Tim Dupin thought — or at least hoped — that Missouri firefighters, paramedics and other emergency medical services personnel would be among the first to get vaccinated against the coronavirus.

After months of feeling overlooked by elected leaders in the distribution of safety equipment and other resources, surely, Dupin thought, their role on the front line of the medical system would be recognized. They had, throughout the pandemic, responded to calls the way they always had: Without regard to whom or what they would encounter at the scene, interacting with people who could have the coronavirus, despite often having makeshift personal protective equipment and masks that were old, faulty or moldy.

Dupin, a captain with the Kansas City Fire Department and president of the International Association of Fire Fighters Local 42, was dumbfounded when the recommended vaccine schedule was released and he saw firefighters would have to wait behind health care workers to get their shots. Despite lobbying Missouri's governor, and even after three members of the KCFD died of covid-19, firefighters were not included in the first phase of vaccine distribution.

Missouri, like many other states, had adapted guidelines from the Centers for Disease Control and Prevention, which put firefighters in the second phase. When the state moved into that round in mid-January, state officials encouraged firefighters to sign up. And now, most members of the KCFD have been offered the shots.

But firefighters in multiple states said the vaccine prioritizations and the pandemic overall exposed a startling misunderstanding of — or lack of concern for — their role in the medical system.

"They don't really understand what we went through and what we do," said Dupin.

Of the country's more than 29,705 fire departments, 45% provided basic life support services, while an additional 17% provided advanced life support services, according to a 2018 report from the National Fire Protection Association. Firefighters respond to car crashes, hazardous materials spills, mass trauma incidents, rescues and far more medical calls than fire calls. In 2018, fire departments received more than 36.7 million calls, according to the association's data. Less than 2 million were for fires, while more than 23.5 million were for medical aid.

"We are the tip of the spear," said Gary Ludwig, fire chief in Champaign, Illinois, and immediate past president of the International Association of Fire Chiefs. "We are health care providers on a truck."

Indeed, for the Kansas City Fire Department, 1,170 of its 1,284 members are licensed as either emergency medical technicians or paramedics, and are scheduled on a rotating basis to ride on fire vehicles or ambulances, said Chief Donna Lake. Firetrucks are dispatched with ambulances to all medical calls — and any responders called to the scene can provide medical care. That is common practice across the country, even in communities where ambulance services are not part of the fire department.

Not all states relegated firefighters behind health care workers like Missouri or per the CDC recommendations. In Massachusetts, for example, the state included firefighters, more than half of whom hold paramedic or EMT licenses, in the first-round distribution of the vaccines, ultimately allowing them to offer the shots within their own departments, according to Rich MacKinnon, president of the Professional Fire Fighters of Massachusetts. Firefighters are now working with the state to develop plans to help vaccinate other groups.

Still, since the pandemic began, many firefighters and first responders have felt as if they are an afterthought to government officials, said David Mellen, a firefighter and paramedic in Wyandotte County, Kansas, and chief medical officer for a volunteer fire department in neighboring Leavenworth County, who conducts training and podcasts about firefighting.

Mellen and other firefighters said they have been consistently let down by government officials who failed to deliver on critical protective equipment, forcing departments — career and volunteer — to bid against one another, hospitals, doctors' offices and other entities for items such as masks, gowns and gloves.

The limited number of vendors almost always focused on fulfilling larger hospital orders, Mellen said. Forced to turn to federal officials, then state leaders — all of whom, he said, had little to offer — firefighters were left with often unusable or impractical equipment.

"When I hear those sirens coming down the road, that brings me a level of comfort. I know that I have help coming," Mellen said. "They may not be there right away, but I know they're coming. If I heard those sirens turn and go the opposite direction? Well, that's exactly what happened."

The lack of support has fueled stress and anxiety in the ranks of first responders, who have also been dealing with widespread pay stagnation and a financial squeeze on departments throughout the country. And now they're seeing their colleagues felled by the coronavirus.

As of Feb. 19, 110 firefighters and 53 EMS workers nationwide have died of covid, according to the National Fallen Firefighters Foundation. It is not known how many contracted the virus on the job. Dupin said contact tracing showed that all three KCFD members who died contracted covid while working.

Some in the field expressed concern about what the future holds amid reports of fewer recruits nationwide the past several years and anecdotal evidence of increasing numbers of retirements and other departures. The concern is compounded by pandemic-driven shortfalls in local and state finances, and what that could mean for future funding.

"The back door is bigger than the front door," said Craig Haigh, fire chief and emergency management director for Hanover Park, Illinois, near Chicago.

Haigh said that while some departments, like his, have maintained attractive wage and benefit packages, firefighters have borne a lot of the strain the pandemic has put on the health system.

It has been exhausting, Haigh said. So much so that he, like others, has begun to think about walking away from the job he said he was "born to do."

Now, Haigh, 53, is reconsidering his future. "'I'll work until I'm 65' has changed to 'Maybe it's time for me to let someone else make these decisions,'" he said. "I'm not the only one who falls into that category of 'We're just worn out.'"