In early 2020, when the coronavirus began making it difficult for many people around the world to breathe, hospitals became a central front against a disease that, more than a year later, has killed nearly 4 million human beings and counting.
At one hospital in Mission Viejo, Calif., a team of nurses and doctors were recruited for what became the Isolation Intensive Care Unit. Many volunteers at Providence Mission Hospital had come from cardiac and surgical intensive care units, where they deal with death and trauma each day.
Launched in March 2020, the isolation unit would come to be known as “Tip of the Spear,” a military term used to describe a group doing dangerous work. Many nurses who would spend countless hours with patients, helping them return to health or helping them say goodbye to family, got tattooed with spears, hash marks and a heart.
Today, those nurses speak of forming deep bonds and of the joy in helping some deathly sick patients survive. But they also can’t forget horrific and heart-breaking experiences that are very much still with them, even months after the hospital’s special unit shut down as cases in California dropped sharply.
With little knowledge of how to treat patients, and amid enormous personal risks, these nurses had leaped into the abyss. They will never be the same.
To capture the reality that the horrors of COVID-19 will be with us for years to come, even as many countries move beyond the pandemic, Associated Press photojournalist Jae C. Hong turned to an unusual form of photography not typically used in the context of reporting the news. He employed a special exposure technique in photographing 10 nurses in areas of the isolation unit, now empty.
First, Hong made pictures of each nurse. Then he asked them to step aside and shot images of the same background. By using a multiple exposure function, he made the images overlap. The result: pictures that create the feeling that the nurses are both there, in the photo, in the present — and also somewhere else.
Here are their pictures, and the experiences they are wrestling with to this day:
Anthony Wilkinson still thinks about those 30 hours — the ones when three patients died.
The first was a woman who had been on a ventilator for weeks. One day, her oxygen levels dropped sharply and an emergency team began CPR. One lung ruptured, so a doctor inserted a tube in it to begin removing the blood. Then the other lung collapsed. There was no saving her.
That day, the family of a second patient being cared for by Wilkinson decided to withdraw care. The person had been hanging on with the help of a ventilator and medicines.
“You try to keep somebody alive, but their body is decomposing,” says Wilkinson, 34.
Just when Wilkinson’s team was bagging up the body of the second person who died, another patient’s bowel burst. The patient was in a Rotoprone bed, a cage-like, cylindrical structure that rotates patients to improve circulation. “We had to open the cage and bang on his chest. His lungs were already so filled with pressure from the ventilator,” Wilkinson says.
Hours later, the patient died.
Wilkinson says the ICU team and his wife, also a nurse, helped him get through days like that. It also helped that he became a father during the tough year, which allowed him to leave the ICU ward and go home and do “dad stuff.”
The memories, however, linger: “I don’t know if I’ve unpacked a lot of the blood and all the stuff we did to save people’s lives.”
During brutal days at the hospital, Christina Anderson and other nurses would scream or cry together, knowing that at home it would be hard for their families to understand what they were going through.
Still, there was no such thing as leaving their work at the hospital. The stress carried over to loved ones at home who were curious, worried, struggling to understand. Anderson’s 12-year-old would ask: “Mommy, how many lives did you save today?” Or: “Mommy, how many people died today?”
People died and people recovered. But most days, patients were somewhere between the living and the dead.
One of Anderson’s most vivid memories was when five patients were in RotoProne beds. They were in the “bay,” an open post-operative room that could be seen through the window of the anteroom, where nurses would put on personal protective equipment before going in.
Periodically the hospital’s CEO would visit the wing. One day, Anderson asked him if he had seen the bay lately. He had not, so she took him to the anteroom to have a look.
“Oh my God,” she recalled him saying.
“It hit me,” she says, “that what we were seeing and experiencing and how we were treating these incredibly sick patients was anything but normal.”
Debbie Wooters, an ICU nurse for 15 years, vividly remembers a man who had just retired and made big plans with his wife. They had placed an offer on a house out of state. They’d planned to travel.
Each day in the hospital, he got worse. Eventually, he was placed on a ventilator. He died a few days later.
“Instead of looking forward to a new beginning, we were FaceTiming his wife so he could say goodbye and thank her for the lifetime of memories,” Wooters says.
Learning they would be put on ventilators frightened many patients. And naturally so: There were numerous stories of people who had been intubated and never survived. Wooters remembers a patient who “looked at me and said, through his gasping breath, ‘I don’t want to die.‘”
“I explained to him that he was in the best hands and we will fight like he was our own family,” she says.
The ICU unit was isolating, not just for patients but for nurses as well. While keeping people alive was the main job, the nurses also needed to keep patients motivated or, when the chance of survival looked less likely, provide comfort.
“There were countless patients that we sat with, talked to, and touched so they knew they weren’t alone while dying,” Wooters says. And then there were the times they connected patients to families via their phones. “The cries and devastation heard,” she says, “was unbearable.”
There were days Lisa Lampkin didn’t eat, drink water or go to the bathroom during her shift. The reason: Going in and out of the isolation unit took time.
It wasn’t just putting on and taking off gowns, gloves and masks, as with regular ICUs. It also required intense hand scrubbing and cleaning her air-purifying respirator, which resembled an astronaut helmet and had its own air system. Then she had to put it back on, scrub her hands again and climb back into the gown and the rest of her gear.
“What was once a 30-second ordeal was now a two-minute ordeal,” says Lampkin, a nurse for 20 years. “And in nursing, minutes are valuable. We remained in the room for hours to allow our patients to have those precious minutes.”
The extra time was needed to overcome communication barriers. Masks and shields muffled words, making it hard for nurses and patients to understand each other. It didn’t help that the patients struggled to breathe, which made talking that much harder.
At the end of each day, Lampkin would weep with joy for making it through her shift without a wave of new patients, or weep with sorrow for all that her patients were enduring.
“I would go home, try to sleep,” she says. Then she would “wake up to the reality of this pandemic again.”
While Elisa Castorena remembers many patients who died, she prefers to focus on happy memories such as working with other nurses to bathe bed-ridden patients while listening to music and joking with them.
Sponge baths gave nurses a chance to assess patients’ skin, give their arms and legs some motion exercises and help relieve pressure points.
“I think what I loved the most about bathing the patients was seeing them all fresh and clean and knowing they got much needed tender loving care,” says Castorena, 40, who has two young children and is married to a police officer.
She also cherishes a memory of caring for a man in his 60s who came to the brink of death and survived—because he “stayed positive.” As his condition went from bad to worse over the course of several weeks, the man needed to be intubated, sedated and put in a RotoProne bed.
Slowly, he began to show improvement. He was given a feeding tube and a tracheostomy, eventually managing to speak a few words through a talking valve.
“He told me he had faith in us and he knew if he stayed positive, he was going to make it out of the hospital alive,” Castorena says.
Castorena gradually learned other things about him. For example, he owned a mechanic shop in San Clemente that her family had frequented for years. When she learned the man’s son was a firefighter, she remembered that the mechanic shop had patches from many fire departments on the wall.
Months after he was released, Castorena visited the shop and her old patient. He still had some minor symptoms but had recovered enough to work. Castorena gave him a patch from her husband’s police department to add to his wall.
As an ICU nurse the last five years, Jamie Corcoran got used to seeing death. She dealt with it by remaining detached.
With COVID-19, detachment wasn’t possible.
Months after the special unit closed, Corcoran can still visualize a board in the COVID ward with the initials of each patient that the team lost.
“I can remember every single name and face with their initials on that board,” says Corcoran, 31. “Every single one.”
The death of a man in his 20s still haunts her. Sick at home for over a week before going to the hospital, once there the man began showing signs of organ failure.
One night, when Corcoran was helping the man get repositioned in bed, he told her he felt afraid. The man was clearly declining, but there was still hope he could improve. If anything, his youth was an advantage.
The next night, at the beginning of Corcoran’s shift, the man stopped breathing. He was put on a ventilator and given various drips to try to revive him. Nothing worked. Within a few hours, his pulse was gone and a “code blue” was called. A half hour of CPR and defibrillation were unsuccessful.
A co-worker said a brief prayer and the team began cleaning up. Shortly thereafter, the room was clean. It was, Corcoran says, as if nobody had been there.
“But,” she says, “for many months after that, those of us that were in that room were left still trying to find the pieces of our hearts that were lost in that room.”
A few months ago, Nikki Grecco and other nurses commemorated the anniversary of the first death in the COVID ward.
Grecco vividly remembers the man and how he died. He was in his mid-60s, married with two daughters in their 20s. One day, Grecco sensed that something was wrong and called in a doctor. The man was showing signs of distress and a team frantically tried to stabilize him. It was too late; he was bleeding out internally and had lost his right lung and part of his left.
The man’s wife was at his bedside when he died.
“I have never felt so defeated as I did in that moment,” Grecco says.
Grecco, 34 and the mother of two young children, says being married to a pulmonary nurse practitioner helps because he knows the stresses and rigors of ICU work.
Still, the memories rush back and can overwhelm. Sometimes the trigger can even be a moment on a TV medical drama like “Grey’s Anatomy” or “The Good Doctor.”
“Their portrayal of what it was like in a COVID ICU is pretty close,” says Grecco, adding that often she has to “fast forward through a few episodes because some hit too close to home.”
Driving to work, Cathy Cullen sometimes tears up when thinking about what she and the other nurses endured.
Outside the hospital, “Thank you” statues put up early in the pandemic still stand. Seeing the display can unleash a flood of emotions, as can memories that fellow nurses share over text messages.
An ICU nurse for 31 years, Cullen has experienced a lot of death and heartache. Still, she doesn’t know how to relate the experience of taking care of extremely ill patients to anything else.
“The birth of my children and marriage aside, being a part of this team, this endeavor, and this pandemic is by far the greatest, worst, most rewarding, most painful thing I have ever done in my life,” she says.
Many of her memories are of awful things, like the time her team lost three patients in a single day or walking by a refrigerated truck every morning and knowing that it full of bodies because the hospital morgue was full. But there were also the wins, and it’s those she tries to focus on.
One of Cullen’s earliest patients was a young woman in her 20s, the age of one of her own daughters. The young woman was terrified, particularly when her breathing became so labored that the only option was a ventilator.
“Please don’t let me die,” Cullen remembers her saying.
The patient’s mom and her sisters would provide thumb drives with all kinds of music — hip hop, classical, classic rock, 80s dance beats. Even though the patient was sedated, the nurses would play the tunes and hold up a phone so family could look and her and speak over Facetime.
After several months and many close calls, the young woman made it.
“She was one of the victories that we celebrated,” Cullen says — “literally jumping up and down in happiness.”
There is a scene that replays in Jill Shwam’s head each day: an 11-year-old boy screaming while his mother, in her early 40s, doesn’t respond as doctors try to save her.
The woman had Type II diabetes but otherwise was healthy. After being very sick and on a ventilator, she recovered enough to start breathing on her own.
One day, while speaking on the phone with her son, the woman’s breathing became more labored than usual.
“You need to say goodbye,” Shwam remembers saying as the woman’s oxygen levels dropped sharply. The woman told her son: “I hope this isn’t the last time I talk to you. I have to go.”
Within 20 minutes, the woman was back on a ventilator and began experiencing what nurses and doctors call a “second storm” of the disease. Her heart rate spiked, her blood pressure tanked, and assorted intravenous drips made no difference.
Within 24 hours it was clear that most likely the woman wouldn’t survive, so her son was allowed to be by her bedside. As the woman “coded” and doctors and nurses worked frantically on her to no avail, her son wailed.
Shwam, 40, had seen a lot of trauma and death as a cardiac nurse, but this shook her to the core.
“I think about her a lot,” says Shwam, crying softly. “I think about them a lot.”
Verlin Frazier still remembers watching a woman walk between RotoProne beds to reach — and say goodbye to — her husband.
It was Spring 2020, just as COVID-19 started hitting California hard. The unit was full, and there were six people in the bay. Three of them were in RotoProne beds, including this man, a recently retired firefighter.
His body was shutting down. It was clear he would die before the night ended. Nurses had held his hand and rubbed his forehead. Now it was time for his wife to say goodbye. Watching her do that, after having walked between “five of the sickest patients in the hospital,” hit Frazier hard.
“I remember biting my tongue and cheek, holding my breath, anything to prevent myself from bursting into tears,” says Verlin, 34.
To make it worse, Verlin wasn’t able to console the wife because just as she was saying her goodbyes, another patient in the bay began deteriorating and needed attention.
Within a few months, Verlin saw a pattern in many of the sickest patients, which still sticks with him. A patient would struggle to speak simple sentences to family members on the phone. In the background, nurses and respiratory therapist would frantically prepare for intubation.
Then, says Verlin, the familiar words: “Stay strong,” or “They are going to take great care of you,” or “You are going to be home soon.”
“There was always an `I love you,’ which was where I usually had to pull the trigger in ending the phone call,” he says, “because they were deteriorating so fast that even talking was making it worse.”
Peter Prengaman is The Associated Press’ news director for the western United States. Follow him on Twitter at http://twitter.com/peterprengaman. Follow Los Angeles-based AP photographer Jae C. Hong on Twitter at http://twitter.com/jaethephotog