After the first confirmed coronavirus case on U.S. soil, 800 miles to his north, the chief of a Northern California fire department gathered his executive team in mid-February to prepare for the inevitable landing of the virus in his community.

They planned to screen patients carefully and have their first responders gear up in gowns, masks and goggles if they believed one could be infected. Yet even though the outbreak was already spreading nationwide, Rocklin Fire Department Chief William Hack decided to hold off on putting the high-level response into action until the first case showed up in the county.

Fate worked against them, Hack said. On Feb. 27, firefighters in Rocklin, a suburb of Sacramento, responded to a call to help a person who had taken a tumble. The patient coughed on the firefighters; days later, that patient tested positive for coronavirus. Three of the responders had to be quarantined for 14 days.

In hindsight, Hack said, he realizes his department’s response came too late, but he believes that they had the operational measures and protective equipment in place. “You don’t want to jump the gun too soon because there’s a cost to it,” he said, both in equipment and creating panic. They had expected the virus to pop up first somewhere else in the state, he said. “Little did we know we’d be the first agency to have this happen to.”

As the coronavirus spreads in the United States, emergency medical providers are scrambling to keep up, with key direction on how to protect themselves lagging behind the unprecedented threat. (A recent report in The New York Times placed first responders high among workers who face the greatest coronavirus risk.) It’s yet another example of a fragmented and halting response at the highest levels of government, including getting testing off the ground and ensuring an adequate supply of resources.

It took nearly four weeks from the time the World Health Organization announced China’s novel coronavirus outbreak for the U.S. Centers for Disease Control and Prevention to issue guidance for first responders.

The CDC’s direction came more than two weeks after it confirmed the first known U.S. case on Jan. 20 in Washington state. It came nine days after a first responder from Kirkland, a suburb of Seattle, was exposed to the virus on Jan. 29 while responding to a call at the Life Care Center of Kirkland, a nursing home that became an early epicenter of the virus’s American spread.

Emergency providers are prepared, by nature of their profession, to jump into action when a crisis strikes. A car crashes, a tornado touches down, and they mobilize. At the local and national level, they approached the rapidly spreading coronavirus in a similar way.

Leslee Stein-Spencer is a program adviser at the National Association of State EMS Officials, a liaison between state and federal emergency authorities and other partners. One of the group’s roles is to prepare for the coronavirus by holding conference calls between state agencies and the National Highway Traffic Safety Administration’s Office of Emergency Medical Services, whose mission is to “reduce death and disability by providing leadership and coordination to the EMS community.”

Those conference calls didn’t begin until March 5, after the outbreak had been spreading in the U.S. for more than six weeks. A NHTSA official declined to comment.

“We weren’t aware of the impact that this was having,” Stein-Spencer said of the earlier days. “You don’t want to cry wolf if there isn’t really anything.”

Stein-Spencer said she believes front-line providers are prepared in the immediate term.

Those on the front lines are not so sure. “There doesn’t seem to have been a strong coherent response or assessment of risk from the top down,” said Haydon Pitchford, an emergency medical technician in central Virginia who is desperately searching for the N95 masks, which protects the face from airborne particles and liquid.

On Saturday, he’s scheduled to pull a shift at an agency that has about 20 of the masks and about 100 more that are old and expired. They’ll run out quickly if they get many calls for suspected coronavirus. Pitchford tried ordering them. He scrounged around at the local hospital, where people donate expired medical equipment. He even called his congressional representatives. No masks could be found.

ProPublica reporters have spoken to more than two dozen EMTs, firefighters and paramedics across the country. The conversations raised a variety of concerns, including a looming shortage of protective gear and staff, confusion around infection control practices and poor communication from dispatchers.

Some emergency responders feel ready but others do not. None are certain they have the staffing and supplies to perform as well as they may need to in the coming months.

Pitchford, who works part time at multiple agencies, said he’s grateful for the leadership of his supervisors, but he acknowledged they are frustrated, too. If he and his colleagues don’t have the equipment they need, he said, they could become sick. Or, they could become carriers, spreading the virus to the weak and vulnerable people they care for in their community.

“It feels like I’m watching a train wreck in slow motion,” Pitchford said, “and I’m about to be thrown in front of it.”

As Resources Vary, So Does the Quality of Response

There are about 20,000 emergency medical service agencies in the country, with oversight that looks different in each state and assets that fluctuate wildly. About a third of the states depend on volunteer organizations. The system is staffed thin and designed to share people and resources regionally during major disasters. But now these agencies are facing a sweeping global pandemic that could infect patients in every jurisdiction.

“We’re under-resourced from a staffing perspective when the sun is shining, much less when the sky is gray,” said Tim Frazier, faculty director of Georgetown University’s disaster management program.

The fragmentation leads to varying levels of sophistication when it comes to services and quality. Residents of well-resourced communities may benefit from a more prepared, better-staffed response.

In San Francisco, for instance, there are specialized field nurses designated to respond strictly to potential coronavirus cases. EMTs drive the nurses to test such patients, but they don’t lead the testing effort of the patient, said Sasha Cuttler, one of the six nurses on the San Francisco team. If there is an emergency, the EMTs can shuttle the patient to a nearby hospital.

Elsewhere, resources are so scarce that managers have to gamble on how much precaution they should take from call to call. Nathan Boone, a South Howell County ambulance field supervisor in West Plains, Missouri, says if he sends his staff out wearing protective gear every time, they risk running out of gowns and masks and other equipment. That could get worse if the virus continues to spread. But not wearing masks in some cases could mean exposing and temporarily losing his staff.

“It’s almost like an impossible situation if you look at it,” he said.

Dennis Lawson, president of the Washington State Council of Firefighters, echoed concerns about the possible shortage of supplies if the crisis goes on for a long time.

“We don’t know how big this is going to get or how long it’s going to last,” he said.

There has been some confusion about the CDC guidance to prevent the spread of infection, as it relates to supplies. Nathan Smith, a national representative for the International Association of EMTs and Paramedics, said he and his colleagues have debated whether masks need to be discarded after each use. In light of the N95 mask shortage, he told ProPublica on Wednesday that his understanding of CDC guidance was that they can be reused.

“Actually, that respirator mask is good until the seal won’t seal or it starts falling apart, or it becomes obviously contaminated,” he said. “So once you wear it, you kind of should wear it for the rest of your tour and then throw it away, instead of putting a new one on every call.”

But the CDC guidelines are clear that first responders should not reuse masks and other equipment after transporting a potentially infected patient.

When a reporter read the guidelines back to him on Thursday, he corrected himself, later realizing he confused the guidelines with those he said were issued by a different federal agency.

“If they are recommending we get rid of them, we will recommend getting rid of them,” he said. “Hopefully we don’t run out of masks.”

Advanced Warning Is Crucial but Not Always Possible

First responders depend on dispatchers to ensure they’re not flying blind when they arrive at the site of an emergency. On Feb. 11, Evan Hurley, a firefighter in Kirkland, was responding to a call about a patient suffering back pain at the Life Care Center. He found out after about 15 minutes that the patient had symptoms of an ongoing infection. Hurley got exposed to coronavirus.

“We don’t always know when we’re talking to a patient whether or not they have these issues,” Hurley said. He doesn’t blame his dispatcher, but “in instances like that sometimes you find yourself after the fact wishing you’d known more,” he said.

Hurley did not test positive and doesn’t have any symptoms, unlike dozens of patients and staff members at the home; 22 people have died, according to public health officials. As of Wednesday, the number of Kirkland firefighters that had been quarantined or isolated is up to 40, including one positive test. The same thing happened to an additional 10 first responders from neighboring agencies who had to be quarantined or isolated.

Hurley said he is still frustrated — six weeks into the crisis — by the lack of testing for coronavirus for his fire department. Only 17 of the 105 members have been tested, he said.

“We are at the front line, the epicenter, and we can’t get tested,” he said. “It’s embarrassing and represents a danger to the public.”

In the age of the coronavirus, a dispatcher’s questions could mean the difference between identifying a case in advance or getting a first responder infected. But the dispatch screening guidelines are supposed to be based on the CDC’s guidance. In the initial weeks of the outbreak, the CDC had narrow recommendations for identifying a “person under investigation” for possible coronavirus. If a person, in the past 14 days, hadn’t traveled from China or been in contact with a patient with confirmed COVID-19, the disease caused by the novel coronavirus, the CDC said early on they should not be considered a risk.

In the past three weeks, dispatchers in Grand Rapids, Michigan, started screening callers for coronavirus symptoms, as well as whether they had traveled to countries considered at risk. The dispatchers relay the information to first responders, who decide whether they should treat the call as a potential coronavirus case. Jason Murphy, a paramedic who has been responding to calls in Grand Rapids, said he and others have chosen not to suit up if a patient didn’t have a travel history, even as recently as Tuesday, when the virus was spreading from person to person within the country.

If a dispatcher asks all the right questions, language barriers and misinformation can still create confusion, said James Wheaton, an emergency responder in New York. “It’s a garbage in, garbage out situation,” he said.

Even first responders who are confident they are prepared for the crisis say they’ve never seen anything like it.

“It’s going to be a test of the system, I can tell you that,” said Tim Hinchcliff, managing director of Burholme Emergency Medical Services in Pennsylvania. “Many of us feel prepared but we don’t know how widely this thing will go.”

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