Emergency Medical Services officers in New York told Business Insider that their mental health is at risk as the city's coronavirus outbreak leads to record-setting 911 call volumes.

EMS workers with the FDNY are seeing an unprecedented number of cardiac arrests and struggling with feelings of hopelessness as they attempt to save patients.

Union leaders say the "war zone" is causing people to lose sleep, start drinking, become depressed, and even contemplate suicide.

Psychiatrists and psychologists say emergency medical technicians and paramedics are at risk of developing post-traumatic stress disorder because of the pandemic.

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A handful of emergency calls from the coronavirus pandemic keep playing in Anthony Almojera's mind like montages in a film.

Almojera, a lieutenant with the New York City Fire Department's Emergency Medical Services, has been a paramedic for 17 years. Earlier this month, he said, he arrived at a New York apartment to find a woman in her 50s administering CPR to her elderly mother. The mother was in her 70s and had been sick all week with telltale symptoms of COVID-19. She collapsed because she couldn't breathe.

As emergency medical technicians tried to resuscitate her, Almojera asked the daughter if anyone else in the house was sick.

"You guys came on Thursday and did the same thing to my dad that you're now doing to my mom," she told him.

"I said, 'Your dad passed away on Thursday, and now it's Sunday, and your mom is lying on the floor?'" Almojera said.

He rushed back to his team. "Please tell me you have a pulse," he said. But the look in his fellow paramedic's eyes conveyed the truth: The woman had died.

A patient is helped into an ambulance by EMT workers in the Bronx, New York, on April 16. David Dee Delgado/Getty Images

New York's first responders are confronting these in-home tragedies daily in what Michael Greco, the vice president of the FDNY's Local 2507 union in Queens, calls a "war zone."

New York City has been hit harder by the coronavirus than any other city in the world: More than 14,600 people there have died, and a new death is recorded about every three minutes, per city data.

Based on the accounts of at least eight EMS officers who spoke with Business Insider, the incessant pressure, unprecedented levels of stress and uncertainty, and constant exposure to death is severely jeopardizing responders' mental health.

"We're seeing more dead bodies than we've ever had to," Greco said. "Not only is the workload high, but the effects of this are going to last well beyond the emergency. There's going to be a psychological toll on EMTs and paramedics that we're not going to be able to understand for a long time."

Almojera, who's the vice president of the FDNY's Local 3621 union in Brooklyn, put it more bluntly.

"Nobody's getting out unscathed," he told Business Insider.

'An enemy that's going around randomly killing people'

A healthcare worker sits on a bench near Central Park in Manhattan, New York, on March 30. Jeenah Moon/Reuters

New York's EMS units have been facing between 5,000 and 7,000 911 calls and upwards of 300 cardiac arrests every day. The average daily call volume, by contrast, hovers around 4,000, with about 50 to 70 cardiac arrests. First responders are now working 16-hour shifts for four and five days on end.

But the challenge isn't the volume alone, Almojera said.

"We can rationalize the everyday 911 operations that we see in EMS: Someone was selling drugs and got shot, or Grandma was in her 80s and had a heart attack," he said. "We try and compartmentalize things to cope. With this pandemic, we're not able to do that."

Now, he said, he can't shake the grief when he gets home. He struggles to decompress and has a hard time falling asleep.

"It's the same killer," Almojera said. "I'm fighting this war against an enemy that's going around randomly killing people, and it makes me feel hopeless. How do I shake that?"

A paramedic transports a patient into the Trauma Center at the Elmhurst Hospital Center in Queens, New York, on March 29. Mary Altaffer/AP Photo

Working on the front lines of the coronavirus response in New York puts EMS providers at risk of acute stress during and after the crisis, Dr. Charles Marmar, the chair of the department of psychiatry and director of the PTSD research program at New York University, told Business Insider. The condition is generally marked by insomnia, exhaustion, loss of appetite, and mild depressive symptoms.

"Just like people get sick if they're overexposed to this virus, people also become psychologically ill if they're overexposed to the kinds of stressors" that paramedics see on the job, Marmar said.

Post-traumatic stress disorder, meanwhile, more often surfaces months or years after a sudden, violent event. That is a very real threat too, Laurie Nadel, a psychotherapist and author, told Business Insider. But she said it's difficult to anticipate the lasting psychological effects that New York's emergency workers face because the pandemic isn't comparable to any other well-studied traumatic experiences.

"We have never experienced living through a global pandemic, which potentially threatens every human being on the planet," Nadel said.

'Overwhelming guilt'

Earlier this month, Almojera said, he responded to a call about a man in his 30s with severe COVID-19 symptoms. The man had been working through the pandemic at a restaurant that remained open for takeout and delivery — it's considered an essential business. The man needed the income to take care of his 7-year-old child, the man's mother told the emergency responders.

With CPR, intubation, and other treatment, the man regained a pulse — an anomaly, Almojera said — and was then rushed to a hospital.

"He's young, we got here quick, we might be able to save him — this is the one that's going to refill our reservoir of hope," Almojera thought to himself while in the man's home. "We all saw his daughter on the way out, and I thought to myself, 'We've lost so many other people. Well, this one gets to keep her dad.'"

But the man flatlined at the hospital. "She doesn't have a dad anymore," he said.

People wearing protective masks wait to be allowed into a grocery store in New York City on April 16. John Lamparski/Getty Images

Dr. Shauna Springer, a licensed psychologist and trauma-recovery expert at the Stella Center in Illinois, said some emergency personnel were suffering from "overwhelming guilt at times because of those they can't save."

"They tell me that they carry a heavy burden of responsibility when they lose a patient," she said, adding that every life lost "can feel like a moral injury."

That is especially challenging for first responders right now because their triage abilities in the field are abnormally limited. In response to the surge in New York's coronavirus cases in late March, protocols were adjusted to enable paramedics and EMTs, who were stretched to their limits, to help more people. This was also necessary because about 20% to 25% of the EMS workforce was out sick.

FDNY officials instructed ambulance workers not to "initiate resuscitation" if a patient "meets criteria for obvious death," the New York Post reported. EMS providers were told to spend 20 minutes trying to revive patients but to stop after that if there's no response.

"After 20 minutes, we have to tell them, 'Sorry, there's nothing else I can do,' when we know that there's more that can be done at the hospital," Oren Barzilay, the president of the Local 2507, told Business Insider. "What a traumatic event for people, and they're not doing it just one time a day — now they're doing it five, six times in a shift. PTSD is going to settle in very soon."

Before the pandemic, medics could also call a doctor if people with serious illnesses were refusing to be taken to a hospital.

"That way, the refusal of medical assistance is not on me as the provider — it's on the doctor," Greco said. But he added, "The system is so overwhelmed that I know I just pronounced somebody [dead] after 20 minutes, I know I could've called the doctor, but in today's world, I can't."

Emergency workers are at greater risk of depression

In his capacity as a union leader, Almojera is fielding calls from other EMS members whose work is already taking a mental toll, he said.

"I'm getting messages from people who can't sleep at night, who can't function," he said. "They're worried. They're separated from their families in some way. They're starting to drink, or they're starting to drink too much."

A member of the National Guard helps a motorist arriving at a COVID-19 testing center in the parking lot of the Aqueduct Racetrack in Queens on April 16. John Nacion/NurPhoto via Getty Images

A May 2018 report from the Substance Abuse and Mental Health Services Administration cited a study finding that nearly 7% of EMS workers had depression. Following disasters, however, clinical-depression diagnoses among first responders tend to spike. After the East Japan earthquake in 2011, for example, more than 21% of frontline medical workers were diagnosed with depression, the report said.

"It is estimated that 30 percent of first responders develop behavioral health conditions including, but not limited to, depression and posttraumatic stress disorder (PTSD), as compared with 20 percent in the general population," the report said.

Firefighters and EMS workers contemplate suicide at a rate 10 times as high as that of American adults, a 2015 survey of more than 4,000 active professionals across all 50 states found.

Greco said EMS members had told him they go home crying every night.

"It's a human emotion to feel sadness and empathy," he said. What worries him is what it will mean when their tears dry up.

"If your psychological state is so bad that you become numb to the fact that you're seeing death and destruction, that is a bad place to be mentally," Greco added.

An overstretched healthcare system

Two weeks ago, Almojera said, ambulance workers out of his station in the Sunset Park neighborhood of Brooklyn were called to the home of a person complaining of chest pains. The patient's blood pressure was elevated. But when the medics tried to take him to a hospital, the man turned them down.

"He told them, 'No, I'm not going anywhere, because I'm going to die in the hospital,'" Almojera said.

The crew was unsure whether he had COVID-19 or a different ailment. But the man's choice highlighted a new development: Some New Yorkers are avoiding hospitals, likely because of a lack of faith that they'll get high-quality treatment at overrun facilities, and out of fear of catching the virus in a hospital setting.

Elmhurst Hospital Center's vigil for patients and colleagues who have died of the coronavirus. John Nacion/NurPhoto via Getty Images

Plus, healthcare resources are stretched so thin — New York has faced a shortage of ventilators and hospital beds, a lack of diagnostic testing, and a rising number of doctors and nurses who've gotten the virus themselves — that people with mild symptoms have been asked to ride out the illness at home.

"About four or five hours later, the same crew gets a 911 call from the same house, and they're thinking, 'Oh, it's this guy again. He probably wants to go to the hospital now,'" Almojera said. "Instead, he was dead when they got there."

Almojera said he thinks the man could "still be alive if he went to the hospital."

The demands on the healthcare system have affected EMS workers' own health too. The FDNY previously did not provide "dedicated testing" to its workforce, Almojera said. But last week, the department rolled out testing services to those frontline workers who are showing symptoms.

But that has still left EMS providers perpetually afraid that they may have the virus and just not know it yet.

A person at the otherwise empty 2nd Avenue subway station on April 16. John Lamparski/Getty Images

Lt. Faisel Abed, a paramedic supervisor at Station 16 in Harlem, said he found it difficult to get tested even after he showed COVID-19 symptoms.

"I'm not trying to be rude or disrespectful ... but I'm on the front line," he told Business Insider. "I have to know if I have the coronavirus, because I'm going out there taking care of you and your family, and I'm going to bring this home to my family."

Abed, 62, who responded to the 9/11 terrorist attacks, was hospitalized with COVID-19 in late March. He's now back home but remains on supplemental oxygen, and he said the "fear factor" was making him reconsider whether or when to return to the EMS. "It's traumatizing," Abed said.

Social distancing means no consoling families of deceased patients

An intrinsic part of being first to the scene of a critical incident or casualty is interacting with and supporting the families of people who are sick or have died.

"EMTs and paramedics are very good at consoling a family member when their loved one dies, even down to a hug or talking to them for 20 minutes while we're waiting for the police to show up," Greco said. Such work, he added, helps them accept that they did right by each patient and their family.

But the need to maintain social distance has made that impossible.

Greco recalled a crew that recently responded to a call involving a couple who'd been married for over 50 years. The woman died, he said.

"We couldn't even console the husband," Greco said. "There's the psychological trauma. We're going to finish the day, we're going to do our jobs, but these are the things that linger."

FDNY members joining in a round of applause outside NYU Langone Health to show their gratitude to medical staff and essential workers who, like them, are working on the front lines of the coronavirus pandemic. Noam Galai/Getty Images

EMS workers are also increasingly facing personal loss and grief. The service lost one of its own on April 12.

Gregory Hodge, 59, spent 24 years as a first responder at two stations: first in Harlem, then in the Bronx. He was among the thousands of emergency personnel who rushed to ground zero when the World Trade Center collapsed. Most recently, Hodge worked as an EMS watch commander. But when Almojera first joined the EMS, Hodge was his partner.

Almojera described Hodge as "literally the nicest man on the planet," someone who never raised his voice at anyone "no matter how crazy the situation or scene was."

"This virus is real — we've known it's real, but we kept thinking, 'Oh, we can roll with it, we can manage,'" Almojera said. "But now one of us is dead."

If you are in crisis, please call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255), or contact the Crisis Text Line by texting TALK to 741741.