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.”
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.
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.”
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.
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.
“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.
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.
“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.
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.”
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.
He served in the Air Force as a medical evacuation captain until late 2019, when he shifted to reserves and began working at the hospital. COVID-19 arrived a few months later.
Chaplains, doctors and nurses talk of straddling an emotional fence -- trying to empathize while preserving clinical distance so the trauma doesn’t crush them.
Ramirez says the coronavirus makes it hard to offer hope: Once a patient gets intubated in the ICU, prospects are bleak.
“We’ve had patients where we’ve thrown everything at them and they just don’t get better,” Ramirez says. “Our staff really has to be careful with what verbiage they use … and not make false promises.”
When COVID spiked, Dr. Marwa Kilani’s caseload for palliative care tripled to 70 patients.
Now, as she begins making her rounds, it's at 49.
Room 1339, after checking the vitals of a sedated patient on a ventilator: “This poor guy, … he could probably hang in there another week — maybe two.”
Room 1404: “Hi, hon. You’re doing good. I’m going to talk to the whole family and try to figure out how to get you home.”
Room 1410, a 94-year-old, sedated: “Beautiful man.”
Room 1407, a patient who's gone 17 days without virtual visitors: “Como estas? Asi mismo?”
Room 1325: The patient asks, “When am I going to get out of here?”
Kilani answers gently, “Honey, you’re not going anywhere.” As the glass door slides shut, she says, “He’s a tough bird, though. We’ll see how he does.”
This is the daily ritual.
With cancer or heart disease, Kilani says, treatment often continues for months or years. Families visit regularly. By the end, most reach a point of understanding, resignation, even relief.
But the coronavirus “just hits you hard and takes you down. The patient experiencing it is absolutely alone," Kilani says. “And there are a lot of misconceptions.”
Family members sometimes press for untested drugs, offering to sign waivers. But doctors aren’t comfortable experimenting on patients, Kilani says. Some of the supposed remedies are unauthorized, unavailable or unsafe.
Eventually, after medical staffers reach a consensus about palliative care, it is time for the dreaded phone call.
In Room 2111, an elderly man is extremely bloated, his body and the machines unable to expel fluids. He’s been hospitalized 59 days.
The sun is setting, sending angular shafts through a window.
Kilani pulls out her iPad to ring family members. The patient’s wife had an anxiety attack during the last video call, so her adult daughter answers.
“Are you ready to see Dad?” Kilani asks.
Kilani turns the camera toward her patient and begins a commentary: “Dad’s much more swollen. His skin is just falling apart, super chapped.”
She says his kidneys have failed from medication overload. The oxygen feed is at 90 percent. There’s no gag reflex.
“He is not in good shape, sweetheart,” Kilani says. “You know I’ve been honest with you. I feel, I just feel like we’re torturing him, his body is so beaten up.”
The daughter resists, saying her mom does not want to disconnect the patient.
Maybe, Kilani suggests, they could continue the present care but no more. “An escalation of treatment is just not going to be beneficial. He’s been through enough. He’s not going to survive this,” she says, her voice trailing off.
The daughter begins to weep.
The room is silent except for the hiss and buzz of machines.
The family wants to keep trying. No changes.
Kilani acknowledges her, adding, “No escalation of treatment.”
A minute later, Kilani is on the phone with another daughter — her own. “Sure, go ahead and make the cookies,” she says. “But don’t put jelly in the middle.”
“Here Comes the Sun” plays over the intercom once, twice and then a third time. ICU nurses are smiling: a good afternoon.
A day earlier, Kilani had spoken via phone with the wife and family seen crying outside the hospital lobby. She explained that the patient in Room 2106 was in shock and ready to go. The family wasn't ready.
“They said, ‘We have faith. We have hope.’” Kilani says. “They did what they felt they had to do not to give up on him.”
A final visit was scheduled. In the morning, Chaplain Kristin Michealsen spent more than two hours with the family members.
When they entered Room 2106, Michealsen says, the wife seemed to grasp reality, telling her sedated spouse, “You’ve been a good husband and father.” But the adult children urged him to fight, saying, “You can do it. Echale ganas!”
“The son, he could hardly breathe he was crying so hard,” Kilani says.
A Rosary was recited at bedside. The priest delivered last rites. The family returned to the lobby and crumpled outside, consoling one another.
The man in Room 2106 died that afternoon.
“Coping is something I struggle with,” Kilani says, her voice catching. “Recently, it’s really been hard for me because of the anxiety. We try to be there for each other. We try to celebrate wins.”