As Covid-19 tears through southern California, small hospitals in rural towns like Apple Valley have been overwhelmed, with coronavirus patients crammed into hallways, makeshift ICU beds and even the pediatric ward.
When AFP visited St Mary hospital in this desert town of 70,000 people this week, palliative care supervisor Kari McGuire said her team were seeing "astronomical numbers of patients who are dying" from the novel coronavirus.
"It's most definitely the darkest period of my entire career. Most definitely," she said, fighting back tears as she recalled the loss of patients, including staff and their families.
"I've personally had to watch people that I know that I care for watch their loved ones die. It's been very difficult."
Populous Los Angeles, just 80 miles (130 kilometers) away, has suffered the highest number of Covid cases and deaths in California. However when per capita the outbreak in neighboring San Bernardino county -- where Apple Valley is located -- has been even worse.
While rural regions further north have been helped by their isolation, this mainly working-class town in the Mojave Desert, where towns stuffed with warehouses and factories have long since replaced orchards, has seen more than one-in-10 people infected.
In crowded hospital corridors, the constant hum of beeping monitors and coughing patients is regularly punctured by Covid victims going into cardiac or respiratory arrest.
The intensive care unit originally had 20 beds, but the hospital is currently struggling to treat 54 ICU patients, improvising with plastic walls to create isolated "pods."
"Where do you put 60 ICU patients when you only have planned to hold 20? And then with staffing as well?" asked Randy Loveless, interim director of the emergency department and ICU.
"We've had to be very creative about how we've managed that. But currently, we are managing it."
Still, employees are working up to 18-hour shifts, and some patients have to wait days for a room.
"The impact that this surge of COVID has had on the hospital is tremendous... an operational strain, as well as a tremendous emotional strain."
- 'Hard to swallow' -
Mendy Hickey, executive nursing director, said her team was battling with post-traumatic stress disorder due to the non-stop extreme pressure.
"People are extremely exhausted, people are definitely angry, it's tension all the time," she said, with "spiritual care teams" called in to help her nurses.
Many have now received vaccines, part of a massive statewide inoculation effort that -- after a slow start -- has seen sites including Disneyland and the Los Angeles Dodgers' baseball stadium converted to soon administer doses.
California health secretary Mark Ghaly said Tuesday that flattened state hospitalization numbers were "encouraging," although he warned numbers could pick up again in late January.
But it comes too late for many at St Mary, which in December saw patients dying at rates "at least three to four times" higher than in usual months, said Hickey.
"In the beginning of COVID, back in the spring, there were times... you would get patients off of the ventilator, you would see patients go home."
"Now, that is not the swing of things -- majority of times now, we're having families coming in, we're having difficult conversations about patients and how they're doing multiple codes every day.
"The patients are just so sick. So sick... every day you come in and more and more patients are dying, it's hard," she said.
Adding to Hickey's frustration is the continued skepticism about the virus and protective measures among many Americans, including in rural California.
"You hear a lot of negative comments about 'it's a fake disease. This isn't real. It's so hard to swallow, when you're in the middle of it, living it every day," she said.
"When your nurses are breaking down and crying on the unit, because another patient died."
She added: "You wish you could bring them in here and see what we see. It would definitely change people's minds."