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In growing Charleston County, EMS has scrambled to expand as call volumes rise. But is it enough?
Written by Jocelyn Grzeszczak
February 2, 2025
https://www.postandcourier.com/news/special_reports/charleston-county-ems-agency-911-call/article_b2d5df06-dce6-11ef-9a2a-8bf137f4452f.html
Nathaniel Frasier lay on the sidewalk for eight minutes waiting for help, pain squeezing his chest.
First came a police officer, flagged by bystanders in downtown Charleston's East Side neighborhood.
Next the firefighters, who rolled him on his side before placing a mask over his nose and mouth. Then an ambulance from Charleston County Emergency Medical Services.
The EMS crew loaded Frasier, 62, into the parked ambulance, where it remained for the next 27 minutes, surveillance footage shows. Halfway through that wait, a second pair of EMS employees arrived in an SUV. They grabbed equipment and disappeared into the ambulance.
Much remains unclear about what happened to Frasier that Monday morning in May 2022. He died at Roper St. Francis Hospital at 9:24 a.m. — 43 minutes after the ambulance showed up to the East Side. Doctors said his heart wasn't getting enough blood. And his only child contends delays in transporting him to the hospital contributed to his death, which has upended her life.
"What blew my mind the most was how the EMS just let him sit in the truck," his daughter, Jessica Williams, said. "The hospital is 1.4 miles away."
Williams filed a wrongful death lawsuit against Charleston County and its EMS department in May. A county spokesperson said privacy laws prevent the county from discussing specific patient care, but there are medically necessary reasons why EMS might remain on scene.
Still, Frasier’s death has raised fresh questions about the agency responsible for providing emergency medical care to South Carolina's third-most populous county.
Once lauded as the nation's best EMS system, the Charleston County agency has battled turnover, staffing shortages and internal discord in recent years. Call volumes continue to soar, pushing the boundaries of a system that few residents likely consider until they need it.
The agency is tasked with covering a county that spreads out like a misshapen pancake, unforgiving in its vastness. Crews in Charleston contend with nearly 1,400 miles of islands and bridges, rural roads and congested highways. And the population keeps growing. An estimated 30 newcomers pour into the region each day, forcing EMS to find new methods to meet the need.
In June 2023, roughly a year after Frasier's death, the agency reported 61 vacant positions — a third of them paramedics. During a 17-day period the prior month, emergency dispatchers recorded 125 instances where the county went "status zero," meaning its core fleet of paramedic-staffed ambulances was unavailable for calls.
Similar incidents played out nearly 600 times from July 1 through Nov. 30, 2023, sometimes multiple times per day, Charleston County records show. More recent data isn't available. Dispatchers stopped logging "status zero" events in November 2023, after The Post and Courier filed a Freedom of Information Act request about the practice.
EMS Director David Abrams said the data is flawed and doesn't accurately reflect the number of available ambulances. "Status zero" doesn't account for every paramedic-staffed truck, or SUVs driven by medics. It also doesn't consider ambulances with emergency medical technicians. EMTs provide basic life support, whereas paramedics are more highly trained.
It's unclear what effects, if any, "status zero" events had on patient care. The county would not provide more detailed records, like call notes, citing medical privacy laws. Some of those incidents dovetailed with requests to neighboring county agencies and private ambulance companies to help run calls because Charleston was overwhelmed, records show.
Emails and other county documents obtained through FOIA requests also depict a department struggling, at times, to recruit and retain employees — a challenge for EMS agencies across the country.
A summer 2023 staff survey showed roughly a third of EMS workers felt morale at the agency was poor.
And a committee tasked with improving the EMS department raised concerns about the leadership abilities of Abrams and other top officials. A county administrator organized mandatory leadership training around that time.
Still, the agency is making strides to augment its ranks and resources by filling vacancies and adding new positions. The workforce has expanded by more than 40 people since summer 2023. An in-house training academy has aided this effort, paying prospective EMTs to earn their certifications. Bigger annual budgets — $32.5 million this year — also have helped the department increase its ambulance fleet from 44 to 56.
But the chief isn't satisfied. The agency must keep growing to stay above demand, Abrams said. Response-time goals haven't been met in at least five years, records show.
"We need more ambulances. We need more paramedics," he said. "We need more resources out there."
How does EMS respond?
On a recent Friday morning, paramedic Charlie Cross flicked on the lights of his ambulance. The vehicle, also carrying EMT Tyler Brooks, sped toward West Ashley.
Information from Charleston County dispatchers filled the computer screen between them, providing real-time updates about their next call.
A patient's medical alert device triggered 911. But dispatchers rerouted the pair before they could cross the Westmoreland Bridge to respond. A call for a cardiac arrest had just come in. That took priority.
Charleston County uses a mixture of response models to address demand and get the right type of ambulance to a patient, Abrams said.
The system works like this: Say someone dials 911 with a minor issue, like knee pain. Call-takers in Ladson collect basic information and send it to a coordinator tasked with finding the closest — and most appropriate — ambulance. Each complaint is preprogrammed in the system with an EMS response that varies depending on its severity.
Charleston County EMS has different types of vehicles: ambulances staffed by EMTs, ambulances carrying both a paramedic and an EMT, and SUVs driven by paramedics. The majority are part of the "core" fleet, roaming the county based on current and predicted demand. Another five "anchor" trucks are stationed in the county's hard-to-reach areas, such as Ravenel and McClellanville.
Paramedics hold a higher certification level, giving them more tools to treat a patient. They can administer medication through an IV, for instance, or use a manual defibrillator — critical in a cardiac arrest call. Charleston County also employs a handful of advanced EMTs, who are mid-level providers.
For the patient with knee pain, the county aims to send its closest ambulance, Abrams said. But if an EMT-staffed truck is nearby, it will get the nod, keeping paramedics free for more complicated calls.
If an EMT crew happens to be closer to a serious complaint, such as chest pain, it will respond. Paramedics are deployed with them to provide more advanced care.
Abrams said he won't put patients at risk — and that includes not waiting to send help until an ambulance with paramedics becomes available.
Adapting to growth
The county didn't always operate its ambulances this way.
When Don Lundy became EMS chief in 2000, paramedic-only crews drove in every ambulance, he said. After his departure in 2015, the model evolved into staffing trucks with one paramedic and an EMT.
That's partly because growth exploded in Charleston County — and across much of South Carolina. The Palmetto State saw its population increase by more than 850,000 people between 2010 and 2024, according to U.S. Census data. It edged out Florida in 2023 for the nation's fastest growth rate.
Three of South Carolina's four largest cities are in Charleston County: Charleston, Mount Pleasant and North Charleston. And the tri-county area is projected to grow to more than 1 million residents by 2042.
EMS call volumes in Charleston County surged more than 40 percent between 2011 and 2024, records show.
Around 14 ambulances were deployed daily when Abrams left the county as a paramedic in 2002. That number hadn't changed much when he returned as chief 14 years later.
The county consistently ran out of ambulances during its busiest hours, Abrams said. There weren't enough paramedics to put one on every truck and adequately meet demand.
Staffing shortages are a perennial challenge in the EMS industry. Front-line providers contend with long hours and low pay, grueling physical conditions and repeated exposure to trauma.
Burnout can cause turnover, said Daniel Patterson, a paramedic and professor at the University of Pittsburgh's emergency medicine department. Many EMTs and medics enter the field for altruistic reasons. Some use their position as a stepping stone to better-paying jobs in the medical field, like becoming a nurse or doctor.
The paramedic supply worsened in the wake of the pandemic. The turnover rate for full-time medics was 27 percent in 2021, according to an American Ambulance Association survey. As of January, there were roughly 4,500 licensed paramedics to serve South Carolina's more than 5 million residents.
Departments across the country have had to adapt. Charleston County was no exception, Abrams said.
The agency's data shows around two-thirds of patients taken to a hospital require basic care, such as splinting or a cervical collar — services EMTs can provide, the chief said.
After a month-long pilot in 2019, Charleston County EMS changed its response system to add EMT-staffed ambulances to the mix. More advanced trucks have one paramedic and an EMT on board.
Lundy, the former EMS director, doesn't disagree with Abrams' decision. Two paramedics aren't needed on every call, he said.
"But during an emergency, that's not when you want to find out you need two paramedics," Lundy said. The transition preceded a tumultuous time for the agency.
Its medical director resigned in November 2020, blasting leaders' decisions on everything from the new response model to "stalled" mental health programs, saying top management was "putting the public at risk," Post and Courier columnist Steve Bailey reported. The department was also battling a string of lawsuits over its use of ketamine, an anesthetic commonly used in human and veterinary medicine. The controversies cast the agency in an unflattering light.
Still, experts maintain that patient care hasn't suffered under the hybrid response models.
"Surprisingly, the systems that implemented these things didn't end up having stacks of dead bodies," said Henry Lewis, executive director of the S.C. EMS Association, a nonprofit trade organization.
For the strategy to work, patients must adequately describe their emergency, he said. And the agency must still have enough ambulances.
Abrams went to County Council in March 2021 with a plea for more resources. To meet demand, he said, the county needed to operate 31 ambulances. Currently, it could send only 17. The department had 126 paramedics and EMTs on staff. It needed money to hire 80 more, he said.
Council members approved nearly $3 million in extra funding. It was enough to buy four ambulances and immediately add 44 EMTs and paramedics, with even more positions available in the next budget cycle.
But county data shows the department struggled to fill those spots. By late November 2022, there were roughly 60 vacancies for EMTs, paramedics and trainees. Seven months later, that number hovered around 45.
Growing pains
To address this issue, Charleston County EMS leaders set their sights in January 2023 on recruitment and retention, according to emails obtained through FOIA. But holding onto current employees proved challenging.
In July of that year, an anonymous letter circulated among top staff. It outlined recent improvements in the department but also questioned some leadership decisions that affected morale, including setting shift schedules with less employee input.
Abrams told a deputy chief that he agreed with much of the concerns, emails show.
A department-wide survey followed in August 2023. Of the 90 employees who responded, 60 percent said they were satisfied with their job. As for morale, roughly a third described it as good, a third said it was neutral and a third labeled it "poor."
Employees offered suggestions for improving work-life balance. They also criticized leadership, lamented inadequate staffing and bemoaned pay. Crews here remain the lowest-paid in the tri-county area, despite handling more 911 calls than both Berkeley and Dorchester counties combined.
That same month, members of a workforce improvement committee sent a letter to Deputy County Administrator Eric Watson, who oversees public safety. They asked him to intervene, presenting a litany of concerns: favoritism, retaliation and a lack of professionalism among leaders, including Abrams, whom they called "disengaged."
"Morale of the front-line staff in EMS is very low and we are losing good employees due to frustration, lack of leadership, and no clear direction," the letter states.
Watson said he agreed with the committee, in part. He thought the department could improve its leadership development, so he lined up mandatory training for all EMS supervisors through the College of Charleston. The agency needed to coach them in mentoring, conflict resolution and communication, he wrote in a September 2023 email.
Watson said morale and retention have improved, but the department still has a long way to go. A memo he sent in August 2024 to Abrams and deputy chiefs echoed several of the committee's concerns. He said he plans to set up another training session, likely through the college.
Abrams told The Post and Courier he is "very much" engaged with his employees. He praised the college’s program but noted some of the department’s supervisors could be more receptive to growing their leadership skills.
'Status zero'
A call came into the 911 center in May 2023. A 49-year-old man was almost catatonic, according to dispatch notes. He was conscious, but his breathing didn't seem normal.
Fast-forward three months. An elderly woman dialed 911 with breathing problems. The call-taker noted her difficulty speaking between breaths.
What became of these people is unclear. A private ambulance ultimately responded to both calls, records show. In each case, dispatchers at the Charleston County 911 center noted: "SYSTEM STATUS ZERO - NO MEDIC UNITS AVAILABLE." It wasn't the only instance.
Dispatchers made that notation more than 570 times between July 1 and Nov. 30, 2023, documents show. Center director Jim Lake said he believes his staff stopped tracking the metric after the newspaper submitted its FOIA request.
Dispatchers used the phrase to monitor EMS resources, Lake said. But situations were often dynamic; a cluster of ambulances might be dropping off patients at hospitals, only to become available 30 seconds later.
The information also wasn't accurate, both Lake and Abrams said. "Status zero" was never defined, leaving dispatchers to interpret the phrase and choose whether to document it in their notes. It gave the false impression there were no available ambulances in the county, Abrams said.
The 911 center's analysis failed to factor in EMT-staffed vehicles and other trained personnel who could pitch in, Abrams said. He can't recall a time the county has ever completely depleted its resources.
"People were raising alarms when there were no alarms that needed to be raised," the chief said.
But others picked up on the phrase, too. Mount Pleasant Fire Chief Mike Mixon emailed Abrams dozens of medical calls in May and June 2023 that firefighters responded to. The reports, obtained via the FOIA request, detail wait times for ambulances belonging to both Charleston County and private companies.
More than a dozen incidents describe Charleston County EMS at "status zero." Mixon did not respond to a request for comment.
The EMS department does not track "status zero" incidents, Abrams said.
He has asked supervisors to alert command staff when the system becomes overwhelmed. If so, he expects them to use their take-home SUV and help run calls.
Comparing counties
There is no one-size-fits-all solution to operating an EMS system, said Lewis, the state association's director. Every region has different needs. Some systems are for-profit companies, while others are government operated. This makes it difficult to create coverage models or standardized measurements.
The state health department, which regulates emergency medical services, does not police "status zero" events.
Dorchester County didn't start tracking "status zero" situations until July 2024. From July through Jan. 14, the county was at "status zero" nine times. Anywhere from seven to 10 ambulances roam the streets each day. And unlike Charleston, all are scheduled with a paramedic on board.
Greenville County — the state's largest — logs a "status zero" event when its EMS service has been without ambulances for at least five minutes, a spokesperson said. This happened more than 600 times between July 2023 and August 2024.
Along South Carolina's western edge, Aiken County EMS contended with a "status zero" crisis amid staffing shortages. There were 192 times in January 2023 where 911 calls sat waiting for an ambulance, the Aiken Standard reported. A scheduling change later helped improve the situation.
Staffing isn't the only factor triggering "status zero," said Patterson, the Pittsburgh professor. The system might have seen a sudden influx of calls. Perhaps emergency rooms are backed up, delaying first responders from dropping off patients.
Still, it's concerning if an agency frequently finds itself in that position, Patterson said.
"If I get a call from the dispatcher saying, 'Well, they're not going to be there for 45 minutes,' " Patterson said, "I'm a concerned citizen. And I want to know why."
'I was dumbfounded'
When Stephanie Lemke's father collapsed at a party in October, she was told it would be 20 minutes before an ambulance arrived at the home in northern Mount Pleasant.
Some doctors who were at the party rushed to help, concerned that the 79-year-old man might have had a stroke, Lemke said. Firefighters quickly arrived and examined her dad. One mentioned the EMS department was short-staffed, she said.
One of the doctors ultimately drove Lemke's father the short distance to Roper St. Francis Hospital on Highway 17. He was OK — likely overexertion, she said. But the experience left her rattled.
"I was dumbfounded," Lemke said of the EMS response time. "Aren't we entitled as residents to have that kind of service?"
Lemke contacted Mount Pleasant Mayor Will Haynie. He forwarded her concerns to County Councilmembers Herb Sass and Larry Kobrovsky, who represent East Cooper. It wasn't the first time Haynie had heard about long waits for an ambulance, he wrote in an Oct. 7 email.
Sass told The Post and Courier he and other county staff looked into the complaint and discussed how it could be prevented. Lengthy response times concern Sass, who was recently replaced as council chairman. But the EMS department does a good job spreading its resources across the vast county, he said.
"We're answering 60,000 calls in a year," Sass said. "We're not going to do them all right."
Measuring success?
The EMS industry is moving away from viewing response times as the sole benchmark of success. Experts say the majority of medical calls in the U.S. are not time sensitive.
In Charleston County, for instance, only 6 percent of calls require crews to activate an ambulance's lights and sirens on the way to a hospital for a better patient outcome, Abrams said. Think gunshot wounds, strokes, sepsis and heart attacks.
But the chief wants an EMT or paramedic at every medical call within 20 minutes — regardless of the patient's complaint. Response-time data helps gauge the agency's performance.
For minor complaints, Charleston County EMS should arrive at the scene in under 15 minutes 90 percent of the time. The bigger the emergency, the smaller that window gets. Crews should be at the most severe calls within 11 minutes 90 percent of the time.
The agency hasn't met those goals in at least five years, records show. But metrics improved in 2024 for almost every complaint level. And for the most acute calls, crews hit their benchmark 84 percent of the time.
Charleston County's 911 center, which has dealt with its own staffing troubles, can play a role in driving up response times. If the center is short-staffed, it can take longer to move through calls.
But the biggest obstacle to eliminating long responses is the county's complex geography, Abrams said.
High call volumes result in ambulances clustered at hospitals — often the area's two largest, Roper St. Francis and Medical University of South Carolina, on the Charleston peninsula.
Help will quickly arrive for someone nearby. But if a patient calls from Lincolnville, in the county's northwestern-most corner, a delay is more likely.
Requesting backup
Charleston County EMS has turned to other ambulance services for help responding to calls, documents show.
Dispatchers or EMS supervisors will request assistance if they think a private ambulance or neighboring county can get to the scene more quickly, Abrams said. And vice versa. At least five hospital-based and private ambulance companies operate in the area.
The agency supplied mutual aid nearly 380 times between July 2023 and August 2024. It received help more than double that — roughly 850 times — sometimes at several points throughout the day. Some instances align with times that dispatchers recorded "status zero" in their call notes, records show.
Mount Pleasant fire reports show about 50 instances in a two-month period where the EMS system appeared overwhelmed. In each case, private ambulance companies stepped in to handle medical calls, according to the reports that the town's fire chief sent Abrams in July 2023.
Charleston County receives more help than it provides because it's the busiest system in the tri-county area, Abrams said. The county responded to more than 64,000 calls last year, compared to nearly 25,000 in Berkeley and almost 27,000 in Dorchester.
Greenville County, which reports annual call volumes around 80,000, received mutual aid more than 9,000 times between July 2023 and August 2024.
Mutual aid happens every day in most communities, Patterson said.
Abrams said his goal is to have enough EMS staff that the agency wouldn't need to use mutual aid. But it’s not there yet.
Staffing improvements
Back in the ambulance, EMT Tyler Brooks and paramedic Charlie Cross responded to three back-to-back emergencies. A heart attack. A fall. Difficulty breathing.
A break arrived around 3 p.m. They quickly ate a pasta lunch in a hospital parking lot, keeping close to the radio in case a call came in. It never did.
To the pair, that break was evidence that staffing has improved in the past year.
"I remember when it was low. It was a totally different game," said Brooks, who has worked as an EMT for about three years. "This is the best staffing I've ever seen."
The department has managed to shrink its vacant positions over the last year and a half. Recent pay increases for EMTs and paramedics have brought their hourly rates closer to the competition. The department hired two cohorts of paramedics in 2023 from Australia, where there's a surplus of positions. It's looking to bring over more, Abrams said.
The biggest boost to recruitment, however, has been the department's in-house EMS Academy. Trainees are paid while they study to become certified EMTs, rolling directly into the workforce after graduation.
The academy, which started in February 2023, is in its fourth class and has put nearly 40 new EMTs on Charleston County's streets. Another 17 are set to graduate this month.
Abrams trusts that the agency's current hybrid system is safe. Still, his goal is to one day put a medic back on every ambulance. He's now focused on building out the EMT pipeline to ultimately create more paramedics. The agency has plans to expand its academy into a full-fledged training center, certifying its own advanced EMTs and medics.
The state's EMS association recognized Charleston County as the best large system in 2023, heralding its "pioneering" recruitment and retention strategies.
Today, the department has roughly 280 budgeted positions and around 20 vacancies for EMTs, paramedics and trainees. Fifty-six ambulances are available to deploy.
Abrams wants to see that number climb to 75 within the next five years. He just needs the people to fill them.
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