Heads of Triangle EMS agencies are concerned with a population boom not matched by the available Emergency Medical Technicians.

"The gap has taken a huge jump in the last couple of years," said Skip Kirkwood, the chief of Wake County's EMS agency.

Wake County, Orange and Durham make up the difference by stretching available staff.

"To a very high percentage, we can staff the units that we need to staff with overtime," Kirkwood said. "You can do that for a while. You can't do that forever."

If there are no takers for overtime, that means a system could be down an ambulance or two, raising response times in situations where minutes count.

Wake County's EMS system has seen call rates jump from 42,463 calls a year in 1999 to 60,874 calls in 2006. During that time, there was no change in the number of Emergency Medical Technicians on the job.

In October, Wake County added 14 positions, but still hasn't filled them all.

Paramedics, the highest-trained level of EMT, are the most at risk to leave. Unlike entry-level EMTs who are qualified for basic first aid, paramedics get two years of training and are constantly updating their qualifications.

That training easily bridges over to work as a nurse or a clinical technician.

Pickings of qualified paramedics are slim and retention is the No. 1 problem for EMS agencies across the state, said Drexdal Pratt, the chief of the N.C. Office of Emergency Medical Services.

His agency is conducting the state's first emergency medical services work force study, due in September. Preliminary results are clear -- North Carolina needs more paramedics.

Those results show that EMS departments in North Carolina have, on average, only 90 percent of the staff they need to effectively staff their departments.

Compared to health workers with similar training, such as nurses or specialized medical workers, paramedics make tens of thousands of dollars less and have more demanding work schedules.

Most local governments don't have the funds to pay commensurate salaries. EMS often takes a back seat to fire and police departments, said Neal Richmond, the head of a Louisville, Ky, EMS agency.

"I think in the old days, so to speak, EMS was much more of a career," he said. "A lot of the new people want to use it as a stepping-stone into fire or police."

On average, police officers nationwide earn $18,000 more and firefighters almost $11,000 more than EMS workers. And police and firefighters require less training to do their jobs, Richmond said.

Once hired, EMS workers are difficult to hold onto.

Between May of 2006 and June, Wake County has lost 31 EMS workers to better paying, less-stressful jobs -- mostly in health care -- said Kirkwood, the Wake EMS chief.

EMS departments judge themselves by the survival rates from cardiac arrest patients. The more experienced the paramedic, the more likely a heart attack victim will survive.

"You're going to want someone with 12 years working on you rather than 12 months," said Brent Myers, the medical director of the Wake County EMS system.

In the mid-1990s Orange County's EMS system saw staffing problems on the rise and altered its service and use of its paramedics, said Kim Woodward, operations manager for Orange County EMS.

"Our retention is quite good," she said. Unlike Wake and Durham, Orange paramedics respond in SUVs instead of ambulances.

The idea is to give paramedics more autonomy and place them in a supervisory role over lesser-trained EMTs who drive the ambulances.

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