMS-training pipeline, it’s unclear when that might be. 

“EMS providers are the backbone — in my opinion — of the health care system,” said Kehler from McDowell County. “They are at the forefront of all of these common issues that we’re facing, whether it’s the opioid crisis, whether it’s violence, whether it’s the pandemic. EMS is at the forefront.”

These workers make tremendous sacrifices, he said. “And it’s up to each community to really step up and ensure that EMS providers are well cared for, not just financially but also from a mental health standpoint — that they’re provided the resources that they need to stay mentally and physically healthy.”

NOTE: Daren Ziglar, former director of Forsyth County EMS, spoke with NC Health News for this story in late July. He died on Aug. 26. 

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Rachel Crumpler

Rachel Crumpler is our Report for America corps member who covers gender health and prison health. She graduated in 2022 from UNC-Chapel Hill with a major in journalism and minors in history and social...

Clarissa Donnelly-DeRoven

Clarissa Donnelly-DeRoven covers rural health and Medicaid. She previously worked at the Asheville Citizen Times where she reported on the police, courts, and other aspects of the criminal justice system....