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The rapidly escalating surge in COVID-19 infections across the U.S. has caused a shortage of nurses and other front-line staff in virus hot spots that can no longer keep up with the flood of unvaccinated patients and are losing workers to burnout and lucrative out-of-state temporary gigs.

Florida, Louisiana, Arkansas and Oregon all have more people hospitalized with COVID-19 than at any other point in the pandemic, and nursing staffs are badly strained.

In Florida, virus cases have filled so many hospital beds that ambulance services and fire departments are straining to respond to emergencies. Some patients wait inside ambulances for up to an hour before hospitals in St. Petersburg, Florida, can admit them — a process that usually takes about 15 minutes, Pinellas County Administrator Barry Burton said.

One person who suffered a heart attack was bounced from six hospitals before finding an emergency room in New Orleans that could take him in, said Joe Kanter, Louisiana’s chief public health officer.

“It’s a real dire situation,” Kanter said. “There’s just not enough qualified staff in the state right now to care for all these patients.”

Michelle Thomas, a registered nurse and a manager of the emergency department at a Tucson, Arizona, hospital, resigned three weeks ago after hitting a wall.

“There was never a time that we could just kind of take a breath,” Thomas said Tuesday. “I hit that point … I can’t do this anymore. I’m so just tapped out.”

She helped other nurses cope with being alone in rooms with dying patients and holding mobile phones so family members could say their final goodbyes.

“It’s like incredibly taxing and traumatizing,” said Thomas, who is unsure if she will ever return to nursing.

Miami’s Jackson Memorial Health System, Florida’s largest medical provider, has been losing nurses to staffing agencies, other hospitals and pandemic burnout, Executive Vice President Julie Staub said. The hospital’s CEO says nurses are being lured away to jobs in other states at double and triple the salary.

Staub said system hospitals have started paying retention bonuses to nurses who agree to stay for a set period. To cover shortages, nurses who agree to work extra are getting the typical time-and-a-half for overtime plus $500 per additional 12-hour shift. Even with that, the hospital sometimes still has to turn to agencies to fill openings.

“You are seeing folks chase the dollars,” Staub said. “If they have the flexibility to pick up and go somewhere else and live for a week, months, whatever and make more money, it is a very enticing thing to do. I think every health care system is facing that.”

Nearly 70% of Florida hospitals are expecting critical staffing shortages in the next week, according to the Florida Hospital Association.

In Oregon, Gov. Kate Brown announced Tuesday that state employees must be fully vaccinated by Oct. 18 or six weeks after a COVID-19 vaccine receives full federal approval, whichever is later. Her office planned to announce a statewide indoor mask requirement on Wednesday.

“Oregon is facing a spike in COVID-19 hospitalizations — consisting overwhelmingly of unvaccinated individuals — that is quickly exceeding the darkest days of our winter surge,” Brown said. “When our hospitals are full, there will be no room for additional patients needing care.”

Texas Gov. Greg Abbott on Monday directed state officials to use staffing agencies to find additional medical staff from beyond the state’s borders as the delta variant overwhelms its present staffing resources. He also has sent a letter to the Texas Hospital Association to request that hospitals postpone all elective medical procedures voluntarily.

Parts of Europe have so far avoided a similar hospital crisis, despite wide circulation of the delta variant, with help from vaccines.

The United Kingdom on Monday had more than 5,900 COVID-19 patients in hospitals, but the latest surge has not overwhelmed medical centers. As of Tuesday, the government said 75% of adults have been fully vaccinated.

The same was true in Italy, where the summer infections have not resulted in any spike in hospital admissions, intensive care admissions or deaths. About 3,200 people in the nation of 60 million were hospitalized Tuesday in regular wards or ICUs, according to Health Ministry figures.

Italian health authorities advising the government on the pandemic attribute the relatively contained hospital numbers to the nation’s inoculation campaign, which has fully vaccinated 64.5% of Italians 12 years of age or older.

The U.S. is averaging more than 116,000 new coronavirus infections a day along with about 50,000 hospitalizations, levels not experienced since the winter surge. Unlike other points in the pandemic, hospitals now have more non-COVID patients for everything from car accidents to surgeries that were postponed during the outbreak.

That has put even more burden on nurses who were already fatigued after dealing with constant death among patients and illnesses in their ranks.

“Anecdotally, I’m seeing more and more nurses say, ‘I’m leaving, I’ve had enough,'” said Gerard Brogan, director of nursing practice with National Nurses United, an umbrella organization of nurses unions across the U.S. “‘The risk to me and my family is just too much.'”

Hawaii is seeing more new daily virus cases than ever.

In a Honolulu hospital’s emergency department, patients have had to wait for beds for more than 24 hours on gurneys in a curtained-off section because there’s not enough staff to open more beds, nurse Patrick Switzer said.

“Somebody who’s been sitting in the emergency room for 30 hours is miserable,” he said.

He described being “in this constant state of anxiety, knowing that you don’t have the tools that you need to take care of your patients because we’re stretched so thin.”

COVID-19 hospitalizations have now surpassed the pandemic’s worst previous surge in Florida, with no signs of letting up, setting a record of 13,600 on Monday, according to the Department of Health and Human Services. More than 2,800 required intensive care. At the height of last year’s summer surge, there were more than 10,170 COVID-19 hospitalizations.

At Westside Regional Medical Center in Plantation, Fla., the number of COVID-19 patients has doubled each week for the past month, wearing down the already short staff, said Penny Ceasar, who handles admissions there.

The hospital has converted overflow areas to accommodate the rise in admissions. Some staffers have fallen ill with COVID-19.

“It’s just hard. We’re just tired. I just want this thing over,” Ceasar said.