Extended Shifts Putting Strain on SC County EMS Workers

In just eight days in January, an EMT and a paramedic with Beaufort County EMS each racked up more than 140 hours doing a job that required quick thinking and reactions at any time of day or night, from rushing to transport trauma patients to the hospital to responding to life-threatening medical emergencies.

Three times, their initial, 24-hour shifts ended. And three times, rather than clock out, they started another.

These extended 48-hour shifts are the norm rather than the exception in Beaufort County, budget documents and schedules reviewed by The Island Packet and Beaufort Gazette show. The newspapers' analysis reveals the county's EMS department has blown through its overtime budget repeatedly in recent years, overspending by millions of dollars while potentially compromising worker and patient safety, employees and experts warn.

Between January and March, an average of 142 EMS shifts each month stretched over 35 hours, the majority spanning two full days, schedules show. Each month, over 50 different EMTs and paramedics with the department stayed on duty for at least one of these extended shifts, many working them repeatedly.

Some didn't choose to pick up the overtime, but were forced to fill scheduling gaps, working "mandatory 48s" demanded by county policy. While these first responders are able to rest between calls, extended shifts can still take a toll.

No federal or S.C. laws restrict EMS shift length, leaving it up to local agencies to set their schedules, which range widely across the country.

Reporters spoke with five current and former EMS employees who had concerns about Beaufort County's scheduling practices. Two of them said extended hours put the public at risk, linking the two-day shifts to impaired judgment, exhaustion and mistakes with potentially life-threatening consequences.

Employees have elevated these concerns to upper levels of county administration this year and last, according to documents obtained by the newspapers. But many said these warnings fell on deaf ears.

In an interview, EMS Director Donna Ownby, a 38-year veteran of the department, says she's heard the concerns, but offered no specifics on changes she's made in response, beyond trying to recruit more staff.

Her department, which covers all of the county except Hilton Head Island, is down 10 full-time positions from being fully staffed. "If we didn't have the overtime, that would put a deficit on the citizens' care," she said.

"I'm doing my best right now, and if I find something that sticks out to me as a safety issue, obviously, as a director, I'm going to address it," Ownby said to concerns about marathon hours worked by some employees and red flags raised by others.

While short staffing plagues EMS across the state and nation, two similarly sized South Carolina counties appear to have found ways to keep their EMS overtime spending in check, the newspapers found. And one prohibits double shifts.

For Christopher Prener, a sociologist at Saint Louis University who has studied EMS after working for years as an EMT, the newspapers' findings are cause for concern.

"It seems like a system that's very much struggling to tread water," he said.

A culture of overtime

Beaufort County EMS' budget has ballooned over the past six years as the agency raced to keep up with the area's explosive population growth.

Overtime spending has kept the department in the red each year — and short-staffing has increasingly left money reserved for regular wages unspent.

Between 2015 and 2020, Beaufort County EMS projected roughly $5.5 million in overtime costs. The actual expenditures more than doubled that, reaching $11.7 million, budget documents show.

Still, overtime has never been flagged as an issue, Ownby told reporters. This year, the agency's overtime budget was bumped up by nearly $1 million, reaching $2.2 million. The department had not surpassed that target as of April.

Paramedics and EMTs in the department are supposed to work 24 hours on, followed by 48 hours off. This schedule is popular with fire departments, which benefit from an exemption in federal labor law that raises the hours a firefighter must work before overtime kicks in.

Beaufort County EMS pays overtime after 40 hours, meaning time and a half is already baked into employees' regular schedule. And when that schedule has holes, employees are subject to recall after their shifts end, according to the department's policy.

Between January and March, roughly five employees each day on average were on an extended shift, working at stations in Okatie, Bluffton, Beaufort and other parts of the county, according to the newspapers' analysis of schedules.

The schedules don't show whether or not an employee chose to pick up extra shifts, but many emergency providers appear to have been held over at the same station.

Sometimes, they worked with a partner also picking up extended hours. At least 16 times in those three months, both members of the two-person crew manning an ambulance assigned to a part of the county found themselves on the tail end of a shift spanning two days.

Some employees racked up mountains of overtime in quick succession. In the first three months of 2021, at least 15 different EMTs and paramedics surpassed 100 hours on duty in a one-week period. One paramedic worked over 1,000 hours in extended shifts in three months, managing an average of close to 80 hours a week.

Those kinds of hours are "not really a common practice," Ownby said, adding that her providers "get a lot of downtime in between calls," including the chance to sleep, and that open shifts are made available ahead of time for employees to fill.

Unlike with jobs such as long-haul truckers, nuclear power plant operators and medical residents, there is no national standard for shift length in EMS. South Carolina's public health agency, which oversees EMS, doesn't regulate shift hours.

Guidelines from the National Association of State EMS Officials recommend limiting shifts to less than 24 hours, and studies have found longer shifts are linked to higher rates of injury and poor performance toward the end of a shift.

"Relying on holdovers as a default strategy is a concerning practice," said Prener, the sociologist, who added EMS agencies sometimes address staffing issues by leaning more on EMTs, which require less training, or using a commercial service to fill vacancies.

Short-staffing is a "chronic issue" in EMS nationally, and addressing it means facing the ultimate issue of pay, he said. "People like OT in part because they're being exploited. So preference for OT is actually a kind of logical response to poor working conditions."

The county hopes to raise its wages, Ownby said. Pay begins at $13.33 an hour for EMTs and $14.66 an hour for paramedics, maxing out at between about $19 and $21 an hour, according to the county's pay scale.

"We are definitely working on that," the EMS director said in an interview May 12. The following week, EMS employees got the news of a small pay bump: a $250 bonus for picking up open shifts or working a mandatory 48-hour holdover.

The bonus had previously been $50 for a two-day shift, Ownby said in an email. "We have been talking about increasing it for a while now and did so," she added.

How do other counties compare?

Beaufort County's EMS system's reliance on overtime stands out from systems in some similarly sized parts of South Carolina, while mirroring the kind of spending reported by others.

In fiscal years 2019 and 2020, Beaufort County EMS spent at least $1 million more on overtime than departments in Dorchester, Florence and Aiken counties.

Over that period, Beaufort County averaged 40.3% of its total wages paid at an overtime rate, close to smaller Aiken County and larger Berkeley County, but roughly double the proportion dedicated to overtime in Florence and Dorchester counties.

A spokesperson for Dorchester County said its system uses 12-hour shifts and caps extended shifts at 18 hours. In Berkeley County, where recall is used to fill vacancies, an overtime coverage pattern is published months in advance, a spokesperson said.

Ownby dismissed the possibility of 12-hour shifts as infeasible with Beaufort County's staffing levels. She declined to discuss how Beaufort County compared to other parts of the state.

"I don't know what the other counties' budgets are, so I can't compare or talk about that issue," she said.

Red flags raised

Last summer, before Beaufort County Council members forced her to resign, Administrator Ashley Jacobs met with nearly 50 EMS staffers in a series of listening sessions.

"A number of questions and suggestions have been raised over [the] past several months, and it appears these have not been answered satisfactorily," read a notice to employees about the roundtables.

Employees suggested a range of improvements, from addressing cats kept at EMS headquarters to improving the quality of ambulance repairs. Among the recommendations was also the "prompt scheduling of overtime."

"If you're working a 48 hour shift at a busy station, it can be extremely tiring and wear on you," one employee wrote. "Sometimes you don't have relief for a month, and you just hope and pray someone signs up for the open shifts."

Ownby told reporters EMS administrators addressed feedback that was feasible. Asked for specifics, she said, "any kind of personnel issues I really can't get into."

Employees' warnings didn't stop.

In a resignation letter to top EMS and county officials obtained by the newspapers, another employee blasted a "dysfunctional and toxic" system that is "more concerned with turning a blind eye or taking whatever steps necessary to cover (not correct) legitimate concerns within the organization."

The letter targeted various areas, among them "an administration who appears to be viewed as taking advantage of mandatory 48 hour shifts during the current pandemic resulting in an overall unhappy field staff."

Ownby declined to respond to the letter, saying she could not discuss personnel matters.

"I do talk to my employees, and some are concerned and some are not," the EMS director said, adding she and her supervisors do the best they can to avoid having first responders stuck on double shifts.

County Council members react

Beaufort County Council members, who approve and oversee the EMS department's budget each year, are in the midst of finalizing their spending plan for the upcoming year.

When contacted by a reporter, several said they had heard vague concerns about the department's use of overtime and employee fatigue over the last year.

But, when told about employees working over 100 hours in a week and the OT overages, many of the officials in charge of approving the EMS department expressed shock.

"That's insane," said newly elected council member Logan Cunningham.

Council member Gerald Dawson, who worked as a paramedic in the late 1970s (briefly for Beaufort County) said all council members have received emails about the department's use of overtime, worker shortage and employees' lack of downtime.

He acknowledged the department has "a lot going on down there."

Citing his personal experience in the field, Dawson said most people don't understand the stress levels EMS workers have to deal with on the job. He said paying workers a higher wage — which is the reason he left the profession — is important, but it's not the only solution.

"Compensation is only a piece of the puzzle," he said. "The recruitment package has to be something attractive to where you get new people coming into the force, and you have more employees to rotate on and off shifts."

Council members Cunningham, Dawson, Brian Flewelling and York Glover said the council has directed county administration to look into the concerns expressed by employees. One of the major solutions is the county's upcoming compensation and classification study, which Glover said he hopes will raise wages and retain and attract more employees.

"It was disturbing just to find out what some of the employees are being paid," he said. "We can't expect the kind of services and the quality of services we want if we're not compensating our employees properly."

When contacted by a reporter, Council member Stu Rodman, however, said "overtime never bothers me." He said he learned while working at Ford Motor Co. that paying employees overtime was cheaper than "straight time."

It's more efficient, he said.

"I'd be anxious to see what everyone else thinks," he said. "It's a useful heads up."

Council member Flewelling said he's periodically forwarded emails about EMS conditions to administration for years. Some of the things he read from employees, he said, were "heart wrenching."

While he said the authority to address personnel matters inside EMS is up to administration (as required by S.C. Law Section 4-9-660), he said the council would look for ways to alleviate problems within the department.

Asked if EMS employees working over 100 hours a week worried him, Flewelling said yes.

"Obviously we don't want EMS employees to be overtired and miss diagnostic cues or misapply procedures, which would endanger citizens' lives and not to provide the kind of care that we expect from EMS," he said. "I think that's a danger."

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