By Karishma Vyas Foreign Correspondent ABC.NET New York April 21, 2020
New York paramedics are responding to a 911 call in Queens. Inside the apartment, an elderly woman lies on a sofa bed gasping for air. Her chest moves rapidly, in and out, a desperate rasp escaping between breaths. Four paramedics work quickly in the cramped and cluttered space between a walking frame and a religious shrine. It's Good Friday, the Christian holiday that marks the crucifixion of Jesus over 2,000 years ago.
Today in America, the nation has just passed its own grim milestone — it now leads the world in COVID-19 deaths. In this city, as one paramedic with decades of experience put it, "death is everywhere".
If hospitals are the front line in New York's war on COVID-19, paramedics are fighting deep behind enemy lines, inside the homes and apartments of infected New Yorkers.
The enemy they are fighting is in the very breath their patients exhale, an invisible menace filling the room around them. It clings to their equipment and contaminates their clothes, hair, goggles, gowns and shoes. For how long, they don't know. As first responders, New York's paramedics and EMTs — emergency medical technicians — don't know who is infected and who is not.
"We're very scared," says John Rugen, a paramedic working in Queens. "We're scared for ourselves, because even though we're healthcare professionals, we have members who have underlying medical conditions." Some paramedics in his unit still have medical complications from responding on the day of 9/11. John himself is a lung cancer survivor.
"They are out here doing what they took an oath to do and they're putting their lives in jeopardy. They're also putting their families in jeopardy." So they have learnt to presume every patient they now treat has COVID-19, whether the call-out is for a fever and cough or a fractured ankle. It was a hard lesson learnt quickly after hundreds of first responders became infected in the chaotic weeks after New York discovered its first official COVID-19 case on March 1.
In the seven weeks since then, over 14,000 have died in New York and the city has become the world's coronavirus epicentre. Among the dead were hundreds of frontline health workers. The sudden loss of colleagues to illness, coupled with a staggering increase in emergency call-outs, has nearly crippled the paramedic corps and left those holding out exhausted. Many are traumatised.
Some quit almost immediately, overwhelmed by the sudden explosion in their workload and the heightened personal risk of becoming infected themselves. Many who continue to work — often double shifts of 16 hours a day — have been forced to sleep in cars or convert home basements into temporary accommodation to avoid spreading the virus to their partners, children, parents or roommates.
The city has more recently started providing hotel rooms for essential health workers, but the weeks spent away from family and friends has taken a mental toll that is harder to quantify than infection rates or COVID-19 deaths. And yet many of New York's paramedics, consciously channelling the spirit of a city whose first responders faced the horror of 9/11, continue to enter the homes of the sick and dying in the presence of a highly contagious and little-understood killer.
The hiss of oxygen soon fills the Queens apartment, as a paramedic leans down to help the elderly woman who is struggling to keep the mask on her face. "It's oxygen, relax," says EMT Megan Pfeiffer, reaching out to hold the woman's hand. The woman looks ghostly pale and is barely conscious, but there is some better news once the paramedics measure her blood oxygen levels.
She is taken to hospital. Paramedics will likely never learn whether she survived or not. Within minutes they will be called onto the next job. While so little is currently understood about COVID-19, paramedics, nurses and doctors are observing it up close, learning its character and complications. One of the riddles to emerge from the medical front line is the precipitous drop in so many patients' oxygen levels. Health workers are alarmed by their patients' instability.
For EMTs like Megan, the last few weeks have seen the manual virtually rewritten as to what constitutes a grim reading on their "pulse ox" — a tool which attaches to a patient's finger to measure the oxygen level in their blood.
Paramedics say before COVID-19, a pulse ox in the low 90s might have sent them rushing to provide oxygen, or even preparing to intubate a patient. Now they report routinely seeing levels in the 60s and 70s, and some say they have felt a sense of relief if those levels claw back into the 80s.
Puzzlingly, many patients presenting with extremely low blood oxygen levels don't appear as critically ill as health workers might normally expect.
"There was someone who was at 34 per cent and still awake and talking to us. We thought, 'try a different finger, try a different finger'," says Megan. "But it actually was her oxygen that low. I've never seen a person alive with a number like that."
For the first few weeks of New York's outbreak, as the virus spread rapidly, paramedics mostly treated patients who fitted this profile. There was a deluge of New Yorkers in acute respiratory distress who were desperately in need of oxygen and hospitalisation.
Paramedics often arrived to find many already dead in their homes. In amongst the serious cases, there were also many with mild symptoms who were unsure whether to go to hospital or ride it out at home. But then, in early April a second wave of COVID-19-related deaths hit as the virus progressed, many of them not counted in New York's official coronavirus death toll until last week. The city saw a dramatic spike in cardiac arrests.
Crews who would once have considered seeing two cardiac arrests a particularly bad day on the job were now encountering up to five in an eight-hour shift.
"We suspect that most of these are corona patients," says Megan. "There's a good majority who say they were complaining of troubled breathing, or they had a cough and a fever and just went downhill. There are some we just have no idea whatsoever because they have no family or friends around."
The paramedics find other COVID-19 patients who have already been discharged from hospital only to succumb to the disease at home. With the amount of death she has witnessed, coupled with the constant call-outs and long shifts, Megan is experiencing "lots of ups and downs, anxiety attacks, hysterical crying".
They have ramped up their own safety protocols. They wipe down and sanitise their equipment methodically — stretchers, ambulance door handles, dashboards. Then they wipe it down again. Seeing what she has seen, if Megan were to find out she was responsible for passing the virus on to a loved one, "I couldn't live with myself," she says.
John Rugen, 41, has been among New York's first responders since he started volunteering with a local ambulance corps at the age of 13. He is taking us for a ride-along through New York, tailing Megan and her partner responding to emergency call-outs, one after another. The calls are almost all COVID-related.
Since the lockdown in late March, New York's once-bustling streets are deserted. Now there's just the constant blaring of ambulance sirens.
Suddenly the ambulance lights flash, "They've got another job," says John, as we speed off after them through the empty streets. John's medical unit has seen daily call-out volume more than double in the past few weeks. Meanwhile, one-in-five of his co-workers have fallen ill with the virus. Queens, where his unit is based, has been especially hard hit by COVID-19.
On the west side of town, we arrive at the apartment of an elderly couple with suspected COVID-19 who need to be taken to hospital. Their daughter fears her trips to work and to do the shopping means she is responsible for infecting them.
"I guess it's me … I brought it home," she says. "It is difficult because sometimes when I think about it, I kind of blame myself."
The dread of that situation weighs heavily on the paramedics too. John hasn't seen his eight-year-old son, who has pre-existing medical conditions, in over three weeks. Despite not showing any COVID-19 symptoms, he's concerned he's a carrier due to his constant exposure to infected patients. "It's sad, this virus has no discrimination against anybody," he says. "It's attacking kids. Eighteen to 104 years old, it's getting them. It doesn't discriminate, it doesn't care. This is craziness out here."
Separation from their families has created an unusually strong bond among the frontline workers. Some speak of their colleagues as being family. Their common exposure to the virus means they feel less need to physically distance themselves around each other.
A gallows humour helps keep them sane. But after weeks of stress and exhaustion, the strains are beginning to show. John has seen colleagues starting to crack under the relentless pressure and he fears these days of trauma will catch up with many in the coming months and years.
"I've seen them, people I would normally speak to on a daily basis — big, strong, laughing, joking — now they've all got the thousand-mile stare," he says. "I can see they are upset. And they're frustrated because they are limited in what they can do for somebody."
This is the second time paramedics have visited this woman's home in Queens in recent weeks. She has been reluctant to go to the hospital, now it's too late. EMT Alex Nunez is on the phone to a doctor for medical advice, as his colleagues administer CPR. But she is not responding. This time, the patient is not going to make it.
We did everything we could to actually bring her back but we weren't able to," Alex Nunez says outside the apartment.
Alex has been a paramedic for 15 years across different areas of New York, including Queens, Brooklyn and the Bronx. Even with all his experience, it's not possible for Alex to say with certainty whether the woman died of COVID-19. Tests for the virus aren't typically carried out by paramedics.
The woman's family says she hasn't left home and there is no way she could have COVID-19. They suspect she died of an unrelated heart problem. But for Alex, her illness fits the pattern of COVID-19 deaths seen in recent weeks. The family also reveal she was not prone to seeking medical treatment prior to the coronavirus outbreak and was unlikely to go to the hospital, especially under the current circumstances.
It's a harrowing dilemma for many New Yorkers caring for infected loved ones at home: is their condition serious enough to risk going to an ICU overwhelmed with contagious patients?
Paramedics are urging many to ride it out in their homes rather than risk further exposure among the critically ill in hospital, where they could be made to wait hours in a hallway before they can be given a bed. "We try to educate them and explain to them the situation — if it doesn't need to go to that point and be around sick people," says Alex.
Some COVID-19 patients have been sent home from hospitals and their families told not to call back until they can't breathe and can't speak in full sentences. But for others, by the time they reach that point, it's already too late. Dr Michael Pappas, a young resident at a hospital in Manhattan, has seen another pressure deterring poorer Americans from getting entangled in the New York hospital system.
"The first concern of some coming into the hospital is not whether they have COVID, but how much it's going to cost," he says. "How is it going to affect my family financially?"
Dr Pappas is concerned the overloaded US healthcare system is forcing many patients to leave it too late to get treated, especially during the present pandemic. This illness, he says, "exposes all the fault lines throughout American society". As New York continues the fight against the coronavirus outbreak, Megan Pfeiffer fears these past weeks will haunt the first responders for years to come.
"I think it hasn't really hit," she says. "I'm sure once things settle down it's going to hit a lot harder."
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