Hundreds of times a day, New York City paramedics demonstrate that theirs is the most dangerous and heartbreaking job in the pandemic’s ground zero.
The danger comes with the extreme opposite of social distancing, the paramedics racing with lights and sirens to the latest COVID-19-related cardiac arrest in a city where the official death count for confirmed cases stands at more than 3,000, but some 175 more a day go uncounted when they die at home.
The first five days of April saw some 1,000 die at home. Some had been sent home from the hospital; others had visited a doctor or a clinic; some had just toughed it out. Few had likely been tested and therefore went uncounted. Each was pronounced dead by paramedics who first sought to save them and in so doing risked the very same fate.
“With CPR, you’re getting up close and personal,” a Brooklyn paramedic told The Daily Beast.
Unlike emergency medical technicians, the paramedics are certified to perform invasive procedures, starting intravenous fluids in veins and running intraosseous lines directly into bone with a device that sounds like a dentist’s drill. They also intubate.
“That requires you to get pretty much face to face, inches from the patient’s face,” said the Brooklyn paramedic, who asked not to be identified.
Heartbreak comes with a new protocol set by the Regional Emergency Medical Services Council of New York City, a nonprofit organization that sets policies followed by the FDNY EMS and private ambulances. Paramedics in the pandemic are instructed to cease their life-saving efforts after 20 minutes if there is no pulse, and they no longer transport the person to the hospital in those cases.
Before the time of COVID-19—what some on the front lines are calling BC—paramedics often kept working on a cardiac arrest patient for 40 minutes or more, applying a fuller measure of their skills, technology, and medications. And they consulted over the phone with a doctor who pronounced the time of death when he deemed nothing more could be done to save the person.
The burden of making that call now falls on the paramedics themselves, in half the time. And they are instructed not to transport the person to the hospital when there is only the slightest chance of survival, what the Brooklyn paramedic calls “the Big If.”
“In calmer times, we would try to spend more time, expend more resources and efforts,” the Brooklyn paramedic said. “I’ve come across a number of patients I would have done more for.”
The most wrenching moment comes when the paramedics have to rise from beside the body and inform the family.
“You say, ‘I’m sorry, we did everything we could… and I’m sorry for your loss,’” the Brooklyn paramedic told The Daily Beast. “That’s tough. Especially when you have to do that four times a night.”
After each such outcome, paramedics radio a code: “83R.”
“Attempted resuscitation, but we pronounced and the body is on the scene,” the Brooklyn paramedic explained.
The calls where paramedics arrive to find the patient exhibiting such unmistakable signs of death as rigor mortis are “83D.” The “D” meaning dead on arrival.
For either an 83R or an 83D, the paramedics have to wait with the body—and often a grieving family—until either the NYPD or a medical examiner’s recovery team arrives.
The paramedics then go on to the next impending death and the next and the next with advanced life support equipment, including multiple ways to jolt the heart if it is at all possible. They even have a capnographic device that can detect carbon dioxide, indicating that the patient’s organs are still alive during chest compressions.
“We bring the hospital to them,” the Brooklyn paramedic said.
As one emergency medicine doctor noted this week, the actual hospital is a safer, more controlled environment than the home of someone who has just gone into cardiac arrest from a highly contagious virus.
“They go into houses,” the doctor said admiringly of the paramedics. “They’ve been doing the hard work on the front lines.”
This has become all the more true as various doctors have reported to The Daily Beast that hospitals are actively sending patients home when there is no immediate reason to believe that admitting them will change the outcome. The outcome then too often becomes another 20-minute near impossibility for paramedics trained to fight for at least 40. The Brooklyn paramedic and his partner had one cardiac arrest call for a 65-year-old man who had been to the hospital the day before.
“They sent him home because he wasn't sick enough.” the Brooklyn paramedic said. “From what I’ve seen, and from what I’ve experienced, people are much sicker than they know. They think they’re OK and they're not. People will be talking to their family and all of a sudden they will just drop.”
In another case, a patient's husband had been speaking to her when she took a sudden, fatal turn.
”It’s definitely not a normal thing to go from talking to unconscious to dead within a few minutes,” the Brooklyn paramedic said. “People will be talking to their family and all of a sudden they will just drop… They seem fine and then they're gone.”
The Brooklyn paramedic added, “From a medical perspective it’s really interesting, and really scary.”
He and his partner were able to get a pulse going in a man this week.
“That’s one out of, I don’t know, a lot,” the Brooklyn paramedic said.
They soon had the person at a hospital, though even if he survived, the chances of fully recovering from a cardiac arrest are slim.
“But you got to keep the faith,” the Brooklyn paramedic said.
And amidst all the cardiac arrests they do get some cases where the patient is still closer to alive than dead. The Brooklyn paramedic has noted firsthand that patients can remain reasonably alert and and apparently only in mild distress at oxygen levels that cause an altered mental state with other diseases
“Numbers that in another situation would be very scary,” he said. “It’s very strange. It’s especially unsettling because we don’t know why.”
He cited an old maxim.
“Treat the patient, not the numbers; how does the patient look?”
But a patient who looks remarkably well with terrible numbers can quickly change, proving the truth of another maxim.
“Shitty is a medical term,” the Brooklyn paramedic cited. “If they look shitty, pay attention.”
He added, “It’s a whole new ballgame. It’s a really tough call. There’s a lot of gray areas in the practice of medicine. This just threw in a whole bunch of tie dye. It’s pretty wild.”
That included a man the Brooklyn paramedic and his partner intubated and rushed to the hospital. They normally would have been welcomed by a “crash team” who would have immediately taken over. They were now met only by a lone doctor who had nowhere to put the patient. They waited for a half-hour, an eternity in a medical emergency.
“The hospital didn't have a ventilator,” the Brooklyn paramedic recalled. “The only reason he got one was someone had just died upstairs, and one got freed up.”
The Brooklyn paramedic's partner was a combat medic in Afghanistan and Iraq. The partner’s responses as the Brooklyn paramedic rode with him made clear that calling New York in the pandemic a war zone is an understatement.
“The looks that we exchange and conversations we have,” the Brooklyn paramedic said. “He is sometimes also at a loss for words. He thinks this is completely unprecedented also. And this is a guy who's seen active combat in war zones.”
What the Brooklyn paramedic and his partner witness at the hospitals makes clear why the medical staff are sending people home.
“Rows and rows of people on ventilators and people stacked, rammed in space meant for way fewer people,” the Brooklyn paramedic said.
And those images combine with the images of the people who die at home.
“It’s like something out of a horror movie,” the Brooklyn paramedic said. “One of those doomsday pandemics.”
The nightmare takes an added twist when there are no paramedics immediately available, as happened with a cardiac arrest in Brooklyn on Tuesday, a day when 230 people died at home from presumed COVID-19. The nearest free paramedics were in Manhattan and the dispatcher was going to send only EMTs, who can do little more than administer CPR and cannot intubate or perform other invasive procedures.
“Which is unheard of,” the Brooklyn paramedic noted.
The Brooklyn paramedic and his partner were finishing up at a hospital and dashed to the address as soon as they were done. The EMTs had been administering CPR to a stricken woman for 12 minutes. The Brooklyn paramedic and his partner began running lines and intubated her. They kept up the resuscitation effort for another 10 minutes.
Their efforts did not generate a pulse and the paramedics called the time of yet another death. After working through Tuesday night into Wednesday morning, the Brooklyn paramedic and his partner ended their tour. They had handled three cardiac arrests.They have had as many as five on a 16-hour tour.
Just as he was finishing up, the Brooklyn paramedic heard a flurry of new cardiac arrests come over the radio.
“Everybody started waking up, finding out their family member had passed overnight,” he explained.