Where should I begin when describing a period that seemed to have no end in sight? When we, as pediatric emergency department (ED) providers, felt like we were drowning in a tsunami of pediatric patients coming from every direction – from adult EDs needing to transfer seizing children for a higher level of care, from EMS coming in with apneic neonates, and from the endless supply of those from the waiting room? How can I explain the frustration of both providers and families towards the exceptionally long wait times, the intensity of shifts when facing the sheer volume of children acutely needing care, and the feeling of hopelessness for not being able to do more?
It seems fitting to describe it as the period of being “at capacity.” This phrase, uttered an innumerable number of times in our ED during the fall of 2022, in many ways encapsulates the experience of working during the “tripledemic” of RSV, Influenza, and COVID-19. As this vortex of viruses took the pediatric health care system by storm, it tested the limits of resources on all fronts, including those of pediatric trainees. As a third-year pediatric emergency medicine (PEM) fellow, I had personally never before experienced such an intersection of volume, acuity, responsibility, and strain upon providers and systems in the hospital setting.
When I started my fellowship in the summer of 2020, “at capacity” was not yet a term in my vocabulary. Volumes, at least in the pediatric ED, were low. Through the fall and winter, RSV was nearly non-existent in comparison with prior years. We learned how to adapt to constantly wearing N95s and how to diagnose likely MIS-C. We raced to sign up for our first COVID vaccine and celebrated, albeit cautiously, when each wave of disease seemed to have crested its peak. As masking and social distancing mandates weakened, daycares and schools re-opened, and the usual viruses began mounting a slow resurgence. My first intubation of a baby with bronchiolitis occurred in July of 2021, and marked, at least for me, the start of the type of pediatric ED experience I had imagined fellowship would provide.
I did not, however, anticipate the deluge of viruses that descended upon the pediatric population in the fall of 2022 and the impact it would have upon families, providers, and the pediatric hospital infrastructure as a whole. Suddenly, “at capacity” became a new reality as our volumes increased by over 5000 ED visits per month. PICU beds quickly filled as cases of respiratory failure requiring both non-invasive ventilation and intubation rose. Available general pediatric inpatient beds also became a rare commodity due to the sheer number of patients requiring oxygen, intravenous fluids, antibiotics, and a host of other interventions. We were inundated by both previously healthy children being sickened by common viruses and by more medically fragile children suffering complications as a result of their underlying conditions. The ED rapidly became the middle ground for the exponentially growing number of children requiring care. With both critical care and the inpatient services “at capacity,” there was nowhere to admit patients. Our ED rooms are filled with “admit holds” — patients who would normally be cared for by hospitalists, specialists, or intensivists. In these times, we had no choice but to be the generalists, rounding on our boarding patients with bronchiolitis and gastroenteritis and calling our specialists or intensivists for assistance in managing our patients with hypertensive emergency, acute ischemic stroke, or fluid-refractory shock. With our ED beds “at capacity,” as so many were filled with those awaiting inpatient admission, we could no longer keep pace with the waiting room. Both the truly ill and the worried well lined the hallways once our typical waiting area was “at capacity.” Pediatrician visit availability was scarce, particularly for our disadvantaged and uninsured population, and they flocked to the ED for evaluation. Wait times for those triaged as having less acute presentations frequently exceeded 8 hours, and rates of those who left before ever being evaluated by a provider predictably rose. EMS continued to roll in with patients from home, from school, or from practice who required emergent evaluation and, not infrequently, immediate resuscitation. Calls from outside hospitals flooded in as they hoped to transfer pediatric patients to our ED—yet when our own facility was bursting at the seams, we sometimes had to admit that we, too, were “at capacity” and could not accept one more transfer at this time.
Not only were our facilities “at capacity” physically, but our staff were also asked to operate “at capacity” from the moment their shift began until after their relief came hours later. Looking at the ED track board and seeing over 100 patients in the waiting room was defeating, as it was logistically impossible to move them all through our limited number of open rooms. While just the volume alone could be overwhelming, the acuity of patients presenting during this time was also astounding. This fall, a 4-day stretch of my shifts brought a code or peri-coding patient on each of them. After unsuccessfully attempting to resuscitate a neonate found down at home on Thursday, obtaining the return of spontaneous circulation in a young child with arrest in the setting of a failing Fontan on Friday, preventing the arrest of a toddler in extremis with a hemoglobin of 1.9 mg/dL on Saturday, and running a code which resulted in an ED thoracotomy on Sunday, I was wary of what Monday would hold. And though the degree of critical care was by nature, taxing, more taxing, perhaps, were the endless related and unrelated needs that waited—from calling the medical examiner and the tissue bank to doing our best to explain to families what had just happened in the resuscitation bay, and to return, without time to process, to the host of stable patients anxiously awaiting evaluation and disposition. Each shift, for 24 hours each day, brought a never-ending onslaught of patients and asked us to dig deep into our reserves of strength, intuition, clinical training, empathy, and compassion. Exhaustion at the end of a shift was tempered by gratefulness for being able to make a small difference; relief at the possibility of going home to rest was confounded by guilt for not being able to do more.
And yet, while so much was demanded of us, the pediatric medical system as a whole somehow stretched its capacity in the attempt to meet more of the needs of our patients. In the ED, we opened “internal waiting” spaces to expand our patient care area and move patients from the waiting room to a place where a provider could see them. ED fellows additionally took on the role of residents during regular and extra shifts, working to evaluate and treat as many new patients as possible. PICU fellows and attendings came to help manage boarding critically ill patients when we had reached our capacity for stabilization. Specialists started rounding on complex patients who spent days waiting for inpatient placement and opened available beds on their teams to patients with general pediatric indications for admission. The hospitalist team increased their capability to admit patients who might have otherwise required specialized or critical care and worked to establish a service to manage low-acuity patients in the ED itself. In the face of staffing shortages leftover from the pandemic, nurses and techs worked incredible amounts of overtime to keep their department, and by extension, our ability to care for pediatric patients, running.
What have I learned from this experience? What do I take away, and how have I grown as a physician, a colleague, and a team member? As both influenza and COVID numbers seem to have receded, staffing shortages have been largely eliminated, and life has returned to a steady state in the ED, how can I use the memory of this time to inform my present and future patient care? I will take to heart the memory of parents waiting over 10 hours for their children to be seen and remind myself of how much fear, love, and care prompts each ED presentation. I will remember the teamwork which made treating patients possible. None of our efforts to triage, resuscitate, transfer, admit, or discharge would have been successful in a vacuum. Even though the crisis has passed, we still need the same degree of collaboration to continue to effect change improve care. And finally, I will strive to serve my patients and teammates with an increased capacity for empathy, for asking for assistance when I have reached my limits, and for gratitude for this incredible opportunity to care for patients and their families in the ED, no matter the circumstances.
Jacqueline Bolt is a pediatric emergency medicine fellow.
