In December, the questions parents ask in the hospital are different. Instead of “Will my child be OK?” we pediatric hospitalists hear:

“We have plane tickets to go skiing for Christmas. Will he be well by then?”

“She’ll be home for Christmas, right? We’ve never been away from home for Christmas.”

“It’s his first Christmas. He’ll be discharged by then, right?”

And every other variation you can think of. The hospital for Christmas is not what anyone wants, but it is what some children and their families get.

Over the years, I learned how to say,

“I hope he’ll be ready to go home by Christmas, but I can’t promise.”

“I don’t think skiing is in the cards for you this year. I can write a letter to send to the airlines to help you get a refund.”

“I’m sorry to tell you, she will definitely be here for Christmas. And we will take great care of her.”

“Yes, your baby is still going to be in the hospital, and by the time she’s a teenager, she’ll be sick of hearing you tell the story of how she spent her first Christmas here.”

Winter is always a busy time in a children’s hospital; there is more sickness, so there are more admissions. It’s a bustling place. We struggle when the “house is full.” We often have no available beds, so there’s a juggling act that goes on.

There are patients in the ER who need admission. There are ICU patients who have improved enough to leave the ICU and come to a regular room. There are surgical patients coming out of the OR who need a room. And of course, there are patients who are worsening, who need to go to the ICU. Add to this the patients in other hospitals who need to be transferred to us for specialized care. When we are operating at 100 percent capacity (which is often in the winter), there is nowhere for any of these patients to go.

So, the first order of business every winter morning is to decide who is improved enough to be discharged. It takes a while for doctors to review lab work, learn how patients did overnight, decide who can go home, and meet with them. Then there are IVs to remove, bandages to change, medications to review, and equipment to go over. More time passes while families arrange transportation, pack up, get all their discharge instructions, and actually leave the room. Then, the busy and meticulous housekeeping team must clean the rooms. The precise room cleaning protocol, designed to keep the next patient from catching anything the last patient had and to keep the housekeepers safe, takes over an hour. (Among the many unsung heroes in children’s hospitals, housekeepers rank pretty high on my list.) Then, once there are available rooms, the dominoes can begin. Of course, the surgical patients need a room on the surgical floor, the pneumonia and asthma and RSV patients need to go to the respiratory floor, etc. Thankfully, the house supervisor (a nurse wizard) is adept at making sure everyone ends up where they should be.

But all of this is behind the scenes. If you are a patient or a parent, you don’t see this. For you, what is most evident is that the nurses are chattering about Christmas decorations (Shall this year’s theme be Santa, reindeer, elves, or snowflakes?). Small tabletop Christmas trees sprout in most patients’ hospital rooms. Every day, kind-hearted volunteer groups visit the hospital to sing carols, distribute gifts, donate toys, and add to the excitement the children already feel. Football teams come to sign autographs, basketball teams bring swag, racecar drivers park a cool car outside for kids to sit in. A huge Christmas tree brushes the ceiling of the two-story hospital lobby. There’s a calendar of events for the kids who are well enough to leave their rooms: face painting, construction paper Santa hats, popsicle stick North Pole houses, cookie decorating. Some nurses dress as elves. Even doctors can be seen wearing festive Santa hats or Christmas tree earrings. One year, a snow machine was put on the roof, and magically, snow fell for several hours, drifting down past patients’ windows on Christmas Eve afternoon.

About December 23, the hospital starts to empty out, sort of. Cancer patients have had their chemotherapy schedules carefully arranged months earlier so that Christmas can be spent at home, if at all possible. All elective surgeries have already been done and children are recovering at home. On December 24, any child who can possibly be discharged goes home, with grateful parents. The census is as low as it ever gets in the winter. What a blessing.

And what about the children who spend Christmas in the hospital? The hospital makes sure that, late at night on Christmas Eve, Santa comes to each and every child in the hospital, leaving a sack of presents hanging on their door. Even the premies in the NICU get a gift from Santa. As much as possible, good memories are made when children spend Christmas in the hospital.

The sad reality is that the patients who are still in the hospital are really sick. And any child who gets admitted on Christmas Day really has to be in the hospital. So, although the numbers may be lower, the intensity is higher. The doctors, nurses, respiratory therapists, and other staff who work on Christmas must be at the top of their game. They work hard.

Lunch on Christmas Day is a potluck affair, held in the nurses’ break room, with casseroles, brownies, sandwiches, and pies brought from home and shared. People eat in shifts, darting in and out between taking care of patients. There’s not much complaining. Everyone knows that’s just how it is. They will have Christmas with their family tomorrow, or tonight.

For many years, on Christmas Day, a Jewish civic group volunteered in our hospital, doing any job that could be done by non-medical personnel (working at the information desk in the lobby, stocking supplies, rocking babies) so that Christians who celebrate Christmas could have the day off.

We all know a young man who saves his allowance and lawn-cutting money all year so he can stand at the cash register in the cafeteria, wish each parent a Merry Christmas, and pay for their lunch on Christmas Day. He’s done it for years. He remembers being in the hospital on Christmas and wants to give back.

Working in a children’s hospital has opened my eyes. I now know that people are at their best during Christmas, especially in the hospital.

Ann F. Beach is a pediatric hospitalist.