Dr. Kathy Parnell is known throughout the hospital where she works as a pillar of strength, always smiling, trying to stay upbeat, offering compassion to her patients, and encouragement to nurses and to other doctors.
But in recent weeks, it's been harder for Parnell, an internal medicine specialist at Baptist Health Medical Center in Little Rock, to maintain her veneer of optimism. She says she's worried a breaking point could be near.
"I'm sorry to cry," Parnell said on a recent morning. "I've cried every single day this week because the people are so young now."
Parnell is referring to her patients who are dying from covid-19.
On a recent Saturday, a 25-year-old patient died, leaving behind an 18-month-old, she said.
Two days later, a 20-year-old was placed on a ventilator and on ECMO, a last resort treatment for failing lungs.
"Yesterday, a 33-year-old passed away who has a 6-year-old," Parnell said. "So many people are losing their moms and their dads. It's just so different than the first time, just the young people, and they're not responding to the treatments that we know."
On the front lines of one of the deadliest global crises in history, health care workers liken the latest wave of covid-19 washing over Arkansas to a slow-motion tsunami or a never-ending horror film where the villain is seemingly defeated, yet somehow keeps returning in scene after scene while doctors and nurses are captive audience members who have no choice but to watch as the horror continues to unfold.
Many, like Parnell, say they are not sure how much more they can take.
"It's just so sad," Parnell said. "It's just so surreal."
After more than a year of battling the pandemic, doctors and nurses are experiencing burnout. Some say their colleagues are exhibiting signs of post-traumatic stress disorder, a condition experienced by those who fight in wars or who are exposed to prolonged trauma, like the deaths caused by the coronavirus.
Doctors are retiring early or looking for jobs outside of emergency departments.
Nurses are quitting.
"We've literally had nurses who walk out in the middle of a shift because they can't take it anymore," said Dr. Cam Patterson, chancellor of the University of Arkansas for Medical Sciences. "For a lot of our team members, this is the third time through this drill."
"They have been through the wringer," he said.
Those who choose careers in health care undoubtedly expect to see tragedy, trauma and death. But what has been happening this summer in hospitals across Arkansas, and increasingly across the nation, is something nurses and doctors say is beyond tragic, beyond heart wrenching, really beyond anything they know how to describe.
What makes this wave of the coronavirus different -- and perhaps even more tragic -- from previous surges is that the severe illness and deaths it's causing are preventable. Public health officials say nearly 100% of mortalities since January could have been avoided with covid-19 vaccinations.
Many who are dying from covid-19 now are younger than before, and in some cases, have no underlying conditions. Data from the Arkansas Department of Health show that between January and July of this year, hospitalizations across all age groups have increased with the exception of 65 and older, the segment of the population with the highest vaccination rates.
For myriad reasons, younger people have been more resistant to getting vaccinated. Early on, medical experts said young, healthy people experienced milder symptoms. It was one reason there was little urgency to get vaccinated.
With the highly contagious delta variant, that hypothesis appears to no longer be true.
Health care workers say they feel more alone in this latest battle, that for the general public, the war against the coronavirus seems mostly over. People have moved on while doctors and nurses are entering yet another theater of war.
"Burnout is an issue that affects all health care providers, sure," Patterson said. "But this is more than just normal wear and tear. This is becoming less like employee burnout and more like acute stress leading to mental trauma."
Across social media platforms like Twitter and Facebook, doctors and nurses in Arkansas have been posting harrowing stories of death in their intensive care units while publicly pleading for people to get vaccinated. It's perhaps the most vocal they've been since the pandemic began at the end of 2019.
Hannah Montgomery, who works at Conway Regional Medical Center, emailed a Facebook post to the Arkansas Democrat-Gazette detailing her recent experience in the hospital's I.C.U.
"Let me tell you why health care workers and people who have been personally affected by this virus are warning you," Montgomery wrote. "We see the statistics, too, but our statistics have a name and a face. They are lying in our I.C.U. beds, fighting for their lives."
Montgomery continued: "Will every person who contracts covid end up like this? No. I know that, and thank goodness not everyone does, but if you do, and this happens, it is devastating. It is heartbreaking as a healthcare worker to see this."
She signed the post: "Sincerely, a scared, heartbroken, traumatized, 20-year-old, patient care tech in an I.C.U. and future nurse." (Montgomery is enrolled in nursing school at UAMS, and in a phone interview, says she plans to continue her studies).
"This current surge is the worst mass casualty event I have ever seen in my 30+ year career that includes being a physician in the U.S. Army for many years before entering civilian practice," Dr. Gregory "Scott" Harrington, a physician at Baptist Health Medical Center in North Little Rock, said in a Facebook post shared more than 3,000 times in a little over 24 hours.
"It is an unexplainably horrible, gut-wrenching and heartbreaking experience to watch your patient smother to death, or to have to make the agonizing decision with a family to compassionately extubate their loved one who is dying on the ventilator," Harrington said.
"Something I have had to do dozens of times over the last year and a half, and our hospital team has had to do hundreds of times, more and more each day," he said.
"I am sick of our hospital being so full of covid patients that we don't have room for others who are sick," Harrington wrote.
Baptist Health Medical Center and UAMS recently allowed the Democrat-Gazette access to the hospitals' covid-19 units where doctors and nurses detailed what it's like for them now to be going through another surge.
These hospitals, and many others, are again stretched beyond capacity with not only coronavirus patients but other patients who, unable to receive regular care during the pandemic, are filling critical care units.
Many health care workers say they are faced with conflicted emotions: frustration at dying patients for not getting covid-19 shots while trying to continue to show concern and empathy.
Doctors tell stories of patients who are critically ill with the disease yet deny having it. Or who recover from a serious case and still refuse to get vaccinated. Or families who are more defiant, demanding that physicians cure their loved ones when sometimes it's simply too late.
"I would just find myself kind of mad at people for not getting the vaccine," Parnell, the Baptist Health doctor, said. "Like, I was just angry, but that is just wrong. It's the patient's right, and the patient's choice, and I just had to bring that back to the forefront of my thinking, and so the anger went away."
"My feeling is that this didn't need to happen," Dr. Aaron Wenger, an internal medicine physician at UAMS, said. "If there had been better uptake of the vaccines, especially in the spring when it seemed like we were starting to get the upper hand on covid, I don't know that we would be dealing with this at all right now."
"In fact," Wenger said. "I think we probably wouldn't."
Wenger said what is "most concerning" is the limited resources hospitals have to work with.
"Intensive care unit resources are more stressed," he said.
WAIT FOR BEDS
During a news conference last Thursday, Gov. Asa Hutchinson said four covid-19 patients that day were waiting in ambulances because no beds were available. Physicians describe emergency rooms where patients are kept in beds in hallways for rooms to become available.
Hutchinson said he had called the White House requesting that a "surge response team" come to Arkansas to assist with maximizing hospital capacity. But even if there are more beds, there is still not enough staff, specifically nurses, to help.
Before the pandemic began last year, hospital administrators said nursing shortages were a problem. Now they say staffing shortages are so bad, it's reached crisis levels.
"Without a doubt, we have not just a nursing shortage, we have a nursing crisis," Patterson said. "There are too many nurses who have left the profession altogether."
Takela Gardner, a UAMS nurse, joined two of her colleagues in a break room on one of the hospital's three dedicated covid-19 units to speak to the Democrat-Gazette.
They discussed how full the hospital is and how patients -- sick with covid or something else -- are waiting hours in the emergency department to be admitted.
"One of my patients a couple of weeks ago waited about 38 hours [in the ER]," Gardner said. "After one patient is discharged, within five minutes, that room is already assigned, and it hasn't even been cleaned yet."
"We don't even have time to breathe," she said.
They also discussed how much more quickly patients are becoming critically ill, telling a story of one individual who went from being lucid to being confused in a matter of hours.
"He's saying he has bugs in his water, seeing bugs on the wall," Gardner said. "Just within hours."
Some people who contract the virus experience a condition called covid encephalopathy, which can cause hallucinations.
Gardner had just left the room of a covid-positive man in his 30s whose condition was declining fast. "Why didn't he get vaccinated?" she said. "I don't know, and being in the condition he is in now, if you ask, he can't tell you."
In July, Gardner worked five, consecutive 12-hour shifts, which is almost unheard of.
She was exhausted.
They all were.
"A lot of my co-workers, even with the overtime, the extra pay, some of them are just not even choosing to do it because they're tired," Gardner said.
"It's just like,' oh my gosh, how much can I do?' But you also do it because you want to make it less stressful for your co-workers because we're working short, and it's hard," Gardner said. "We're losing good nurses."
Gardner's colleague, Terry Prowse, also a UAMS nurse and a clinical services manager, said he's worried about the mental health of the nurses he manages. Some have become recluses, are suffering from depression or anxiety, or have anger issues: all PTSD symptoms.
Prowse said he is worried that some might fall into alcoholism or other forms of addiction to cope.
He also said he believes it's become harder for nurses and doctors because once they leave their shifts to go home, the public appreciation that existed at the beginning of the pandemic is no longer there.
"That's gone," Prowse said. "We see what the reality of it is in here, but the community is still not grasping what is going on."
"Last year, at least someone might walk up to you and say, 'Thank you for doing that. Thank you for being a nurse,'" he said. "You don't get the gratitude now that you once got outside of the hospital."
When Dr. Larry Johnson, a UAMS pulmonologist, began his career as a doctor in the early 1980s, a mysterious and deadly virus was just starting to enter the American public's consciousness.
HIV, and the syndrome it causes, Acquired Immune Deficiency Syndrome, or AIDS, became one of the largest public health crises of the past century. It was terrifying for front-line workers, particularly since in the beginning it was unclear how the disease was transmitted.
Johnson remembers that.
He also remembers 2009 when a deadly strain of the flu, called H1N1, swept across the country. He recalls the I.C.U. where he still works at UAMS being filled with more than a dozen pregnant women during the summer of that year who were becoming very ill with the virus.
"Now, we have this," Johnson said, walking past those same rooms where the pregnant women once were, now occupied by covid-19 patients, some who appeared to not even be 40, on ventilators and fighting to survive. "We will probably have something else in 15 years or 10 years."
Johnson walks through the "E4" I.C.U. where there are both covid-19 patients in isolation rooms and patients sick with other conditions. UAMS has had to combine covid-19 patients with others on this floor because the hospital's dedicated covid units are full.
"That is a covid room," Johnson said, pointing to a room with an unconscious man attached to a ventilator and hooked up to an ECMO machine that was taking blood outside of his body, re-oxygenating it and pumping it back in, like scuba diving gear for dying lungs.
He then points to a nurse wearing a powered air purifying respirator, or PAPR, a device worn to protect health care workers from contracting tuberculosis and other highly contagious diseases spread by air. It looks like something an astronaut might wear on a trip to the moon.
"There's just no balance now," Johnson said. "The balance [that] was always there was the expectations of the kinds of diseases we would have in the I.C.U. and what the survivals were going to be, who we could help and who we couldn't help."
"That's all been destroyed by this disease that's now dominating our culture, dominating what we do in hospitals," he said.
But the question that is unknown is how long this pandemic will continue to dominate the lives of health care workers, particularly younger doctors and nurses who are now seeing patients die who are their age.
If history is any indication, the impact will be lasting.
"It makes them think about their own mortality," Johnson said. "It makes me think about my own mortality, that you are not here forever, that anything can happen to you. How do you deal with that? How do you adjust to it?"
In his office, Patterson, the UAMS chancellor, discussed how he'd recently watched a documentary series about the Vietnam War, a conflict that dragged on for years and eventually faded from the American public's psyche even as thousands of young men were still losing their lives in battle.
Nearly 60,000 American troops died in the conflict. For many of those who survived, the trauma of the war remains with them today.
"The one thing I took out of revisiting the Vietnam War experience was a grave sense of hopelessness," Patterson said. "I think that as a nation, when there was a recognition of hopelessness, that's when the battle was lost."
Covid-19 has killed more than 600,000 Americans. In Arkansas alone, more than 6,000 have died.
Front-line health care workers have been witness to it all.
"We've got to be careful that we don't create a sense of hopelessness with regards to covid-19," Patterson said. "If we are fighting with each other, it is going to make it so much easier to fall into that sense that there's no solution here, but there is a solution, and the solution is science and truth."