‘NO ONE HAS BEEN TRAINED FOR THIS MUCH DEATH’
ICU workers carry a heavy burden of grief and trauma
LOS ANGELES – 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 535,000 people killed by the coronavirus in the USA.
But in this moment at Providence Holy Cross Medical Center, he’s not a statistic.
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, outside the hospital lobby, relatives of the patient in Room 2106 hugged one another, 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.”
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?
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.
On the phone, Ohakam explains that COVID-19 has no cure. “He has pneumonia, and his lungs are filled,” she says. “It’s not as simple …” She is cut off, listening again.
The father couldn’t breathe, so a tube was inserted into his trachea, pumping oxygen. That requires sedation, which means he 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 says. “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, shaken. “I feel for him. God forbid if that was my family member.”
“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.”
“It’s much easier to blame the doctor or nurse or emergency room instead of hearing, ‘We did our best.’ That’s not enough. … Psychologically, we’d rather feel guilty or angry than feel helpless.” David Kessler Grief.com
‘Code Blue in 2117’
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. After each alarm, medical staffers wearing masks, gloves, face shields and multicolored protective gowns congeal like white blood cells on a wound, trying to revive the patient.
Kevin Deegan, a hospital chaplain, 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.”
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 “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 the coronavirus leave 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 the coronavirus 2.3 times more frequently than white non-Hispanics, according to federal data.
“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 can be emotionally volatile.
Family members 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.
The shock to relatives is magnified by quarantines. Unable to visit loved ones, families cannot see the disease’s swift devastation and have trouble facing endof-life decisions.
David Kessler says denial and anger, often the first stages of bereavement, trigger a search for culprits: the people trying to save 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 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. “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,” in which 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 in bad deaths, Carr says, so it is no surprise that conversations about palliative care turn into questions and accusations.
Hospitals offer counseling, massages, peer groups and employee bonuses. Those help, but Medeiros says pain builds until it 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.”
‘What if you can save someone?’
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.”
More than a week later, the daughter-in-law, Cheyenne Quintanar, agonizes over 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.’ ”
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 USA, she earned a college degree, raised a family, became a citizen.
Quintanar spoke with a physician friend who suggested a medication used for treatment of parasitic worms. The drug isn’t approved for the coronavirus, but she found congressional testimony and data suggesting it might work.
She pushed harder with Aguilar’s physicians, insisting, “What if you can save someone?”
Finally, they relented. Aguilar began to improve, Quintanar says, but relapsed.
On Feb. 16, the phone rang. Doctors saw no hope of recovery.
At 5:28 p.m., Marta Aguilar died. She was 77. 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.”
‘Here comes the sun’
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.
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. They slide him over and begin hooking up more than 20 tubes and cables.
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.
Chaplains, doctors and nurses talk of straddling an emotional fence – trying to empathize while preserving clinical distance so the trauma doesn’t crush them.
“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-19 spiked, Dr. Marwa Kilani’s caseload for palliative care tripled to 70 patients. Now, as she begins making her rounds, it’s at 49. Kilani says treatment for cancer or heart disease often continues for months or years. Families visit regularly. By the end, most reach a point of understanding, resignation, even relief.
The coronavirus “just hits you hard and takes you down. The patient experiencing it is absolutely alone,” Kilani says.