No Room at the Inn

Pale and gasping for breath, the thin, elderly man stumbled into the emergency room complaining of fevers and a wet cough that had worsened over the previous week. Coughing spells had prevented him from sleeping, and his panoply of emphysema inhalers did little to quell his wheezing.

This was months before “coronavirus” and “pandemic” became household words, and the colleague taking care of him was distraught. “He needed to get to an intensive care unit right away,” she told me. But instead, sandwiched between one patient with a finger laceration and another suffering from chest pain, the man ended up waiting for several hours on a narrow gurney in an open emergency room bay.

The hospital census was high that day; patients had no option but to wait in the overcrowded E.R. until a bed became available. With ever sicker patients pouring into the emergency room, the nurses and my colleague could do little more than give the man an initial round of medications and place him on a monitor to watch his oxygenation levels before running to the next new patient.

Several hours later, after an elaborate logistical Kabuki dance involving discharging hospitalized patients and temporarily “boarding” other critically ill patients in makeshift I.C.U.s, the elderly man moved out into the medical intensive care unit to get the care he needed.

“It made me really nervous to hold that man down here for that long just waiting for a bed, but it’s that same old problem,” my friend confessed later. She shrugged her shoulders, then repeated a phrase familiar to any health care provider: “There was no room at the inn.”

As I have watched the new coronavirus quickly spread across the world, that phrase — “There’s no room at the inn” — rooted in the Christmas nativity story and originally used to describe the lack of altruism toward strangers, has played over and over again in my mind.

The U.S. health care system has been struggling with severe overcrowding in emergency rooms for many years. Researchers have pointed to several factors, including inefficient processes for seeing patients, more E.R. visits by the uninsured and a growing dependence on emergency room services by referring doctors. But most health care experts believe that the biggest culprit by far is simply too few beds, along with a lack of doctors, nurses and the medical equipment needed to care for each admitted hospital patient.

This bottleneck at the gateway of American hospitals has led to as many as two-thirds of all emergency room patients, sick enough to be hospitalized, sitting in waiting rooms, “boarding” on stretchers in emergency room bays or dozing in chairs in the hallways until a bed opens up. With patients crammed in every available space, E.R. nurses and other health care providers quickly become overwhelmed, leading to fatal medical errors and significant delays that affect the outcome of patients who have suffered heart attacks, strokes or infections.

The pressures on an already overextended system intensify during annual outbreaks of influenza, peak periods when hospitals and emergency rooms sometimes revert to “diversion,” redirecting ambulances to other emergency rooms in an effort to relieve overcrowding. While such diversions can provide temporary relief at one hospital, it can also lead to a domino effect, pushing other surrounding emergency departments beyond their limits. Most importantly, for critically ill patients, diversions mean delayed care, putting them at risk for worse outcomes and higher mortality rates.

Whenever I am asked for my professional opinion about coronavirus, I think about our country’s already overcrowded hospitals and overwhelmed health care providers. And I think about a virus that is more contagious than the seasonal flu, a virus with such a remarkable avidity for lung tissue that a significant number of patients — likely someone we know — can progress from cough to respiratory failure in a matter of days.

While there are vaccines and medications to attenuate the repercussions of seasonal flu, there is little health care providers can currently do to mitigate Covid-19’s devastating effects. In the best of circumstances, the only thing doctors and nurses can do for a patient with a severe coronavirus infection is to support that person’s breathing with ventilators and advanced supportive care.

But only if there is room in the inn. Only if there are beds, medical equipment and health care providers.

Covid-19 will be of minor medical consequence for most of us. We might experience the inconveniences of a passing cough, a spell of work from home, and a temporary shortage of our favorite hand sanitizer and disposable disinfecting wipe. But for those of us in the lucky majority, the most important thing we need to remember is that we can do something not only for ourselves but also for others. The good news is that we can afford to be altruistic at a time when not doing so could have devastating consequences.

All we need to do right now is to begin practicing the social distancing recommended by the Centers for Disease Control and Prevention along with common sense mitigation measures. Stay at home if you develop a tickle in your throat. Don’t drop by urgent care clinics at your first cough. Avoid emergency rooms unless you are beginning to have difficulty breathing. And use the phone to call your doctor if you have any questions about where to go.

By slowing the rate of infection — and thus the rate of severe infections — we can avoid overwhelming our already overcrowded emergency rooms, overstressed hospitals and overworked health care providers. We can create room in our health care system.

Dr. Pauline W. Chen, the author of “Final Exam; A Surgeon’s Reflections on Mortality,” is a physician who practices in Boston.


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