SACRAMENTO, Calif. >> For Caroline Brandenburger, the coronavirus outbreak that has overwhelmed California hospitals comes with a very personal toll.

“Just today we had two deaths on this unit. And that’s pretty much the norm,” said Brandenburger, who works on the COVID-19 unit at St. Joseph Hospital in Orange, south of Los Angeles. “I usually see one to two every shift. Super sad.”

“They fight every day, and they struggle to breathe every day even with tons of oxygen. And then you just see them die,” Brandenburger said. “They just die.”

California avoided surging cases for months, but now the virus is raging out of control. The state, which is the nation’s most populous with nearly 40 million residents, has seen more than 2.5 million confirmed infections. Only Arizona tops California in cases per resident.

A surge following Halloween and Thanksgiving produced record hospitalizations in California, and now the most seriously ill of those patients are dying in unprecedented numbers. State health authorities reported Thursday 583 new deaths and a record two-day total of 1,042.

There have been more than 28,000 COVID-19 deaths in the state since the start of the pandemic.

Hospitalizations are nearing 22,000, and state models project the number could reach 30,000 by Feb 1. Already, many hospitals in Los Angeles and other hard-hit areas are struggling to keep up and warned they may need to ration care as intensive care beds dwindle.

Lawmakers and public health officials have repeatedly praised medical workers as heroes as they struggle to treat the infected. Many nurses already stretched thin are now caring for more patients than typically allowed under state law after the state began issuing waivers that allow hospitals to temporarily bypass a strict nurse-to-patient ratios law.

The nurses at St. Joseph Hospital illustrate the toll that comes with the work.

“This past week has been probably the hardest week for me physically and emotionally,” said Donna Rottschafer, a nurse in the COVID-19 unit. “I’ve been here 21 years, and I’ve seen more people pass away in the last week — in the past couple weeks really — than almost like combined in all of my career as a nurse.”

“We’re seeing patients who are maxed out on oxygen, who are basically just suffering,” she said.

To the north in Los Angeles County, figures released Thursday showed a new daily caseload of nearly 20,000, a 66.5% increase over the previous day, Los Angeles Mayor Eric Garcetti said.

The more than 8,000 people hospitalized was the largest number since the pandemic began early last year, Garcetti said.

The county has a fourth of the state’s population but accounts for about 40% of COVID-19 deaths.

Garcetti said federal authorities should step in to send the region vaccines, money, doctors and personal protective equipment, noting that medical workers and PPE flooded into New York when it hit its peak early in the pandemic.

“This is our peak, and we need you,” Garcetti said. “We need national leadership, we need vaccines and we need resources to pay for them. Give us those and we know how to get the job done.”

Los Angeles is one of 14 counties in the two hardest-hit regions — Southern California and the agricultural San Joaquin Valley — that for about two weeks have essentially run out of intensive care unit beds for COVID-19 patients.

Intensive care availability at Bay Area hospitals fell to the lowest levels yet, dropping from 7.4% to just 3.5% as of Wednesday, according to state data. The Northern California region, which includes 11 mainly smaller and rural counties, had the best capacity at around 25%.

Earlier this week, state health officials caught hospitals off guard and left them scrambling with new orders limiting nonessential surgeries and requiring hospitals that have scarce ICU space to accept patients from those that have run out, an order that may require transferring patients hundreds of miles.

During an earlier surge, patients in Imperial County along the border with Mexico were sent to hospitals as far away as the San Francisco Bay Area. But the current outbreak is so widespread that only 11 mostly rural counties north of Sacramento and San Francisco are above the state’s threshold of having at least 15% capacity for coronavirus patients in ICU beds. Those below that level are under stricter restrictions for business operations.

The biggest fear is that hospitals will be tipped into rationing care in a few weeks when people who ignored social distancing rules to gather with friends and relatives for Christmas and New Year’s Eve start showing up for medical care.

Officials urged people to avoid mixing households or travelling in hopes of slowing the infection spread and preventing what has been called a surge on top of a surge.

In an effort to keep people closer to home, the Newsom administration issued a more strident travel advisory that says people from out of state are “strongly discouraged” from entering California, and Californians should avoid non-essential travel more than 120 miles (193 kilometers) from home.

“This next two or three weeks will define everything for us,” said Garcetti, the Los Angeles mayor. “Our own behavior will dictate everything that we do.”