The call came from Pearson International Airport. A patient arriving from China had a low-grade fever and cough. Mississauga paramedic Kerri Piquette nervously steered the ambulance that February day toward a remote but distinct possibility: This could be her first COVID-19 call.

Safety protocols for the coronavirus were in their infancy. Little was known about the routes of transmission, the incubation period or the virulence. The information void scared Piquette.

Just weeks later, she and her paramedic colleagues have become battlewise. Their knowledge of the virus and how to protect themselves has grown alongside the increasing number of COVID-19 calls.

Yet she’s more terrified than ever.

“None of us ever imagined when we started this job,” she said, “that we’d be facing the reality of dying because of it.”

Across Ontario, paramedics are making the first contact with many of the province’s coronavirus patients, a tally that’s reached 3,800. Some are working 16-hour shifts, backfilling for staff who are sick or in isolation. For many the surge has begun, each day busier than the last. Others work in an eerie calm, a lull they worry means a glut of calls await.

Interviews with more than a dozen paramedics from the GTA and throughout Ontario reveal a profession prepared but bracing for an onslaught. Typically light and social, the atmosphere at some stations has shifted to talk of little but the pandemic, Piquette said. Many used words like “meticulous” and “hypervigilant” to describe their approach to PPE, or personal protective equipment. Like so many health-care workers, some are fearful of shortages of masks and gloves.

The personal sacrifices are great. A Brampton paramedic said colleagues have borrowed trailers and begun camping out in their own driveways, afraid of being exposed through a patient and then infecting their families. Spouses have chosen to live apart, despite needing support more than ever. One paramedic worries about bringing the virus home to his three kids under age five, one a three-month-old infant.

The threat is real. As of Saturday, one paramedic in Toronto and one in the Niagara region had tested positive for the virus; in Waterloo, four paramedics have COVID-19.

“It makes me nervous,” said Carly Martin, who has worked as a paramedic in the Waterloo region for 17 years.

Martin and her co-worker recently picked up a 42-year-old man who was considered a probable COVID-19 case. They were told this ahead of time by the dispatcher, giving them time to prepare, and decided that Martin’s partner would go alone to reduce exposure. But there was no escaping the anxiety for either of them — or the patient.

“The poor man, he looked terrified,” said Martin. “He looked so scared.”

Some paramedics face high-stakes decisions inside a tight five-by-five-foot cube, determining if patients at risk of respiratory failure require aerosol-generating medical procedures such as intubation. These interventions heighten the risk of exposure to a virus for any health-care provider, let alone one in a confined space.

“A lot of people just see the ambulance as a ride to the hospital. There’s nothing further from the truth,” said Darryl Wilton, who has been a paramedic for 24 years and is the president of the Ontario Paramedic Association.

“It is a mobile emergency department on wheels, and we have had patients who were ventilated and intubated who were suspected COVID positive who are now in intensive care units.”

On these high-pressure calls, Wilton and his colleagues have to trust their experience and remind themselves they have the required equipment and training.

“It all has to come together and you can’t make any mistakes,” he said. “There is no room for error with COVID.”

In Toronto, the pandemic was “happening in another place,” said Brian Annett, a Toronto advanced care paramedic. Until it was suddenly here.

“It just started ramping up and escalating quickly,” said Annett, president of the Toronto Paramedic Association.

On Saturday, the count of documented COVID-19 cases citywide hit a grim benchmark, surpassing 1,000.

“We are under extreme pressure and it’s just building,” he said.

Annett and his colleagues “scrambled” through anxious early days to arrange refresher training on personal protective equipment, though he notes paramedics are already highly trained in infection control. Knowledge gained during Toronto’s 2003 SARS outbreak, when Annett was a new paramedic, is being put to use now, including testing to ensure the fit of their N-95 masks.

He stressed that amid the surge in demand, those calling for help will get the right care at the right time.

“Paramedics perform well under extreme pressure,” he said.

Province-wide, emergency dispatchers are screening for COVID-19 risk on calls, asking standardized questions about the presence of a fever or cough or if the patient has been in contact with someone who has tested positive. When paramedics arrive, they ask more screening questions from a distance. If the answer to any of them is “yes,” they proceed as if the patient has the virus.

Crucial as they are, the added precautions clash with instinct, Halton region paramedic Vanessa Vis said Thursday night. That day, her day off, she’d been busy assembling a COVID-19 committee for regional paramedics. (“To be honest with you, I haven’t really stopped working for the last couple of weeks,” she said.)

Typically, her approach is, “Let’s go in there and let’s get the job done.” Now, they have to stand back and take time to properly screen.

“That’s not in our nature to do,” she said. “It’s in our nature to rush in there and help someone.”

The screening process can’t work perfectly every time, so it’s safest to assume COVID-19 is possible in every case. On a recent high-priority call in Toronto, Annett and his colleagues were summoned to help an elderly patient who was “VSA” — vital signs absent. In those circumstances, the patient obviously can’t offer critical information, such as whether they are short of breath or have travelled recently.

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Days later, they were notified that the patient had been infected. Doubt inevitably crept in.

“You think back: Did I wear the mask properly? There is that element of second-guessing yourself and that creates stress.”

Asked if the patient survived, Annett paused before answering.

“No,” he said.

On some calls, a fatal outcome is clear from the outset, said one Ontario emergency call taker and dispatcher who was not authorized to speak on the record. A recent outbreak at a long-term-care facility has generated calls where COVID-19 positive patients are being taken out of a home they will never see again.

“We know when we take the call that those people are not going to survive.”

There’s a range of emotions in these cases, the call taker said, including compassion for the personal support workers on the other end of the line: “You can hear it in their voice. You can hear the despair.”

Some expressed frustration about a lack of understanding when it comes to the urgent need for social distancing. Paramedic Sean Sharp described a call a few weeks ago involving an elderly patient with a fever and new cough. She was with her niece, who’d recently come back from a trip to Italy — a risk both downplayed.

“Ma’am, Italy is the hotbed,” he recalled saying. “The public had denial about what was going on.”

Several paramedics said seeing people still refusing to stay home is demoralizing — “it sends the message to us front line workers that the public values their leisure more than our lives,” Piquette said.

Medics have also encountered problems with patients who aren’t forthcoming about symptoms, perhaps out of fear they won’t receive the same treatment.

Peterborough paramedic Jason Fraser, chair of CUPE’s Ambulance Committee of Ontario, said patients have withheld information that would place them in a COVID-19 positive category until after they are loaded into the back of an ambulance. The paramedics may not have taken all the necessary precautions at that point, he said.

“It’s very, very challenging for us and very, very stressful finding that after the fact. Anger sets in,” Fraser said, reiterating that patients will get quality care regardless of their level of sickness.

Peel paramedic Harkarn Sihota — who lives with his parents — has started wearing his mask on every call, saying the lack of full discretion from patients is one of the aspects that worries him most now: “It’s scary.”

But fears about shortages of protective equipment mean some are aiming to be judicious. When a call sounds minor, some teams are choosing to have just one paramedic suit up and take the lead, said advanced care paramedic Matthew Harris, who works in the Aurora and Newmarket area. That way, “we’ll limit our exposure and we’ll limit our PPE use, because we are really trying to make it last.”

All the while, other emergencies unrelated to the pandemic continue, but some people are afraid to go to the hospital — “we are worried they aren’t calling,” said Harris. On one recent call, he arrived at the home of a seriously ill patient who had lain on the floor for 90 minutes, avoiding calling an ambulance, before a physician family friend urged them to phone 911.

After loading the patient into the ambulance, Harris had to forgo his usual spiel to relatives about bringing a change of clothes and a cellphone charger; he had to tell the patient’s husband not to follow behind the ambulance. The hospital wasn’t going to let him in.

“We’ve never had to tell people, ‘Stay here,’” Harris said.

Two weeks ago, Peel region paramedic Sean Kaw was just starting his shift when he was called to a Salvation Army. It was his first possible COVID-19 call and, in this case, there was little doubt from the dispatcher: this man had tested positive for the virus.

“You can just imagine what that’s like. Heart rate goes up, hands get sweaty and a lot of things are going through your mind,” Kaw said. “I’m probably going to remember that call for a long time.”

Since then, COVID-19 calls have become routine. When he hears the details — the patient has a new cough, or a family member has tested positive — the reaction is no longer the same. He’s getting used to it.

“The scary thing is, as time goes on, I don’t get the visceral feeling anymore,” Kaw said.

For all the challenges they’re facing now, several paramedics said there’s been an outpouring of support from the community: thank yous from strangers while they’re out at work, people coming up to the ambulance to share their appreciation.

“We’ve had kids drop off artwork and thank you notes to some of our stations,” said Piquette. “Every act of kindness I’ve received helps to reassure me that I am supported working the front lines of this pandemic.”

There have been well-meaning comments too, from people asking whether there’s any way they can stay home. Harris said his neighbour recently asked if there was any way he could stop working and reduce his exposure.

“Now more than ever, why wouldn’t I want to go into work?” Harris said. “It might sound hokey, but I’ve got a duty here and I can’t tap out when I’m needed most.”