The fluorescent lights in the back of the ambulance glare above paramedic George Lombardo as he leans over to check his patient’s breathing, steadying himself as the vehicle races at 65 mph down the empty highway.
The man is dying from COVID-19. A machine pumps oxygen into his lungs through a breathing tube. His chest rises and falls in a robotic rhythm.
The EMS crew picked up the elderly man at a hospital and is bringing him to hospice care. He had signed a do-not-resuscitate order. If his heart stopped, no one was to intervene.
With six minutes to go, the ambulance veers suddenly into an empty Bill Miller Bar-B-Q parking lot and brakes to a stop.
The man has no pulse.
Lombardo makes a phone call, speaking loudly because his respirator mask muffles his voice. He unfastens the patient’s oxygen mask. It no longer is needed.
He steps out of the ambulance into the light of a street lamp. He rips off his own mask, breathing in the muggy night air.
The fluorescent lights inside the ambulance go dark.
Once every 24 minutes
This was the second time in less than 12 hours that Lombardo had sped across San Antonio with a COVID-19 patient. The second time he and his partner had carefully donned protective gear — a mask, face shield, gloves and gown — to protect themselves from the virus that often leaves their patients fighting for their lives.
Ambulance crews respond at least once an hour these days to transport COVID-19 patients to hospitals, long-term care facilities or to their homes, where they are sometimes destined to die in hospice care. On the worst days, ambulances went on runs an average of once every 24 minutes, according to city data.
The coronavirus pandemic compounds the stress these front-line responders deal with every day as they respond to accidents and deliver emergency care to patients suffering strokes, heart attacks, broken bones, lacerations and other conditions.
The powerful grip of the disease that was somewhat manageable in the spring now is taxing the medical system at every level, with the daily count of new cases spiking to more than 500, 1,000 and even 2,000 one day this summer. The virus has infected almost 36,000 people here and the death toll is more than 300.
“This is the closest thing medicine gets to war,” said Dave Condie, a paramedic who is clinical care coordinator for Superior Mobile Health, the private ambulance company where Lombardo works.
It’s a daily battle against two invisible enemies — the virus and burnout.
Some EMS organizations are scrambling to find personnel to care for the surge of COVID-19 patients. Emergency medical technicians and paramedics in Texas earn an average of $37,000 per year, $10,000 less than vocational nurses, $18,000 less than firefighters and $27,000 less than police officers, according to the Bureau of Labor Statistics.
Even with the brutal hours, working second jobs is common in the industry.
The life of an emergency medical provider has always been unpredictable. One moment, they might be watching YouTube videos in the front seat in a shaded parking lot. The next, performing CPR.
Each dispatch call brings a new medical crisis that demands life-saving care in the back of a moving vehicle and laser focus behind the wheel.
Patients with COVID-19 require more time, more resources.
Before a COVID-19 patient enters an ambulance, paramedics must carefully don protective gear. Once in their care, those patients are more fragile, often relying on state-of-the-art breathing machines that are normally found in hospital intensive care units and require advanced training to operate.
After the transport, EMS crews must sterilize every surface inside the vehicle. Door handles, cabinets, medical tubing, blood pressure cuffs, heart monitors, handlebars, the stretcher — the list goes on.
Emergency responders may now spend twice as much time on calls to transport patients, with little to no time to eat, use the bathroom or sleep, even on 24-hour shifts. Even off-duty, they are isolated from family and friends, as many forgo contact with loved ones to protect them from the deadly disease.
It feels like working in the aftermath of a hurricane, some emergency medical providers say.
Except this disaster has no end in sight.
Minutes from death
“Here, wipe them down with a rag,” Lombardo said inside the ambulance, as he handed a cloth to his partner for the evening, EMT Dominique Sharp.
It was just before 11 p.m., and Lombardo was 16 hours — and two iced teas and an energy drink — into his shift.
The two were readying their respirator masks, face shields, gowns and gloves before heading into the hospital to pick up the elderly COVID-19 patient. Whenever possible, dispatchers warn them before they come into contact with patients who might be infectious.
They didn’t know that the man they were about to bring into their care was minutes from death.
Sharp, 23, grabbed the cloth and furiously buffed the surface of each face shield. The clear plastic was cloudy from condensation that built up in the 105-degree heat earlier that day.
“Oh, so much better!” she said, after fastening its plastic headband over her forehead.
She fidgeted with the straps of her N95 mask to make sure it fit around her ponytail while Lombardo loaded medical gear onto the stretcher: a tank of oxygen and a portable machine to breathe for the patient. They then lowered the stretcher from the back of the ambulance, each holding one side as they wheeled it into the hospital.
Until then, the day had been routine. Lombardo was on for a 24-hour shift. Usually two EMS providers work each shift so they can trade off driving and caring for patients. But because of staffing problems, Lombardo didn’t have the same partner for his entire shift — one paramedic worked with him during the day, and Sharp took over at night.
Lombardo’s day began in a QuikTrip store parking lot on the north edge of downtown, eating his breakfast in the cramped front seat of the ambulance. He and his partner waited there until just before 9 a.m., when they got their first call — an elderly woman at a nursing home needed to be taken to the hospital.
It was slow for a couple hours after that, so they parked in the shade of a highway overpass to scroll through their phones and nap. Ambulance crews grab a few minutes of sleep whenever — and wherever — they can.
Lombardo brings a neck pillow with him to make napping in the front seat a little more comfortable — it has about as much space as an airplane seat, except it doesn’t recline.
Their rest was short. A patient with COVID-19 needed to be transported from a nursing home to the hospital. After finishing that call, they had an hour free to rest under the highway overpass again, until a man with sepsis at a free-standing emergency hospital needed to be brought to a general hospital.
After that, the paramedics were ready to transport a patient with tuberculosis, but ended up not doing so because there wasn’t an isolation room available at the hospital. Called “negative pressure” rooms, those units are generally now filled with patients with COVID-19.
A “medium day,” as Lombardo had described it. That changed after night fell.
As Lombardo and Sharp worked inside the hospital to hook up the COVID-19 patient to their portable medical equipment, four ambulances were parked outside. As soon as one left, it seemed like another arrived. A mortuary employee with a minivan pulled up, leaving minutes later with a corpse in a body bag.
Not far behind him, a paramedic and an EMT wheeled a woman through the hospital doors to their ambulance. Their expressions were hidden by masks and face shields, their bodies covered by blue plastic gowns.
Photo: Lisa Krantz /Staff Photographer
A machine breathed for her as they lifted her into the ambulance. Her chest rose and fell, at a tempo closer to a heartbeat than a breath.
She had COVID-19. She, too, was going home to die.
Layers of stress
After their patient died in the back of their ambulance, Lombardo and Sharp drove to his hospice destination and waited for the mortuary service to arrive.
Sitting in the front seat, the body still on the stretcher, Lombardo began to write the report of what happened. Sharp, who had worked her second job as a checker at H-E-B earlier that day, sat quietly next to him.
She had graduated from the University of Southern California in May. This was the first time she’d experienced anything like this.
But she’d have little time to process what happened. After this shift ended at 7 a.m., she had four hours to go home to rest before her next shift at H-E-B.
To protect her family, Sharp showers at the station and changes into clean clothes. She lives with her aunt and uncle, who are in their 60s, and her two sisters.
When she gets home, she dumps her clothes in the washing machine. She washes her hands as soon as she enters the door.
Many EMS providers spend more waking hours with their colleagues than with their own families.
Lombardo lives alone. He’s seen his family only once since March, when on the Fourth of July, he delivered fireworks to his parents over the fence. They spoke briefly from a distance.
“We have definitely transported patients who are grandmas and grandpas who haven’t gone out of the house, but their grandkids and kids are in and out and they end up sick,” Lombardo said. “It makes me cautious being around my own family.”
The fear that they could inadvertently sicken their loved ones adds to the layers of stress that fuel burnout among emergency medical providers. Lombardo, 32, who started in the EMS field when he was 19, is one of the company’s most experienced employees. Even he admits he doesn’t want to be a paramedic forever, because “I don’t want to grow to hate it.”
Since the pandemic began, Andy Schultz, the COO of Superior Mobile Health, said one trainee walked off the job, citing fear of exposure to COVID-19. None of his staff has contracted the virus, but he estimates his company still needs to hire a dozen employees to handle the influx of patients.
Superior Mobile Health is a private ambulance company that’s hired by nursing homes, a mental health facility, hospitals and rehabilitation centers to transport patients. It doesn’t operate within the city of San Antonio’s EMS system but provides 911 service on a military base and in some rural communities. In recent weeks, the company has seen calls double for critically ill patients.
Ideally, Schultz said, EMS crews should spend about 16 hours out of a 24-hour shift working, so they have eight hours to eat, use the bathroom and sleep. Recently, some EMS teams have been working more than 20 hours a shift — well above the threshold where crews are expected to begin experiencing burnout.
To stave off turnover, the company has offered to pay the tuition of emergency medical technicians to earn the more advanced paramedic license — an additional two years of training. Busy weekends are rewarded with gift cards for employees. The company often springs for sandwiches and B-B-Q for lunch.
Still, employees who once jumped at opportunities for overtime have backed off, retreating to care for their own mental health and their families. Condie, who is in charge of scheduling, checks in with employees regularly, especially those he knows are “not going to show me they’re going to break before they do.”
How we did it
Reporter Marina Starleaf Riker and photographer Lisa Krantz followed an EMS crew over a 24-hour shift, sometimes riding in the ambulance with the paramedic and patient.
They observed as paramedics for Superior Mobile Health, a private ambulance company, transported patients to hospitals across San Antonio, including multiple who were ill with COVID-19.
Riker interviewed paramedics, emergency medical technicians and upper-level managers to understand how the pandemic has strained EMS services. To protect patient privacy, identifying details have been omitted.
He wants them to take time off because he understands how quickly exposure to traumatic events, long hours away from loved ones and sleep deprivation can turn into severe burnout, mental health crises or substance abuse.
“The strain and the struggle a lot of people go through, they may just carry it forever,” Condie said. “Sometimes, we don’t really have the most healthy ways of dealing with these things, and some of the stuff that’s offered to us, it almost feels pointless … like, ‘We’ll send you to a counselor so you can talk to somebody for a while.’ But who’s going to know about this?”
In Texas, it typically takes a year and a half to two years to complete a paramedic course, which is on top of the basic emergency medical technician training. But it’s not uncommon for paramedics to leave the field within the first five years.
“It seems like a huge investment for a job that will chew you up and spit you out,” he said.
It was 3:12 a.m. by the time Lombardo and Sharp returned to the ambulance hub, nearly five hours since they got the call to transport the dying COVID-19 patient.
Lombardo went inside to a quiet conference room to finish typing up the patient report. It would take him another hour because of the unusual circumstances. Dark circles had begun to appear under his eyes. His skin was sticky with sweat from the 100-plus temperatures the day before.
Over the course of his 24-hour shift, he spent 18 hours working on calls and put more than 200 miles on the ambulance’s odometer.
Outside the station, the crescent moon was rising above the horizon, behind the parked ambulance that Sharp sterilized in silence. The only sounds were the squirt of bleach solution and the occasional sound of a car whizzing by on the nearby highway.
Meticulously, she wiped every surface from floor to ceiling. The cabinets holding supplies. The handlebars on the ceiling that paramedics and EMTs use to stabilize themselves. The stretcher, and its buckles — they’re called “seat belts,” to avoid alarming patients with the terms, “strap” or “restraint.”
It took Sharp 15 minutes to finish cleaning. By then, the dispatcher who’d sent her on the call was standing nearby, smoking a cigarette.
“You OK?” asked Kendra Gil, the lone dispatcher on the night shift.
“Yeah,” Sharp replied.
“Was that your first?” Gil asked, knowing it was likely the first time Sharp had witnessed someone die in her care.
“Yeah,” Sharp answered.
With worried eyes, the dispatcher repeated herself: “You OK?”
Sharp smiled, then added, “I’m tired.”
Emphatically, Gil grinned back.
“I hit that peak about 15 minutes ago,” she said. “I got my second wind.”
Marina Starleaf Riker is an investigative reporter for the San Antonio Express-News with extensive experience covering affordable housing, inequality and disaster recovery. To read more from Marina, become a subscriber. email@example.com | Twitter: @MarinaStarleaf
Lisa Krantz is a national-award winning photojournalist at the San Antonio Express-News. She recently returned to San Antonio from a fellowship with the Nieman Foundation for Journalism at Harvard University where she studied the intersection of journalism and trauma. firstname.lastname@example.org | Twitter: @Lisakrantz
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