In early 2020, Michael Odell sensed that Covid-19 would hit hard. A young intensive care nurse who traveled to hospitals needing an extra hand, he told his family that demand for people like him was surging.

By April 2, just a few weeks into what had become an atmosphere of fear and mass death, he was worried about the toll on health care workers. He had been standing in for families barred from the bedside, watching repeated scenes of patient after patient deteriorating.

“I am already feeling the emotional burnout of caring for patients who, despite some being the sickest they’ve ever been, are unable to have their loved ones by them,” Odell wrote on Facebook that day. “What do you say to someone who is facing death and can’t have their loved ones with them?”

Odell, who grew up in Muskogee, Okla., finished nursing school at age 20. He loved languages and was proud that he could translate for his Spanish-speaking patients. He had a sweet tooth, too. He always had a stock of Skittles, and sometimes carried them around in a urine sample cup to amuse his fellow nurses.

“I feel for them as deep as human empathy can allow,” Odell wrote about his struggling Covid patients, “but I fear the long-term effects this may have on every clinical worker navigating this pandemic and in these situations. Please don’t think me selfish; I get that my level of ‘suffering’ cannot compare to what these patients and their families are experiencing. But the fact is that I have an amazing support system and people who love me and tell me frequently that they do; I fear for those who do not.”

That month, Odell attempted to kill himself. And in January of this year, amid another Covid-19 wave, Odell walked out of his shift early one morning while working at Stanford Health Care. He died in an apparent suicide. He was 27.

The country is approaching 1 million documented Covid-19 deaths, a once unimaginable milestone that invites us to take stock of the manifold harms inflicted by the pandemic. This includes the mental health battering that nurses, in particular, have endured with little attention even as they poured attention on others.

A suicide death can’t be neatly explained. It’s not a simple cause and effect, like how a pathogen infiltrates the lungs and kills. Instead, it’s typically the result of a confluence of factors. Odell, for instance, had been dealing with depression. Experts note that even during periods of immense trauma, it’s a small minority of people who will have thoughts of suicide, and far fewer will act on it.

But it’s also true that nurses — who studies suggest had higher pre-pandemic suicide rates not just than the general public, but doctors as well — have withstood challenges of both greater depth and duration than ever before. They were a sometimes invisible phalanx of frontline workers, counseling families remotely through their grief and taking the brunt of their rage over hospital policies, humanizing patients’ last days tethered to machines, and absorbing a barrage of death in a career that drilled into them that their priority was helping those very patients.

“I would gladly have him care for any one of my family, loved ones, because I know they would be in good hands, because he was just that good of a nurse,” Michael Walujo, Odell’s friend and fellow nurse, told the people gathered at a vigil soon after Odell died. “And he advocated for you, regardless of what.”

“And above all, Michael Odell made you feel seen,” Walujo continued. “He genuinely made you feel seen. He made you feel important. He made you feel that you mattered, and we do matter.”

Growing up, Odell’s computer acted as a gateway to the world, in addition to a place to play games. He found pen pals in Sweden and explained to his older brothers Brad and Patrick the differences between Swedish and Finnish and Icelandic. His brothers leveraged Michael’s time at the computer to their benefit too. When Brad was a teenager, in the pre-iPhone days, he knew he could call Michael at home with a question — what time did Sonic close? — and Michael would happily look it up. “My own little smartphone, just a call away,” Brad said.

Odell came out as gay in middle school and even then was adamant about being himself. In interviews in recent weeks, several of his friends separately mentioned that Odell was younger than them, but that they looked up to him. They treasured his kindness and his intelligence (book smarts, though not always common sense — he once trapped himself in a bathroom while installing a lock on the door). They admired him, too, for his sense of fun, and for the way he showed up in people’s lives when they needed it most.

His family called him Mike, while friends called him Woodhouse, a nickname from the TV show “Archer.” He had a cat named Marge. He had a skepticism that veered into stubbornness when others wanted him to do something, but when he got on board, he was on board.

Odell had a prized Crockpot, and was militant about following recipes. Once, when his friend John LeBlanc — also a critical care nurse — was making chicken parm without instructions, Odell watched in disbelief: How did LeBlanc know how much seasoning to add? How did he know when the chicken was done without a thermometer?

“He could make the best pot roast in the world but I still had to teach him how to fry a chicken breast,” LeBlanc said.

He and his friend Stratton Brooks would stay up all night playing games like League of Legends and talking about their hopes and dreams, and then Odell would go and make his happen. He perfected his Spanish in Argentina and Mexico. He took language classes in Italy.

Odell became a nurse because he cared deeply about others, but he was also practical, those who knew him said. It would provide a solid career, one that paid well. Travel nursing in particular would let him see new places and earn him even more money. Plus, he was the kind of guy who picked up friends wherever he went.

For all the pandemic’s devastation, tracked in case counts and death tallies, much of it has transpired behind closed doors in isolated hospital units. Even the pictures that emerged from Covid rooms felt impersonal. There would be a patient, cloaked in tubes, and an often solitary health care worker, encased in PPE to the point of anonymity. They seemed more hazmat than human.

But underneath those shields and masks, those gloves and goggles, were individuals like Odell.

Critical care nurses told STAT that it wasn’t just the magnitude of death that has worn them down the past two years, but what those deaths became.

Before the pandemic, when someone was approaching death, “as much family as you could fit in the room” would be there, LeBlanc said. They brought in blankets and pictures. Faith leaders could come, and people would sing and share memories. It made the process somehow positive, not just for families, but for the nurses, too.

Covid made it lonely.

Nurses might spend hours by themselves in a room with a sedated patient, picking up the work of a nutritionist, physical therapist, or respiratory therapist to minimize people going in and out. Doctors only arrived for certain procedures. Chaplains didn’t come around.

“It was me,” said Kelsey Vandersteen, a critical care nurse in Wisconsin. Families would video call, but beyond that, “The only interaction the patient had was my touch. Me talking to them. Me putting on their favorite music.”

And yet, between smile-blocking masks and the absence of families who could tell stories, it was harder to build relationships with their patients, many of whom were unconscious. It created a dissonance: Nurses felt alienated from their patients, but in many ways, more affected when they lost them.

Nurses were having to facilitate families’ goodbyes, holding up iPads so they could see the patient one last time. It exposed them to final moments they might not normally hear. It made the bulwarks they imposed against death more penetrable.

“Having to take the role of the family while also trying to keep some distance so you don’t break every time, that can make the brunt of each death harder,” said Jessi Gold, a psychiatrist at Washington University in St. Louis who specializes in health care worker mental health.

Having so many patients who were so sick also weighed on nurses. Particularly in the early days, before they knew which treatments worked, it felt like nothing could stop people’s declines. Stretched thin, nurses doubted the quality of care they were providing. All the while, they confronted the fear of contracting the virus themselves, and of bringing it home.

All that contributes to burnout and mental health issues. Surveys of nurses have found that substantial portions of them felt sad or depressed more often than before the pandemic, and felt traumatized.

“It’s painful on the nurse because they know what should be done, but can’t be done,” said Judy Davidson, a nurse scientist at UC San Diego Health Sciences, who has studied suicide among nurses.

Kathryn Sherman, a critical care nurse in Tennessee, described the lull last summer, when her hospital was seeing more non-Covid patients. “It was almost like a return to normal nursing, when we could actually help people,” she said.

Vandersteen’s hospital is now getting back to standard routines around death. Different health care workers cycle in and out. More family members are there. “Oh, my God,” she said. “It’s one thousand times easier.”

In April 2020, when Odell attempted suicide, home was in Minnesota with his then-boyfriend, but he was working at a hospital in the Bay Area. He described nursing at the time as “death after death after death,” his friend Walujo remembers him saying. He and his colleagues spoke about feeling they had to put on blinders to handle what was happening, and at times they embraced dark humor: another shift, another round of deaths. But no one realized that Odell was struggling so intensely.

Afterward, Odell told his brother Brad that he had stopped caring about things.

Odell headed back to Minnesota, started taking antidepressants, and began seeing a therapist and psychiatric nurse practitioner. His friends initiated Wellness Wednesdays, a chance to check in on how the others were doing or just to vent. On Facebook, Odell used his birthday in June 2020 to ask for donations to the National Suicide Prevention Lifeline.

Brooks, meanwhile, used Odell’s birthdays to let him know how glad he was that he had been born. “I’m learning now that you shouldn’t wait until someone’s birthday to tell them that,” Brooks said.

Odell seemed to be doing better over the months. Last fall, he moved from Minnesota to San Francisco, where he had a strong network of friends, many of whom were nurses and some of whom — like Walujo and another friend, Josh Paredes — also grew up in Oklahoma. Odell took over the spare room in Paredes’ Castro apartment.

Over Thanksgiving, Odell visited family in Oklahoma, and Brad’s family in Missouri. Brad and Michael went for a run together for the first time.

“We could have done that for decades,” Brad said.

In December, Odell started his contract at Stanford. This was during the Omicron surge, a time when, nationally, patients — Covid and other types — once again overflowed hospitals, and infections among clinicians strained staff numbers.

Odell was working in the neuro-ICU, but sometimes had to “float” to other departments because the hospital was so busy, Paredes said. The only change in Odell’s behavior was that he was sleeping more, but Paredes figured that was because of how much Odell was working.

And then, early on Jan. 18, Odell left the unit, telling others that he was grabbing something from his car. His car was later located off the side of the road across the Bay from Stanford. His body was found two days later in a nearby wildlife refuge. While the Alameda County coroner’s office has not made an official determination, the indications are that Odell died by suicide.

Odell’s friends have been wrestling with the unanswerable question of whether something could have gone differently. They’ve heard nothing out of the ordinary happened on his shift, but while Odell walked out around 4:30 a.m., he didn’t leave the parking garage until roughly 7:30 a.m. When Odell went missing, his co-workers called security and searched throughout the hospital and garage, but turned up nothing.

His friends have wondered: During those three hours, was he hoping someone would come find him?

David Hernandez, an associate nurse advocate with Stanford’s nurses union, said the health system should have a plan should someone leave their shift, and that it shouldn’t be up to other health care workers to go looking. He said Stanford, with which the union is in contract negotiations, hasn’t taken such steps since Odell’s death, so nurses have started sharing their license plate numbers and families’ contact information.

“The nurses have figured out that we have to come up with a system on our own,” said Hernandez, who works in the emergency department.

In a statement, Stanford spokesperson Julie Greicius said the health system is “committed to providing a full complement of mental health and wellness benefits,” and is “continually updating our policies and procedures to support our employee’s physical and mental well-being.”

“While Michael Odell, a traveling nurse, was with Stanford Health Care for one month, he was a valued member of our community,” the statement said. “We are deeply saddened and mourn this loss, as do those who worked alongside him.”

Since Odell’s death, his friend LeBlanc has been reading studies about clinicians and mental health. The literature makes clear that nurses have not been the priority, that their feelings of invisibility or even disposability during the pandemic are not new. “Most of what is known about suicide among health care clinicians originated from studies of physicians,” one 2021 paper said, citing “very few empirical studies of suicide among US nurses.” A 2018 report from the National Academy of Medicine noted that there were “no public data identifying a national nurse suicide rate, yet data on suicide rates were readily available for physicians, teachers, police officers, firefighters, and military personnel.”

More recent research has found that nurses’ suicide rates are higher than those of physicians, but many health systems still invest more in physician wellness, UCSD’s Davidson said. “We need to make sure the resources being put into place for physicians, that the staff have at least equal resources,” she said.

Health care workers often worry about seeking help for mental health, fearing they’ll be stigmatized or that it could jeopardize their licenses. Travel nurses in particular may face higher risks for those issues. Because of the high wages that travel nurses command, which have skyrocketed during the pandemic, there is sometimes tension between them and staff nurses. Travel nurses typically don’t qualify for hospitals’ employee wellness programs. And just by the nature of their jobs — moving from hospital to hospital — travelers lack social support at work: the friends they can decompress with or who will pick them up when they’re struggling.

There are signs that the pandemic has compelled the country to take more seriously health care workers’ mental health. In January — by coincidence, on the same day Odell’s body was recovered — the Biden administration announced more than $100 million in awards to stem burnout. Last week, President Biden signed a bill named for Lorna Breen, the New York physician who died by suicide early in the pandemic, that creates grants to address mental health among clinicians and trainees.

“There’s much greater awareness in the general public of these issues,” said Corey Feist, Breen’s brother-in-law.

Suicide is generally the result of multiple factors, and Odell’s family and friends have weighed the stressors Odell had beyond work, including his depression. His start date at Stanford was delayed, Paredes said, so Odell seemed worried about money. Brad said that his brother “wasn’t dealt an easy hand” growing up gay in Oklahoma, though Odell’s friends said he never seemed unsettled by the challenges he faced when he was younger. Odell’s mother died in August, after years of decline caused by a form of early-onset dementia. “We were all really close to our mom, had a lot of respect for her,” Brad said. “She always wanted a girl, but raised three rowdy boys.”

Odell had a supply of medication in his belongings after he died, so he hadn’t run out. But Paredes said Odell had yet to establish care with a mental health provider after moving to California.

“We know that having effective mental health care, and staying in effective mental health care, is hugely critical for protecting from suicide risk,” said Christine Moutier, the chief medical officer of the American Foundation for Suicide Prevention.

If someone had underlying mental health issues, the stress of nursing could exacerbate that. “That’s where the pandemic layer can really tip someone back into being depressed or being highly vulnerable,” Moutier said.

As they’ve grieved, Odell’s family and friends have also been holding onto the small things, letting their memories of Michael fill their minds. How at the movies he would just dump salt on the popcorn. How it would take him forever to get through a meal because he would talk so much. How when a friend was being lazy or was complaining after a hard day, Odell’s message to pep them up was, “You better move those hips.” How he jokingly would never admit when he was wrong, but then how he would unexpectedly offer a friend the most meaningful compliment.

Odell’s friends are starting an organization in his honor dedicated to advocating for nurses and providing peer support.

Soon after Odell died, his loved ones held a vigil in the Bay Area. There were plenty of Skittles to go around.

One person who attended had been his patient at Stanford, after she had tried to kill herself. Odell had stressed to her that she mattered, she told his family and friends. She would always be grateful, she said, because while Odell didn’t know her previously, he showed up in her life when she needed it most.

Update: A year later, Michael Odell’s friends are building out a peer support network.