It’s a Tuesday night in January, and I’m going down to the children’s E.R. with the residents to see a toddler with a rash. I feel for the poor E.R. workers—as the highly contagious Omicron variant of COVID-19 has surged here in Texas, our hospital, like so many others, is short on beds. Often, there have been dozens of kids in the E.R. waiting room. I feel like I should take the E.R. team a roast turkey when I go down there, or a bottle of gin.
In hospital parlance, a “bed” doesn’t just mean the bed (or crib), but everything a sick child needs: the equipment, the medical team, the electricity and running water, the respiratory therapist, and (most critically) the nurse. As I’m writing this, Bexar County, where my hospital is situated, has an over-all COVID-positivity rate near forty per cent. If we don’t have healthy staff, we don’t have beds.
Our bed status affects families across South Texas. We are a safety-net transfer hospital that serves children and adults, many of whom are living in poverty. San Antonio itself has the highest poverty rate of any major metropolitan area in the U.S. Between San Antonio and the U.S.-Mexico border is a long stretch of semi-arid brush country, inhabited by some of the most impoverished communities in this country. Specialty medical care for kids is sparse in this region, and the community hospitals in Edinburg, Eagle Pass, Fort Duncan, and elsewhere often call us to transfer children who are sick enough to need us.
Shortages also affect the kids who are already here. A child who would be safer upstairs with my team waits a few more hours in the emergency department. (In adults, boarding in the E.D. has been associated with longer hospital stays and higher mortality, though the data is contradictory among studies.) After surgery, kids move from the operating room to a recovery room; if they get stuck there waiting for a hospital bed to open, the next surgery can be delayed. With the I.C.U. full, we stretch resources taking care of I.C.U.-level children in a step-down unit. Our worries about these kids—that something bad will happen, that we will miss something or hurt them—affect us all.
As a hospital pediatrician, I help lead the team that cares for these kids. On this night, we are four: myself; my senior resident, Tebyan Rabbani; our pediatrics intern, Arfa Ikram; and a family-medicine resident, Melanie Perez Dones, who is rotating with us. Melanie has a nine-year-old and a three-year-old at home. The three-year-old is currently in isolation because his preschool teacher tested positive for COVID. Melanie’s husband is attempting to work from home and handle child care while Melanie works a string of nights.
The E.R. doc is upbeat. “I probably could’ve sent her home with oral antibiotics,” he says, of the toddler we have come to see. But apparently the kid is on day five of fever and her rash looks terrible, bad enough that he ordered an X-ray to look for infection in the bone. The family are refugees—recently evacuated from their home country. They don’t have a car, and the E.R. doc worries that they won’t be able to follow up if she gets worse. “The interpreter’s in there,” he says, referring to the portable video interpretation tool.
The girl is sleeping in her mother’s arms. “She hasn’t been screened yet,” Teb says, and we pause. All kids who are admitted to the hospital get a screening test for COVID, but usually just before they come upstairs. (If they can’t breathe and the E.R. team suspects that they are sick from COVID, the test happens earlier.) Arfa and Melanie are in surgical masks. I am in an N95 that I brought from home. Teb has a hospital N95—at this point in the pandemic, our hospital seems to have enough. Our patient isn’t in isolation and has no respiratory complaints. We go in.
I sit in the chair next to the mother and gently examine the girl while she sleeps. Melanie logs in to call the video interpreter, and in the meantime Arfa and Teb try their languages with the father. Some of our patients are often polyglots. Teb begins, but he and the father speak different dialects—the dad can understand Teb, but Teb can’t understand him. “Uno momento,” Teb says, forgetting himself when the dialect fails. This makes everybody laugh. Then Arfa proposes another language; the father speaks this, too. By the time the video interpreter is ready, he says he would prefer to continue with Arfa.
The girl is comfortable. Her lungs sound clear and her belly is soft, but the worst part of the rash does indeed look terrible. It is hot and red, with a large area of skin that has eroded all the way down to the muscle, and blackish crusting at the edge. I can feel her pulse bounding through my glove when I place one fingertip against her infected skin. “I am sorry to wake her, but we need to look in her mouth,” I say, and when Arfa translates the mother presses on the child’s cheeks, waking her. The girl squeezes her eyes shut and arches against her mother, instantly transformed from a sleeping child to an angry toddler. This reassures me—if she were severely ill, she would more likely be listless and compliant. I bend my head close to her face and shine a light, looking carefully over each surface of her gums, cheeks, and throat for blisters or erosions. The child screams, and I get a great view of her tonsils. They look fine.
When the little girl calms, she opens her eyes to peer at us past dark, teary lashes. She is startlingly beautiful, so much that we are all silent for a moment. “She’s beautiful,” Teb says. Arfa turns to the father and mother—she has beautiful eyes—and they nod.
Just now, our hospital is short on suture kits, suction cannulae, and occasionally other items. Pam Luper, the nurse who directs three of our hospital’s inpatient units for children, recently sent a manager to the grocery store to get baby wipes for our unit, after the hospital suppliers could not furnish them. Mostly, though, we are short on staff. On our busiest days, Pam has been working around the clock, sending updates every four hours to the medical team so we know if we have any beds for kids.
We have more children hospitalized with COVID than ever before—many of them under age five, and some in the I.C.U. Half of them are here for COVID, Pam estimates, and half were found to be COVID-positive when they were admitted for something else. (Many delivering mothers are also COVID-positive, so they and their newborns are in isolation.)
But the main problem is not pediatric COVID infections—it’s staff. A string of our senior residents have called out with infections, one by one. Many nurses and techs are also out—they have the virus themselves or their children do or they cannot find child care while their small kids are isolating after an exposure. Some of our nurses have left to become travellers—moving from hospital to hospital to fill short-term staffing shortages—and, at the same time, we are paying pediatric travel nurses to come here. Pam says that many of the nurses who have left are young. They have student loans and car payments and kids to support—never before have nurses been able to make the kind of wage that they can as travellers. But it means that instead of a solid team of pediatric nurses who know and trust each other—the kind of team that makes you keep coming back to work even when you’re weepy and exhausted—we have a mix of dedicated longer-term staff and newcomers. Our experienced nurses not only have to do their usual work but are also constantly training new staff.
I have not seen our experienced nurses falter in the quality of care they provide, but I worry for them as colleagues, people, and (often) fellow-parents. The nursing shortage affecting hospitals across the country right now is overlaid on a long-standing, global shortage of professional nurses. The shortage acts as an accelerant of nurse burnout by increasing workloads and stress levels for those who remain.
On those days when we are truly out of beds, we have to ground the pediatric-transport nurses and send them to care for kids in our E.R. or I.C.U. This means that some doctor or nurse practitioner out in that scrub country has to keep trying to make a child comfortable until we can open a bed (or they can find another hospital to take the kid). They do so without a pediatrician at hand, often without the special child-size masks and equipment that kids need, without a pharmacist who knows pediatric dosing by heart, without the ability to call an expert vascular-access nurse who can find a vein on a tiny, sick baby who needs I.V. access now, without a pediatric I.C.U. to swoop in and stabilize the child if they should suddenly worsen. We are the safety net for their sickest pediatric patients, and we are struggling.
Pam sometimes spends part of her mornings sending messages to every staff member who is not in the hospital at the moment, begging for their time. If they can come for any time at all—a whole shift, or even just two hours—she will take them. The calls keep coming in from outside hospitals: a baby with COVID and pneumonia, a kid with chronic kidney disease and a fever, a toddler who swallowed a battery and needs a pediatric G.I. specialist to pluck it out before it erodes through her gut. Most of the time, we’re able to cobble coverage together.
And then the day goes on. The medical team moves kids as quickly as we safely can from hospital to home, and, as soon as a discharge order goes in, Pam and her team prep the family, make sure a safe transport home is in place, and call in our environmental-services team to turn over the hospital room. When you walk around the wards, things can seem as usual—kids, families, doctors, nurses, somebody is breathing faster and needs more oxygen, somebody hasn’t pooped in a week—and you wouldn’t necessarily feel the strain. But sometimes the exhaustion rears up: a resident snaps back at me when I suggest a medicine, or a nurse says, flatly, “Yeah, I’m burned out.”
You cannot see the entire situation from inside any specific hospital room. When you try to look at it all, you wonder how long we can go on.
On Wednesday morning, I open my computer at home and log on to the hospital’s medical system. The toddler with the rash has started on antibiotics and an antiviral. Her chart now has a red banner at the top, indicating that she did, in fact, test positive for COVID.
I think of how close I was when she hollered, her breath into my uncovered eyes and onto my team members, two of whom were protected only by surgical masks. The whole family probably has the virus. I think of Teb—how he was planning to go straight from that overnight shift to an infusion suite for the immunosuppressant that keeps his autoimmune disease in check—and then of my own unvaccinated toddler son, asleep with just fifteen feet of air and a thin door between us. It seems only a matter of time until I bring the virus home to him.
Finally, I think of the girl herself, the straits she has crossed in her own short life to arrive in this particular America. By afternoon, she will be improving, and the team will begin work to send her home.
