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How hospital staff cope with suffering and death

His chest rises and falls rhythmically as the machine pumps in oxygen and releases carbon dioxide with a hissing sound. 

The patient in Room 2106 is ventilated, intubated, sedated.

Julie Medeiros, a respiratory therapist, pauses at the glass doorway. “His family came to say goodbye this morning. He’s doing really poorly," she says. "He’ll probably pass today.”

Her words are a mix of melancholy and matter-of-factness. Medeiros has seen so much death, she knows the signs. They all do. 

A few hours later, the man in Room 2106 will become another data point among more than 530,000 Americans killed by the coronavirus

But in this moment at Providence Holy Cross Medical Center, he’s not a statistic. He’s a flesh-and-blood person in a losing fight for survival. 

He has a face, a name, a 52-year history full of childhood memories, achievements, loves, failures, family.

USA TODAY was granted rare access to the hospital's COVID-19 care units in February, allowed to shadow caregivers on the condition that patients would not be identified unless permission was granted. 

A few minutes earlier, just outside the hospital lobby, relatives of the patient in Room 2106 were hugging one another and crying beneath the foggy gloom of a Los Angeles morning. A young woman fell to her elbows and knees on the sidewalk, sobbing, “No. No. No.”

Later in the ICU, nurse Nina Ohakam dials the patient’s son. “Are you guys still here?” she asks. “I thought if you were you could pick up your father’s possessions.” She listens, then nods. “Well, your dad’s organs are not functioning.” 

Family members cannot understand why he is dying. He wasn’t that sick when they brought him in days ago. Did the hospital give him an infection? Why haven’t they cured the disease? 

As America’s medical workers struggle with the pandemic — death, suffering, fatigue, stress and fears of infection — helping families through denial, grief and anger has added to the trauma.

‘More deaths than anyone should ever have to see’: Life and death inside a COVID-19 ICU

Sandy Hooper and Jasper Colt, USA TODAY

On the phone, Ohakam explains that COVID-19 is a virus with no cure. “He has pneumonia and his lungs are filled,” she says. “It’s not as simple—” She is cut off, listening again, waiting.

The father couldn't breathe, so a tube was inserted into his trachea, pumping oxygen. That requires sedation, which means he also needed an intravenous line for fluids, a catheter to extract urine and dialysis to cleanse his blood. 

“Those things are keeping him alive,” Ohakam says softly. “I’m sorry this is happening. I can’t imagine being on the receiving end of this information. But it’s not because we weren’t doing something. We’ve done everything we—” 

She is interrupted. There is talk of transferring the father to another hospital. Ohakam shakes her head. 

“I understand why you feel that way, but it’s not about the infection per se,” Ohakam continues. “Yes, it starts out COVID, but it ends up multiple organ failure.”

A nurse wipes down a COVID-19 patient's hand on Tuesday, Feb. 9, 2021, at Providence Holy Cross Medical Center in Los Angeles.

A nurse wipes down a COVID-19 patient's hand on Tuesday, Feb. 9, 2021, at Providence Holy Cross Medical Center in Los Angeles.
Harrison Hill, USA TODAY

She tries to brook the delicate subject of comfort care: cutting back on medications, letting Dad go, maybe issuing a do-not-resuscitate directive. 

The patient — in a glass-enclosed, negative-pressure room — does not flinch, has no say. 

The son on the phone is unwilling, unable.

Ohakam says she understands. “I’m going to do my best for him. God bless you.”

She hangs up and turns to her colleagues, visibly shaken. “I feel for him. God forbid if that was my family member."

"The COVID: How do you treat it?" she wonders aloud. "I don’t know.” 

“I realize they’re looking for blame,” Ohakam says later. “This is not the time to say, ‘Don’t blame us,’ even though we know what we’ve been doing behind the scenes. … They’re hurting. They’re grieving.”

A sign over the nurses’ station offers a quote of the week: “The most powerful weapon against stress is our ability to choose one thought over another. Train your mind to see the good in this day.”

The hospital’s public address system blares: “Code Blue in 2117. Code Blue in 2117.” 

It’s the third time in a few hours a heart has stopped beating. With each alarm, medical staffers wearing masks, gloves, face shields and multi-colored PPE gowns congeal like white blood cells on a wound, trying to revive the patient. 

Kevin Deegan, a hospital chaplain making the rounds, shakes his head. “That bell that rings for Code Blue, it’s hard to get it out of our head at night. … I see the faces of staff members in tears.”

Deegan sits in the chapel moments later, a crucifix on the wall, a siren wailing outside. A journal on the podium is filled with entries from family members — scrawled prayers beseeching God for life and comfort.

Chaplain Kevin Deegan prays while inside the Providence Holy Cross Medical Center chapel on Friday, Feb. 12, 2021, in Los Angeles.
Chaplain Kevin Deegan prays while inside the Providence Holy Cross Medical Center chapel on Friday, Feb. 12, 2021, in Los Angeles. "We're beyond a point...
Chaplain Kevin Deegan prays while inside the Providence Holy Cross Medical Center chapel on Friday, Feb. 12, 2021, in Los Angeles. "We're beyond a point of feeling like this is crazy, and this is beyond unprecedented," he said about the COVID-19 pandemic. A year into the pandemic, "as we look ahead, we see a little bit of light at the end of the tunnel with the vaccine rolling out. But with these new strains, these new variants, it still feels like there's still a lot of dark days ahead."
Harrison Hill, USA TODAY

Part of the chaplain’s role is assisting loved ones with video calls when the end is near. His first Zoom session for a COVID-19 patient included about 30 family members scattered around the world. They took turns saying three words — “I love you” — to an unconscious woman. 

A nurse checked the patient’s vitals and shook her head. “We turned the iPad to ourselves and informed the family she’d just taken her last breath,” Deegan says. “That’s something I was not trained to do."

On average, Americans who die from coronavirus leave behind nine close family members. That means about 4.8 million parents, spouses, children, siblings and grandparents in the throes of grief.

Even as the pandemic has subsided from its peak, about 10,750 Americans die each week.

Los Angeles County, where Latinos account for nearly half the population, has been hit particularly hard, with more than 22,000 deaths. Hispanics die from coronavirus 2.3 times more frequently than White non-Hispanics, according to federal data.

SARS-CoV-2: invisible, indifferent, parasitic and mutating. 

The virus acts without malice, driven by a biological imperative. 

“COVID doesn’t ask or choose,” says Edgar Ramirez, a nurse leader at Providence Holy Cross. “It just does what it wants.”

Medical supplies are silhouetted against the blinds in a COVID-19 patient’s room at Providence Holy Cross Medical Center in Los Angeles.
Medical supplies are silhouetted against the blinds in a COVID-19 patient’s room at Providence Holy Cross Medical Center in Los Angeles.
Medical supplies are silhouetted against the blinds in a COVID-19 patient’s room at Providence Holy Cross Medical Center in Los Angeles.
HARRISON HILL, USA TODAY

Doctors, nurses and chaplains recognize when the end is near and try to deliver the prognosis compassionately. But no matter how it’s done, the conversation about comfort care can be emotionally volatile. 

Family members have been awaiting the call, yet holding out hope. Some think it would be a betrayal of the patient, or of God, to give up. Some insist on a natural death, though severely ill patients are kept alive by machines. One week in early February, a man coded and was revived eight times, Deegan says, each episode a trauma for staff.

The shock to relatives is magnified by pandemic quarantines. Unable to visit loved ones, families cannot see the disease's swift devastation and have trouble facing end-of-life decisions.

At Providence Holy Cross and thousands of other hospitals, the scenario plays out every day in video calls with loved ones who sometimes blame the caregivers.

Jacques Coupet, left, a dialysis registered nurse, looks at a patient receiving dialysis treatment while medical staff attends to a patient on Wednesday, Feb. 10, 2021, in the intensive care unit at Providence Holy Cross Medical Center in Los Angeles.
Jacques Coupet, left, a dialysis registered nurse, looks at a patient receiving dialysis treatment while medical staff attends to a patient on Wednesday, Feb. 10,...
Jacques Coupet, left, a dialysis registered nurse, looks at a patient receiving dialysis treatment while medical staff attends to a patient on Wednesday, Feb. 10, 2021, in the intensive care unit at Providence Holy Cross Medical Center in Los Angeles.
Harrison Hill, USA TODAY

David Kessler, coauthor of a seminal book on the stages of grief, says the process begins when families are told the patient will not survive. Denial and anger, often the first stages of bereavement, trigger a search for culprits: the people who are trying to save their relatives' lives.

As founder of Grief.com, Kessler delivers video seminars to medical workers and oversees online support sessions for more than 20,000 family members of pandemic victims.

Loved ones, especially those facing an unexpected death, want answers. And medical staffers may become “emotional punching bags.”

“It’s much easier to blame the doctor or nurse or emergency room instead of hearing, ‘We did our best.’” Kessler explains. “That’s not enough. … Psychologically, we’d rather feel guilty or angry than feel helpless.”

He, other experts and staffers at Providence Holy Cross emphasize that outrage and mistrust are organic reactions to loss — symptoms to be understood and assuaged, not criticized.

But those reactions weigh on health care workers already burdened by patient deaths, job burnout and a sense of helplessness. 

David Kessler, co-author of “On Grief and Grieving”
“They’re always second-guessing themselves, wondering if they could do more. Nurses and doctors are seeing multiple deaths in a day and they’re sitting with the anguish of the families. No one has been trained for this much death.”

“They’re always second-guessing themselves, wondering if they could do more,” Kessler says. “Nurses and doctors are seeing multiple deaths in a day and they’re sitting with the anguish of the families. No one has been trained for this much death.” 

Deborah Carr, chair of sociology at Boston University and a specialist in bereavement, makes a distinction between “good deaths,” where patients and families have time to understand and plan for the inevitable, and “bad deaths” that come unexpectedly and provide little time for acceptance.

The anger stage of grief is most pronounced with bad deaths, Carr says. So, it is no surprise that these conversations about palliative care turn into questions and accusations. 

While it's too soon to know exactly how the pandemic has affected medical workers, nearly half of the coronavirus caregivers in one early study reported “serious psychiatric symptoms” such as depression, anxiety and suicidal thoughts.

Hospitals offer counseling, massages, peer groups and employee bonuses. Those help. But Medeiros, the respiratory therapist, says pain builds until it just gushes out.

“I cry in the car. I talk with my husband about it. I get it out,” she says. “I don’t know if it’ll ever be over.”

Deegan sets up a family video call with Marta Aguilar, a tiny, frail patient with disheveled, white hair.

Behind the mask, her eyes are confused, fearful. Her daughter-in-law appears on the screen with two grandchildren. “Hola, coma esta?” “Hi, Grandma.”

Aguilar tries to speak, her words inaudible as she points to her head. The mask is painful, too tight. A nurse and physical therapist fit her with another.

Chaplain Kevin Deegan facilitates a call between Marta Aguilar, a COVID-19 patient at Providence Holy Cross Medical Center, and Cheyenne Quintanar, her daughter-in-law, on Friday, Feb. 12, 2021, at Providence Holy Cross Medical Center in Mission Hills, Calif.
Chaplain Kevin Deegan facilitates a call between Marta Aguilar, a COVID-19 patient at Providence Holy Cross Medical Center, and Cheyenne Quintanar, her daughter-in-law, on Friday,...
Chaplain Kevin Deegan facilitates a call between Marta Aguilar, a COVID-19 patient at Providence Holy Cross Medical Center, and Cheyenne Quintanar, her daughter-in-law, on Friday, Feb. 12, 2021, at Providence Holy Cross Medical Center in Mission Hills, Calif.
Harrison Hill, USA TODAY

Deegan takes Grandma’s hand and asks God to bless her, “not just in her body, but in her mind and heart as well.”

The call ends. Deegan runs his fingers over Aguilar’s hair. “Descansa, OK?” he says, gently urging her to rest. 

More than a week later, the daughter-in-law, Cheyenne Quintanar,agonizes over Marta Aguilar’s final days. 

Cheyenne Quintanar, about her mother-in-law
“I can’t imagine how horrible she felt, lonely and abandoned. We can’t be there for her. They’re poking and prodding her, and we’re outside praying to the universe. The only time they let you see her is when they say, ‘We’re about to unplug her.’ ”

“I can’t imagine how horrible she felt, lonely and abandoned. We can’t be there for her. They’re poking and prodding her, and we’re outside praying to the universe,” she says. "The only time they let you see her is when they say, ‘We’re about to unplug her.'”

As the pandemic surged, Quintanar notes, her family took great care because Aguilar had an autoimmune disease. Still, the virus found its way in. Aguilar became extremely ill. So did her son and Quintanar's husband, Marco Aguilar.

She speaks with awe of her mother-in-law, a diminutive, courageous refugee who fled El Salvador's civil war in the 1980s with her husband and three boys. In the United States she earned a college degree, raised a family, became a citizen.

When Aguilar entered the hospital Jan. 26, Quintanar says, doctors gave her a 10% chance.

Looking for hope, Quintanar spoke with a physician friend who suggested a medication used for treatment of parasitic worms. The drug isn't approved for coronavirus, but she found congressional testimony and data suggesting the drug might work. 

She pushed harder with Aguilar’s physicians, insisting, “What if you can save someone?”

Finally, they relented. With treatments, Aguilar began to improve, Quintanar says, but relapsed. 

Marta Aguilar dances with her son, Marco, at his wedding in this 2008 photograph.

Marta Aguilar dances with her son, Marco, at his wedding in this 2008 photograph.
Courtesy Aguilar family

On Feb. 16, the phone rang. Doctors saw no hope of recovery. They recommended comfort care with morphine, along with a do-not-resuscitate directive.

Marco and his brothers were granted a last visit, a nod of compassion for patients near death and their loved ones. It requires approvals, a security plan, an escort and a full personal protection outfit for each family member. 

They arrived around 4 p.m., Quintanar says, staying the allotted half-hour with their unconscious mom. At 5:28 p.m., Marta Aguilar died. She was 77.

“They didn’t even get to be with her when she left,” Quintanar says. “I think I’m still in the anger part of it. And the surreal aspect, the disbelief."

She said the family tried not to take out their frustration on Aguilar’s caregivers. “We know they’re doing their best. …I can’t imagine seeing death like that every day.”

Code Blues have dropped off dramatically since the pandemic peak in January, when there were nearly 200 coronavirus patients in the hospital. 

Back then, the alarm sounded several times during a 12-hour shift. By early February, the count of COVID-19 patients had dropped to 100.

In Room 1325, a child’s colorful painting on the wall says, “Get well Grandpa. We miss you.” 

While family members were largely not allowed to visit loved ones battling COVID-19 at Providence Holy Cross Medical Center in Los Angeles, some sent flowers, posters and other mementos to help patients feel closer to their families, like those pictured on Tuesday, Feb. 9, 2021.

The 70-year-old patient reclines in drug sleep. An X-ray technician captures an image of his lungs on a portable machine. The right lobe is what Ramirez, who manages nursing on a COVID floor, calls “a complete whiteout” — filled with viscous fluid and unable to absorb oxygen.

A new patient arrives on a gurney beneath a blanket from home. Panicky eyes flit behind a face shield. 

A half-dozen staffers converge for the transition to a hospital bed. “One, two and…” They slide him over and begin hooking up more than 20 tubes and cables. Spittle is suctioned from his lips.

He is now the patient in Room 2220, at the very beginning of a process.

Ramirez encourages him to breathe deeply. “Echale ganas,” he says. Give it your all.

An instrumental version of the Beatles’ “Here Comes the Sun” wafts from hospital speakers. At Providence Holy Cross, the song is played each time a COVID-19 patient goes home.

As of Feb. 22, the hospital had treated 2,853 coronavirus patients. The music did not play for about 380.

Ramirez's second child was born amid the pandemic. When he goes home, he uses the back door, strips, throws his clothing into the wash and showers before making contact with anyone.

“Then I hug my 3-year-old boy and my 6-month-old daughter,” Ramirez says.

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