The Broken Front Line

Ava Kofman

April 13, 2021

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

It was 4:32 p.m. and Mike Diaz was almost halfway through another punishing 24-hour shift when the call came over the ambulance radio. Nine miles away, a man had lost consciousness. "We're en route from Palmdale Regional," Diaz told the dispatcher, pushing away the thought of grabbing some food, as he flicked on the lights and sirens and sped off into the suburban maze of the Antelope Valley. He had worked as an emergency medical technician here in the northernmost part of Los Angeles County for over a decade, but he still experienced the same thrum of adrenaline on urgent calls. Lately, however, on January afternoons like this one, his excitement was overpowered by a sense of futility and dread.

A few minutes after the dispatcher's call, Diaz backed the ambulance into the driveway of a single-story house with a white picket fence. He and his partner, Alexandra Sanchez, followed a paramedic from the fire department into a dim living room, where an old man was stretched out on a cot, grimacing in pain. As Diaz crouched to check the man's vitals, a middle-aged woman said that she had first noticed her father, who was 88, becoming less coherent around a week ago. The man was more confused than usual, and contractures had stiffened his thin legs into tent poles. Their primary care doctor wasn't picking up the phone. Still, the family held off on dialing 911 because they feared that sending him to the hospital would expose him to the coronavirus. Only now that his condition had worsened had they decided to make the call.

As the daughter spoke, Diaz uttered short affirmative phrases. At 31, he is brawny and compact, with a smooth face, alert eyes and spiky black hair that lends an extra inch to his height. He was used to the brutal rhythms of emergency medicine in the Antelope Valley. The bustling community of 450,000, an hour's drive north of Los Angeles, has only two hospitals and some of the county's poorest and sickest residents. Diaz was overworked and proud of it, driven by the intoxicating rush of saving lives. Even when the 911 system was under strain in the past, he could take for granted that there would be enough resources — supplies, space and staff — to tend to patients. What he lost in sleep and free time he'd always earned back in the satisfaction of helping people. In a job that paid low wages and demanded extreme sacrifice, he'd come to rely on that feeling.

Now he could no longer count on it. The recent explosion in coronavirus cases — an over 900% increase in LA County from November to January — had left the health care system on the verge of collapse. In this new climate of scarcity, the more people there were who needed help, the less EMTs could do to help them. Peering down at the pale old man before him, Diaz was gripped by doubts: Could he still call himself a caretaker when he couldn't properly care for his patients?

Ten minutes later, as he swung left into Antelope Valley Hospital, Diaz was dismayed to note the first signs of gridlock: Five ambulances were already parked in the bay. Diaz and Sanchez wheeled their patient toward the back entrance of the emergency department, where they joined a phalanx of other gurneys. A mother and her crying infant. A man whose legs had swollen up like the limbs of a balloon animal. A woman whose wrists were in restraints. She'd spat at the EMTs who'd brought her in and, because they couldn't find a mask, they'd placed a white napkin over her face. "It looks like it's one of those days," Diaz said.

In the alcove beyond the check-in desk, Sanchez and Diaz installed their gurney along a vacant stretch of beige hallway. Before the pandemic, an 88-year-old man in an altered state of consciousness would be attended to fairly quickly to rule out an infection, prior brain injury or stroke. Today, every bed in the ER was occupied, and Diaz and Sanchez had been relegated to the limbo known to EMTs as "the wall." The term refers to the uneasy period of waiting with a patient until a bed becomes available. Even in quieter times, it was common in the Antelope Valley to "hold the wall" a few times a week. But now crews were waiting to offload patients two or three times a day, and the waits kept getting longer. A few weeks earlier, Diaz had been on the wall at Palmdale Regional Medical Center for 14 hours straight. Around Christmas, Sanchez had dropped off a patient only to see the person still waiting for a bed on her next shift, 30 hours later. Someone had etched tick marks onto one of the hospital's corridors, like an imprisoned soldier counting his days in captivity.

Diaz noticed his patient was struggling with a pair of blue gloves. "I'll help you put those on if you want, sir," he said. "Just let me take your temperature." His gestures were attentive, precise.

The glass doors of the ER slid open and another EMT poked her head through to scan the crowd. "It's a party in here," she said, before returning outside to tend to a heavyset man who was shaking uncontrollably.

"Is your pain still a 10 out of 10?" Sanchez, who is 26, asked their patient. She has a radiant complexion and a serene bedside manner.

"I can't hear you," he said. Down the hall, a heart monitor pinged. The infant continued to wail.

"Your pain," she said, raising her voice above the din. When she leaned over him, her ink-black bangs hung above her mask. "Still a 10 out of 10? Is your pain still really bad?"

She couldn't tell if he was nodding in agreement or simply adjusting his head. Either way, there was nothing to do now but wait.

With its flashing lights and whooping siren, the ambulance has become a symbol of a catastrophe that has unfolded largely behind closed doors. At the start of the pandemic, Diaz hoped the elevated profile of EMTs — their "essential" role — might lead to improvements in the way that emergency medical services are run. But so far, nothing had changed. If anything, the situation had gotten worse.

In Los Angeles County, as in many parts of the U.S., for-profit companies operate the ambulance system. The contract for the north part of LA is held by American Medical Response, the largest ambulance company in the nation. Along with paramedics from the fire department, EMTs employed by American Medical Response handle all of the emergency medical calls in this "exclusive operating area," a roughly 1,500-square-mile dominion that includes the cities of Palmdale and Lancaster, a smattering of quarries and aerospace factories, and swaths of the Mojave desert.

Spending as little as possible is crucial for all parties involved. The government, which pays for the majority of ambulance trips in many parts of the country, wants to save money. And AMR, of course, makes more if it keeps costs down. Diaz is particularly attuned to this dynamic: He represents around 350 AMR employees as president of an EMT union's local.

Los Angeles County mandates that ambulances reach patients within 8 minutes and 59 seconds. To meet this deadline while maintaining profit margins, private companies deploy a thin fleet of ambulances, pay low wages (private-sector EMTs in California make 39% less than their public-sector counterparts) and strategically rearrange the vehicles in their command. AMR's software suggests that vehicles "post" near busier areas so they're more likely to encounter transport opportunities. On hectic days, dispatchers maneuver crews around like chess pieces.

"We're not unlike other parts of emergency health care — we're very lean," said Tom Wagner, president of AMR's western operations. "When dollars are tight," he said, citing low Medicare reimbursement rates, "decisions have to be made about where we station ambulances, how we station ambulances, and do we move them around more often?"

The wave of coronavirus cases that swept across the country late last year put even the most battle-hardened EMTs under unprecedented psychological strain. "All of the structural shortfalls of our industry were really borne by EMTs and paramedics who were at the patient's side, caring for them without the resources that they needed," said Aarron Reinert, who until recently served as the president of the American Ambulance Association, an industry trade group. Some companies, he said, lost money early in the pandemic when many people were reluctant to go to the hospital; other companies, faced with a surge in cases, ran out of masks, gloves, medications, syringes, vehicle parts. In late November, the association sent a letter to the U.S. Department of Health and Human Services, pleading for more government aid. "The 911 emergency medical system throughout the United States," it stated, "is at a breaking point."

A few days later, in Los Angeles, it broke.

The more critically sick patients dialed 911, the more intensive care unit beds filled up; soon, those ICU patients were overflowing into the emergency room and EMTs had to wait for hours to offload newer patients until others were discharged or died. With so many crews stuck on the wall and several dozen more in quarantine or sickened by the virus, there were fewer and fewer ambulances on the road to handle all the 911 calls, which led to dangerous delays in emergency response times. With each passing day, the situation deteriorated. Hospitals assembled disaster tents and installed mobile morgues. Eventually, dispatchers were making informal triage decisions about where to send the last available ambulance.

To combat this vicious cycle, EMTs like Diaz and Sanchez were forced to do things they'd never done before. They stayed awake for 48 hours at a stretch, piled on extra shifts to cover for sick colleagues, and brokered final goodbyes between patients and their loved ones. To free up ambulances to run other calls, they attended to groups of patients. Some patients on the wall had been passed between so many crews that their latest handlers scarcely knew what they'd come in for. All that mattered was ensuring that the person kept breathing.

High-flow oxygen, sent through the nose, is effectively the only stabilizing treatment that EMTs can administer to people infected with the coronavirus. COVID-19 patients can require 10 times the amount of oxygen of non-COVID-19 patients, and as demand soared, ambulances and hospitals ran through their supply. At the start of January, the county's emergency medical services agency instructed EMTs and paramedics to withhold oxygen from those whose blood oxygen saturation was above 90%. (Typical blood oxygen levels range between 96% and 100%; levels below 90% can be cause for concern.)

Some of Diaz's patients appeared to be suffocating, but so long as their blood oxygen saturation was above the threshold established by the county's much-needed rationing protocols, he had to deny them. People gasped and heaved and moaned. It made him feel like he was watching someone drown.

The rationing was even more upsetting for the patients themselves. They were shocked — rightfully so, Diaz thought — by what was happening. This is America, they told him. This is California. These expressions of disbelief, Diaz observed, were often followed by anger. One of his patients, desperate to see a nurse, called 911 from inside the hospital. Others called him names. He understood their frustration. He was frustrated, too. How could he convince someone whose lungs were filling with fluid that he actually wanted to help them when he was mostly just standing there?

As the sun set on Antelope Valley Hospital, more EMT crews arrived, joining Sanchez and Diaz on the wall. They exchanged mordant greetings.

"Fancy seeing you here!"

"Where have you been all day?"

"Welcome to zero space."

The line of gurneys had spilled beyond the doors of the ER, into the cooling night air. EMTs wrapped their patients in coarse white blankets. Nurses wheeled equipment out onto the pavement to take vitals. Diaz and his colleagues milled about.

As the union leader, Diaz was highly sought after by his fellow EMTs. He made his rounds with the easygoing self-assurance of a man who delights in fixing peoples' problems. One EMT flagged him down to say that he was worried about disciplinary action following a dispute about attendance. Diaz reassured him that the matter would be dropped. Another EMT said she was working overtime to pay her bills after calling out with COVID-19 at the start of January. Diaz told her he'd file a grievance and find out why she hadn't received sick pay. (AMR's policy is to compensate coronavirus-positive workers until they test negative.)

In the sea of crisp navy uniforms, Diaz spotted his buddy Gage Oldenburg, a 24-year-old EMT with a bristly blond mustache. They chatted about the frenetic pace of work. For most of January, there'd been more than 200 coronavirus deaths a day in Los Angeles, the equivalent of one death every seven minutes. No one — not their supervisors, not the fire department chief, not the doctors in the hospital — had ever seen anything like it. EMTs and paramedics already suffer disproportionately from post-traumatic stress disorder and suicidal ideation. What the effects of the pandemic will be on these first responders in the months to come remains to be seen. "This took an emotional toll that we will probably be seeing for years," said Cathy Chidester, the director of LA County's EMS Agency, which oversees the ambulance system.

Many EMTs are on duty in 24-hour shifts, but before the pandemic, there were plenty of opportunities at the station to nap, decompress or console one another about harrowing calls. On days off, Diaz, Oldenburg and other AMR friends camped on the beach together, watched Lakers games and grabbed mimosas in the early morning after work. Once the rise in hospitalizations put an end to all downtime, though, these bottlenecks at the hospital had become one of the few occasions where crews could process the unfolding disaster. "It used to be that people enjoyed their jobs, even though there were parts they didn't enjoy," Oldenburg said. "Now a lot of people just show up because they feel like they have no other option."

Diaz did his best each shift to keep morale up. He liked to remind his colleagues that they were "on the front lines of the front line." Yet even he'd found himself becoming inured to scenarios that would have been previously unthinkable. He no longer noticed when every patient in the emergency room was intubated. He was indifferent to the high-pitched ring of the alarms that signaled the end of the hospital's oxygen supply. Of course, some detachment was natural, even necessary, in a profession that routinely deals with the worst day in someone else's life. But it wasn't just that he was desensitized; sometimes he had trouble feeling anything at all.

Shortly after 7 p.m., while Sanchez watched their patient inside, Diaz bolted down a beef bowl from a local fast-food chain using the hood of an ambulance as a table. It was his first meal of the shift. He and Sanchez had been running calls — a cardiac arrest, a dirt bike accident, a COVID-19-positive woman with a blood clot in her leg — since 6 a.m. At one point, they'd had to drive through an hour of traffic to cover a station down in Santa Clarita because too many units there were tied up or out sick.

"This is a good day," Diaz said to Chris Canning, a jovial EMT who wore his hair pulled back into a small bun. Diaz was so accustomed to the chaos of the surge that an unscheduled break during a shift of nonstop calls now seemed like a luxury.

In his happiest moments, Diaz would tell himself, "I'll do 30 years and call it." He loved his job. He was good at it. His life as an EMT was more exciting, more significant and more satisfying than anything he had previously done. Why not keep at it for decades?

Some people enter emergency medicine because they've witnessed a paramedic saving the life of an uncle or mother. Or because a relative died before help arrived and the future medic wishes to prevent the same thing from happening to someone else. Others, teenagers just out of high school, drive ambulances before moving on to higher-paying jobs in medicine. An EMT certification is also a prerequisite for joining LA's highly selective fire department.

Diaz did not want to be a firefighter and he had not lost a family member through a catastrophic event. Rather, he had fallen in love. He was interested in a girl who was interested in another guy. The other guy was an EMT. Diaz didn't see why he couldn't do the same thing his rival did, "but better." At the time, Diaz was studying film at California State University, Northridge and working as a projectionist at a movie theater. Between classes and work, he attended a 12-week EMS course and flunked out. "My mind wasn't in the right place," he realized. "And then I was like, wait, why did I fail that?" At first his pride compelled him to try again, but he was soon transfixed by what he was learning about the human body's extraordinary ability to compensate for its injuries and illnesses. Though he eventually lost the girl, he gained a vocation, and, in 2009, at the age of 20, he joined American Medical Response.

The first year of work was so humbling and surprising that he started to tell people that every 18-year-old should spend a year in the front seat of an ambulance. He imagined a compulsory EMT service, like a military draft. It wasn't just that the world needed more EMTs, in his view. It was that he could think of no other job that put one's own life into such sobering perspective.

To be an EMT is to understand a truism that might otherwise seem abstract: Someone, somewhere is always suffering. Once he tuned in to the frequency of disaster, Diaz found that trivial frustrations no longer bothered him. Life's smaller pleasures became more fulfilling. Other people might have been disheartened by such unrelenting proximity to pain, but the knowledge that things could be worse filled Diaz, a relentless optimist, with a profound sense of calm.

As the years went by, however, Diaz noticed that he was working with fewer and fewer of the people he had started with. His colleagues around the station were always asking each other about their next move. Fire? Nursing? Law enforcement? He dreaded these questions, which implied that their current career was lacking. The low pay, long hours and high turnover rate only reinforced this impression. Even his friends who adored the EMT lifestyle, with its sense of purpose and foxhole camaraderie, usually ended up leaving after two or three years. Did it really have to be this way? Diaz wondered. Why couldn't working as an EMT be a sustainable career in itself?

In the summer of 2017, eight years into his tenure, Diaz ran for president of Local 77 of the International Association of EMTs and Paramedics. Wages were a consistent matter of concern. As one of the most senior employees in the area, Diaz's hourly wage is $17.89, while Sanchez, after four years at AMR, earns $15.88 an hour. No one got into EMS for the money, as the saying around the station went. Then again, the industry appeared lucrative for those higher up the food chain than Diaz: AMR is a subsidiary of the $4 billion Global Medical Response, which in turn is controlled by KKR, a $252 billion private equity behemoth. (AMR's Wagner emphasized that hourly rates are established through the collective bargaining agreement. "We are constantly looking at ways to be able to adjust compensation," he said, "because we're only successful if we have people that want do the job and be aboard our team.")

Diaz threw himself into the union cause. If burnout was built into the job, he wanted at the very least "to go down swinging." His response to the pandemic was to push himself even harder. He filled his days off with overtime shifts, filing grievances on behalf of members and recording livestreams on Facebook to address safety concerns. His phone rang throughout the night with colleagues seeking advice. He always picked up.

Everything was urgent. He was needed constantly. He could not stop to rest, to sleep, to eat. His girlfriend called him Zombie Michael. But he insisted he was fine. He was fine. Really.

Until he wasn't. One night in the middle of December, Diaz was walking down the hallway at Palmdale Regional Medical Center, when he noticed that oxygen tubes had been recently taped along the ceiling. The hospital had exhausted its portable tanks, and the new lines were rushing oxygen from exam rooms to the row of rasping patients on the wall.

It was strange, but as he stared at the taped tubes, the image of scarcity elated him. At that moment, he felt that the only hope for transformative change to the health care system would be if the absolute worst finally came to pass. He imagined what would happen if 30 more people with COVID-19 flooded through the door. If they quit rationing and just ran through the entire oxygen supply. If hundreds of people died that night.

Diaz began to clap, as though he were cheering on a basketball team. "Let's go," he said, raising his voice. "Let's do it! Let's break the system!" He was strolling down the hall now. "Let's bring more patients in," he said, clapping his hands more forcefully. "Let's put everyone on two more liters. Let's just break it."

His euphoria lasted for just a few seconds. People stared at him quizzically and then moved on. They were used to far greater disturbances than a round of applause.

"It's terrible to think about that," he later said. "It's like I was wishing the worst on people in that moment. But it was more in the realm of wanting things to get better. I hoped this would be the tipping point, because I don't ever want humanity to go through something like this ever again."

The fact that this crumbling system had endured, in spite of all its failures, seemed to him the cruelest fate. "I was telling everyone, ‘If we hobble out of this, I quit,'" he said. "And now, we're just hobbling out of this, which is infuriating."

No sooner had Diaz shut the metal door to Station 104 than he heard the familiar ring of a call dropping in over the radio — a two-toned descent, like a drawn-out doorbell. "Ugh," he sighed. "That sucks." He and Sanchez had just returned to the station after finally offloading their 88-year-old patient into a bed at Antelope Valley Hospital. It had taken over two hours, and the jolt of excitement he'd felt earlier that afternoon had long since dissipated.

"Man, this was our first time back in 14 hours," he said.

Diaz had recently switched to this station in Littlerock, a more rural part of the valley known for its fruit orchards and treacherous highway. He'd been working with a different partner at a busier AMR station in Palmdale when he realized he'd had as much as he could take. Clapping in the hallways at the hospital was one sign. Feeling like every problem was the patient's fault was another. He'd also begun to ask himself what he called "Maslow's hierarchy of needs type of questions." Questions, he said, like, "Will I have enough sleep to not negatively affect my home life? Can I eat? Can I use a restroom?" Though the Palmdale station was a five-minute drive from his house, his agitation signaled to him that it was time to relocate to what he'd hoped would be a less relentless outpost. So far, though, his new base had been just as hectic as the old one. The recycling bin overflowed with emptied energy drinks.

Sanchez, who had just slumped into one of the station's La-Z-Boys, rezipped her heavy black boots and trudged over to the receiver. "Can you repeat the precaution?" she asked the dispatcher.

Diaz wriggled into the jacket of his uniform and unfastened the Motorola beeper on his hip. "Possibly COVID?" he read from the green band of screen. "Another COVID-positive. Chest pain, 50-year-old man, elevated heart rate with difficulty breathing."

When Diaz and Sanchez arrived at the address at 8:10 p.m., the road was completely dark, except for the flashing lights on the fire trucks that had showed up moments before them. (Los Angeles County sends both the fire department and an AMR crew to each call.) The patient lived in a converted garage in one of the Valley's less developed neighborhoods, where the low-slung houses were surrounded by desolate stretches of high desert scrub. It was a crowded home, the kind that Diaz had noticed Latino immigrants often shared with several relatives, making social distancing impossible.

A few minutes later, Diaz and Sanchez slid a coughing man into the back of their ambulance as five family members huddled to wave goodbye. Diaz pressed his boot against the gas pedal and told the dispatcher that they were heading to Palmdale Regional.

What he didn't say was that he was hurtling toward an overcrowded emergency room with someone who, in his opinion, didn't need to go there. It's not that his patient wasn't sick: The coronavirus had left the man short of breath and, as Diaz drove, he could hear a succession of quick, dry coughs from a few feet behind him. Still, he didn't think the hospital would be able to do much. The patient was far from needing a ventilator, and with his blood oxygen saturation around 95%, he wasn't eligible for a nasal cannula under the current rationing orders. It was evident to Diaz that what this man needed was to stay put and rest. But by the time Diaz and Sanchez had entered the patient's home, the fire department paramedics were finishing up the paperwork to prepare him for transport.

The situation was exasperating. At the scene, the daughter had explained that her father had already gone to the hospital three times in the previous two days and they kept sending him home. Was it really a good idea to bring him back? Whenever possible, Diaz tried to warn patients that unless they were at imminent risk of death — and if he had time to issue this warning, they likely were not — the hospital might not treat them for hours, even days. Still, it wasn't up to him. EMTs typically handle transport, but the fire department holds the primary medical authority at each call. Again and again, Diaz had seen them abide by a "you call, we haul" mindset. (Dr. Clayton Kazan, the medical director for the LA County Fire Department, said he understands why EMTs and paramedics "are frustrated that they sometimes have to transport people who seem like they really don't need to go to the hospital." But the decision ultimately rests with patients, he noted, and "some of the people who EMTs think don't have to go to hospital really do end up needing to be there.")

The knobbly silhouettes of Joshua trees, lit up by the ambulance's headlights, scrolled by outside the windows. When they approached Palmdale, the arid landscape gave way to a warren of sand-colored strip malls. On rides like this, Diaz wondered, was he helping people feel better or just helping an inefficient system capitalize on people's fears? The majority of people who call 911 do so for non-life-threatening reasons. Nevertheless, EMTs and paramedics have two options at each scene: leave the patient where they are or take them to the ER — and companies can only charge patients when they do the latter. A recent study of the 911 system by the medical directors of the LAFD noted that this business model "creates a perverse incentive in low-acuity cases (and pandemics) to take all patients to a high-cost, inefficient site" — the hospital — "where one might have to wait hours to be seen and possibly even be exposed to others who are sicker."

What happened at the hospital was just what Diaz had expected, just as he had experienced it many times before. Because the patient did not meet the county's new criteria for active monitoring on the wall, Diaz plopped him into a wheelchair and rolled him into the COVID-19-positive section of the waiting room. A scrum of people in pajamas sat on the other side of a plastic curtain. It was the same outcome as if a family member had driven him there. Except for the cost.

Diaz had nine more hours to go, and he could already feel the stirrings of burnout returning: the irritation, the exhaustion, the apathy. But "burnout" didn't capture the extent of his distress. It was as if, Diaz said, he was shrouded by a fog. Or maybe it was the other way around, and the fog had lifted, revealing things as they really were. It reminded him of being at a crowded concert and trying to push past a tangle of bodies toward the exit, only to realize that there was no exit. There wasn't even a door.

A few days later, in early February, Diaz and Sanchez were lying in their sleeping bags in the station's makeshift bedroom area, where five mattresses were pushed up along the walls. Cases had started to decline, and that evening, there'd been a lull in calls. It was one of the first moments they'd had to talk about what had happened to them during the surge.

"I feel like where it really hit me — like, we're not going to get through this for a long time, no matter how much of an effort we put in — was that night in December when I had just come back from having COVID," Sanchez said. "Were you there that night?"

Diaz said he wasn't sure. That might have been a shift he'd swapped to get Christmas off.

"I was still partnered with Kirsten," Sanchez said. "I remember it was one of the first few shifts after I had come back because I was still needing an inhaler nonstop."

That night, she continued, most of the crews had gotten stuck on the wall at Antelope Valley Hospital. There were six or seven COVID-19 patients waiting outside and they all needed high-flow oxygen. Some of them had the lowest blood oxygen saturations she'd ever seen. On 15 liters of high-flow oxygen, her patient's saturation was only around 84% or 85%. They'd been tearing through the portable tanks every half hour or so, far more quickly than they could be replaced. At one point, she and a few other EMTs opened the metal doors of the storage unit outside the ambulance entrance to the ER and saw that only four tanks of oxygen remained. The charge nurse had already told them that whatever was in there was all that was left, but they knew there were still six patients — or maybe it was seven by now — who each needed a tank to keep breathing. She locked eyes with a colleague, snatched a container for her patient, and hurried away. (A hospital spokesperson said the facility did not run out of oxygen; Wagner acknowledged running low but said AMR is "unaware of any ambulance running out of oxygen.")

"We were literally watching patients on the verge of coding" — dying — "because there was nothing we could do," Sanchez said. Although she often thought about this night, she never knew how many of the patients survived. Like many EMTs, she hated to ask the nurses afterward. It was a self-protective measure: out of sight, out of mind.

By the time she picked up another patient, an elderly man, later that night, she'd gone and grabbed one last portable tank of oxygen from the ambulance station. The man's saturation was around 70%, and she could hear the rales in his breathing. It was a bubbling noise, like the sound of air blown through a straw in a glass of water. After the tank ran out, she tried to console him: "I'm sorry there's nothing I can do. You just have to wait a little longer." But he couldn't understand her. For three hours, he kept repeating the only word he knew in English: "Please."

"That was the point where I'm literally in the hallway just looking around," Sanchez went on. "And everywhere you looked it was a disaster. You have the line of patients out the door, still being checked in. And then you hear the frickin' alarms going off because the hospital is out of oxygen. And the nurses running around. I mean, they're always running around, but you could tell they're on a whole other level of overwhelmed."

"Yeah," Diaz nodded.

"It's crazy because you look at your patient and any other day this patient would be a priority, you know? But it's just that everyone else is in the same scenario. You couldn't even say, ‘Oh shit, I'm going to panic.' You just kind of—"

"—shut it out," Diaz interjected. "It was weird."

"Yeah, you're just watching it happen," Sanchez said, her voice quiet.

"It's almost existential," he said. "Like a disconnected, third-person experience."

Diaz shifted in his sleeping bag. "I remember there was this weird day in like mid-December where I went on this hysterical spree," he said, recalling the evening at Palmdale hospital when he'd briefly hoped for the worst. "I started thinking this was all funny, and that the whole system just needed to collapse. I'm almost mad that it's started tapering off. How can we go to this edge and it doesn't collapse? People are going to forget about it in a year, and we're going to be right back to the same place where our system still sucks."

Sanchez tried not to think about the future. Until now, she hadn't had the time to focus on anything other than the immediate needs of patients.

"Usually after you have a bad call, like one with a kid, you can cry if you need to and process those feelings," she said. "But I feel like I never addressed that part of it with these types of calls. I'm sure it's building up."

"It'll probably result in some PTSD later or something," Diaz said, laughing.

Sanchez smiled sardonically. "Yeah, but that's not today's issue."

"That's how it is, and that's very EMS, that way of thinking about things," he said. "Like, ‘Don't worry about something until you have to worry about it.' It's almost in our training: ‘Don't get too ahead of yourself, because doing that will not allow you to be in the moment to help other people.' So it's, like, ingrained in us to—"

As Diaz spoke, the pager on his hip began to vibrate. Then the loudspeaker chimed.

Another call.

They sat up, pulled on their boots, and walked back to their ambulance.

About this story:

Ava Kofman spent three weeks reporting in person with EMTs in Los Angeles for this article. She either witnessed the scenes described here or gathered the details, including participants' thoughts at the time, from interviews with those participants.

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