The man in his 60s could no longer breathe on his own, so the doctor, respiratory therapist and nurses worked together, snaking an oxygen tube into his windpipe. That day in late July marked the first time they had intubated a covid-19 patient in weeks.

As they did so, the medical professionals exchanged silent looks: They knew what they were seeing was the beginning of a third surge of coronavirus patients in the Washington region.

“It was surreal,” said Kanak Patel, the director of critical care medicine at Luminis Health Doctors Community Medical Center in Lanham, Md. “We all knew: Here we go again.”

Nearly two months later, the surge continues, driven by the highly transmissible delta variant and affecting mostly unvaccinated people, including the man that staff at Doctors intubated that day.

Health-care workers say in some ways, this phase has been the hardest yet.

Earlier this summer, it looked like the widespread availability of vaccines might mean the coronavirus pandemic was behind them. Now, those on health-care’s front lines share a hardening view toward the delta variant’s biggest target: the willingly unprotected.

The workers are baffled over how, after so much pain and death, there is still even a debate over whether to get vaccinated or wear a mask in public. Their patience is wearing thin, they say. And as they toil in stifling plastic protective gear, or glance down the growing lists of new patients to contact, exhaustion has settled in. Many have quit, Patel said, or are thinking about it.

“Empathy fatigue,” he said, “is a real thing.”

There have been more than 23,000 deaths in D.C., Maryland and Virginia since the first was reported on March 14, 2020. Health-care workers are now in their 19th month on the front lines. Here are some of their stories.

The vaccinator

After months of putting coronavirus vaccine shots in arms, Tiana Satchell thought she had done her part to help end the pandemic.

Her time working at Six Flags America, Maryland’s largest vaccination site, had been the proudest of her nursing career.

“People wonder their whole lives whether they make a difference … now I feel like I have," Satchell told The Washington Post on July 10, the final day of operation at the theme park site in Prince George’s County.

Officials closed most of the state’s mass vaccination sites during the summer after realizing that waning demand meant they were no longer needed. But Satchell and the other Six Flags staff had focused on the positive during the closing days: More than 342,000 people vaccinated. It was the most of any site in Maryland.

When the final shot was administered, Satchell and the other nurses danced, cheered and snapped pictures.

“I thought we were good,” she said. “I was on cloud nine.”

A few weeks later, she was spending time with her daughter and infant granddaughter when she started seeing more news about the delta variant in the D.C. region.

She felt a sense of dread — and doubt.

Satchell, a contract nurse, had seen the pandemic from a few angles, including working in nursing homes filled with covid-19 patients during the first and second waves.

When she started working at Six Flags in April, she said she felt filled with purpose, especially when she was administering shots for children.

“I hope I can see my friends now,” she remembers them telling her. “I hope I can have a normal school year."

Satchell has been praying for those children recently, fearful their plans will be thwarted by the rising case numbers.

The group chats she has with fellow nurses, she said, have been blowing up lately with people frustrated by the rising case numbers asking the same question: “What is going on?”

The paramedic

Virginia Beach EMS Captain Randy Rudder has seen the toll the delta variant has taken on front line health workers. (Whitney Shefte/The Washington Post)

It’s always the stifling plastic protective gear that Pete Gonzalez dreads when his Virginia Beach paramedic unit goes out on a call.

Twice now, he has been convinced that he was going into cardiac arrest under all that equipment, his body suffocating in the summer heat beneath a respirator, plastic cap, plastic gown and gloves, while helping to treat a patient they believed had covid-19. Gonzalez, 53, has lost nearly 60 pounds since the pandemic started, most of it water weight from sweating beneath the plastic.

Like his colleagues, Gonzalez can feel his patience wearing thin as hospital transports related to the disease skyrocket, while the number of people getting vaccinated in the city feels stagnant. Nearly 40 percent of the city’s 450,000 residents have yet to receive even one vaccine dose.

In late July, an average of one covid patient per day was being hospitalized in Virginia Beach, according to the state Health Department. Now, that figure is up to almost 14 per day. Meanwhile, 911 calls from houses with covid patients tripled between June and July, and then went up nearly 400 percent in August to 204. Meanwhile, 17 rescue workers at Virginia Beach’s Department of Emergency Medical Services have been infected, presumably while working, the department said.

“It can drive you crazy,” Gonzalez said.

He has been a paramedic since 2001. The years of experience have taught him to keep those feelings to himself while out on a call.

Gonzalez reminds his younger colleagues — and himself — that it’s their duty to treat whomever they encounter without judgment, be it heroin addicts, drunk drivers or the unvaccinated.

“Everyone is making their choice to do something that’s not wise,” Gonzalez said he tells his colleagues. “We’ve done this, so don’t let it take the wind out of your sails.”

The contact tracers

The names of people to call are stacking up — hour after hour of conversations that need to be had to rein in what is now a full-blown coronavirus surge in Loudoun County, Va.

Lauren Owensby, a county case investigator working from her home, is back to putting in 55 to 60 hours a week after the early summer lull in cases that allowed her enough time off to travel with her family to Hawaii.

Now, she’s upstairs in her office into the evenings, offering a calm, reassuring voice to people who have recently tested positive for the coronavirus and are nervous and unsure about what to do next.

Ideally, those conversations would happen within 24 hours of the test result, so arrangements could be made for the person to isolate and so a contact tracer can alert those who were around them.

But many Washington-region health departments, such as Loudoun’s, cut back on their contact tracing staffs during the lull, thinking the slowdown would last. Now, Loudoun is averaging about 72 new cases per day, compared with one or two in early July, and the staff members who remain are at their limits.

“There aren’t enough hours in the day, to be honest,” Owensby said, during a recent break. “The overall feeling is disconcerting and overwhelming.”

Contact tracer Kandace Haney says people are mostly grateful to hear from her. She’s helped an anxious single mother find government aid to cover expenses while in quarantine and has patiently answered questions from children who may have been infected. Haney, who is legally blind, had difficulty finding work before the pandemic due to her condition — but contact tracing has been perfect for her.

Lately, there has been a rising drumbeat of worry in those conversations. Where Haney was just making a handful of calls per day in early July, she now talks to as many as 20 people every day.

The higher volume has made Haney feel more vulnerable, her world again diminishing. She went out often when cases were low, including a family trip to New York.

Now, she mostly stays home.

“For me, I feel that’s been the safest thing to do at this point,” she said. “I don’t want to get covid.”

The respiratory therapist

The past 18 months have been, by far, the most labor intensive of Gina Degreenia’s career.

After 12-hour shifts, most of which are spent on her feet, the respiratory therapist comes straight home, takes a shower and then crawls into bed.

Degreenia has been helping people breathe for 35 years; 27 of them at the University of Maryland Baltimore Washington Medical Center in Glen Burnie, Md.

Before the pandemic began, she said, few people in her social circle understood what a respiratory therapist did: “We were the unknown people of the hospital.”

That changed in the spring of 2020, when people struggling to breathe began arriving in droves at hospitals nationwide. Respiratory therapists, everyone realized, then would be integral to keeping people with severe covid-19 alive. Worried friends and acquaintances texted her checking in constantly. Meals, flowers and care packages were delivered to the hospital daily.

Staff feared the virus and all its unknowns, Degreenia said, but that support boosted morale.

“Anything you can think of, they brought,” said Degreenia, 57. “There is less of that now. … I think they are still appreciative. But I think they are tired, just like we are tired.”

The messages of support, too, have slowed, as life for many goes back to normal — even as disturbingly little changes in the hospital.

At the peak at the hospital last year, Degreenia was helping intubate as many as six or seven patients per shift. The number these days has crept up to about three, she said, and she worries it is only getting higher.

Her main feeling these days, she said, is of disbelief. She feels a deep sadness as she spends her days monitoring unvaccinated patients, checking their oxygen levels and blood gases, and, every two hours, turning their faces side to side to ensure there is no skin breakdown.

By the time patients reach her now, Degreenia said, it is too late to convince them to get vaccinated.

But outside of work, Degreenia said she has been trying to convince as many people as she can to get a shot.

“‘What about your loved ones?’” she asks them. “‘If not get vaccinated for yourself, get vaccinated for your loved ones.’ We were helpless then. Now, we can help ourselves.”

The nurse

They are back — the crying, anxious covid-19 patients who tug on Aliese Harrison’s sweaty plastic protective gown, pleading for her to not leave them alone with the disease that is devouring their bodies.

Each time, the veteran southwest Virginia critical care nurse gently assures them that she’ll return. And then she beats back another wave of emotional exhaustion.

Harrison has been a critical care nurse at Johnston Memorial Hospital in Abingdon, Va., since 1998.

Though she’s still committed to her patients — to the point of calling their families with updates during her off hours — the pandemic’s seeming endlessness has her wondering how much longer she can go.

“I don’t think that I’m burned out yet,” said Harrison, 51, now working extra shifts again after returning to 40 hours per week in the early summer when cases were low. “But if anything is going to do it, it’s going to be this past year.”

About half of Johnston Memorial’s tiny critical care ward of 14 beds is occupied by a covid-19 patient after the delta variant swept into the rural communities of southwest Virginia.

The Ballad Health system, which includes Johnston Memorial, has its most patients on ventilators than during any time of the pandemic, at 84 this month.

The burden recently forced the 21-hospital system that straddles the Virginia and Tennessee border to cancel elective surgeries, so resources could be used on the nearly 400 covid-19 patients occupying beds. Two of them are children.

One hospital, on the Tennessee side, is stretched so thin that 20 National Guard troops were deployed there to help, said Ballad spokeswoman Ashlea Ramey.

Harrison and her Johnston Memorial colleagues saw the storm coming in early June. Vaccinations had dramatically reduced infections in the area. But news of the delta variant’s march through India and other countries blared on hospital TVs.

“To see the way it was moving across the world, it was very similar to how the pandemic started,” Harrison recalled. “We were a little afraid and afraid for our families. And concerned that so many people were still getting together, not socially distancing.”

In some surrounding counties, barely a third of the population has been fully vaccinated, according to the state Health Department.

Harrison is frustrated by the attitude of invincibility that she sees in her quiet community.

“I think if people could see what we’re seeing and experience what we’re experiencing, all those minutes in the day,” Harrison said. “How people suffer. If we could explain it to them in a way that they would feel that. I feel like it would help.”

She thought of one covid patient, an unvaccinated man in his 40s she met when he already had an oxygen mask strapped tightly to his face, carving into his nose. She saw the panic in his eyes when she removed it to give him water, the struggle he had to breathe.

She stayed by him when he eventually worsened enough to need a ventilator — and again when he beat the odds and began breathing on his own. But he was far from well.

His image is part of the countless covid-19 memories she carries around with her, a collage of anxious faces and alarm bells that sometimes keeps her up at night.

“You can’t stop thinking about people,” she said.

The doctor

As he thinks about the dangers posed by this third wave, Patel, the ICU doctor, keeps coming back to a moment from the beginning.

It was the spring of 2020, and everyone was terrified. Vaccines weren’t available. But that didn’t stop a nurse, who had an infant at home, from spending hour after hour with a covid-19 patient, helping the man FaceTime with his family as he died.

The only time she left the patient’s room, Patel remembered, was to pump milk.

Watching the scene that day, Patel said he felt reassured the Prince George’s County hospital could make it through difficulties its staff members had never imagined.

Now, after 18 months of putting their own health at risk for patients, he said, staffers are still treating unvaccinated patients with the same care. But, he said, it is emotionally more difficult to care for people who could have gotten vaccinated but chose not to.

Staff in the ICU at Doctors saw some of the sickest patients in one of the hardest hit counties in the state. They know how to treat the pain and anxiety that come with the virus, he said. What they can’t do is take away the guilt from people who haven’t been vaccinated.

Sometimes it is a dying man telling his wife to get the shot, Patel said, and other times, it isn’t expressed aloud but is obvious in the eyes of the sickest patients.

What he worries about these days is that the connection between providers and their patients — the same connection that drove the nurse to keep returning to the dying patient’s room — is at risk.

“If that nurse or that provider who was that innovative and selfless gets disillusioned,” he said, “then we are really in trouble.”

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