First responders in California’s Los Angeles County have been told not to bring patients to hospitals if their survival chances don’t meet certain criteria, as health-care workers try to dig out from a deluge of covid-19 patients forcing them to ration care.

Ambulances should not transport cardiac-arrest patients who do not resume spontaneous circulation on the scene, the medical director of the county’s Emergency Medical Services Agency instructed Monday in a memo.

“We are not abandoning resuscitation,” the director, Marianne Gausche-Hill, told CBS Los Angeles after an earlier version of the memo raised alarms. “… We are emphasizing the fact that transporting these patients arrested leads to very poor outcomes. We knew that already, and we just don’t want to impact our hospitals.”

The directive illustrates the dire straits that the county is in as about 21% of coronavirus tests come back positive, church gyms transform into field hospitals and ambulances wait hours to offload patients to emergency rooms. Hilda Solis, chair of the county’s Board of Supervisors, described the situation on Monday as “beyond our imagination.”

“Many hospitals have reached a point of crisis and are having to make very tough decisions about patient care,” Christina Ghaly, the county’s health services director, said at a news conference.

She warned that the worst is still to come, with the current surge in patients representing infections that stemmed from Thanksgiving travel. Health officials do not believe they are seeing the cases that resulted from Christmas and New Year’s gatherings yet, Ghaly said.