PHILADELPHIA — Raspy cries and barky coughs echoed across the emergency room at St. Christopher's Hospital for Children on a recent chilly morning in North Philadelphia. Kids had just started to stream into the waiting room, yet every available bed was already filled.
Fifteen-month-old Zariya Sutton-Pack wheezed as she waited for medical attention on a hospital gurney. Her chest and rib cage heaved under a white cotton onesie. It looked as though she were trying to draw air through a collapsed paper straw.
"I just burst into tears this morning. I was so scared," said her mom, Tyshanek Sutton, still wearing the puffy black winter jacket that she hadn't had time to take off.
Within minutes of her arrival, emergency-room doctor James Reingold pressed a stethoscope to Zariya's back. He didn't like what he heard. A toddler her size should be taking 40 breaths per minute; her breathing rate was 52.
"This is really nerve-racking," Reingold said. Zariya needed to be admitted, but the hospital was full.
St. Christopher's sits in the bull's-eye of what pediatricians are calling a "tridemic," as RSV, flu, and COVID-19 strike all at once. All across the country, children's hospitals are overwhelmed from an unusually early and severe onslaught of seasonal respiratory viruses.
In this swath of Philadelphia — the nation's poorest large city — chronic disease and poverty have further aggravated the crisis. The neighborhood surrounding the hospital at Erie Avenue and Front Street has the city's highest rate of childhood asthma. More than 90% of life-threatening asthma attacks in children are triggered by respiratory viruses, according to Reingold, chair of the hospital's department of emergency medicine.
When virus and asthma collide, the resulting cyclone of respiratory distress can quickly lead to a hospital emergency for a kid who lives near St. Christopher's.
ER veterans at St. Christopher's have never seen anything like these last few months. And they fear the worst may be yet to come as the region heads into a winter where few people are still masking. Young children are now getting exposed to viruses for the first time.
After listening to her toddler's ragged breaths and racing heartbeat all night, a panicked Sutton drove Zariya to the hospital at first light. Just a few months earlier, her 9-year-old niece lost consciousness during an asthma attack. She called 911, but the girl's lips turned pale, then blue, during the long wait for an ambulance. Sutton, who herself has asthma, started chest compressions and mouth-to-mouth on her own. "It will never not be in my brain," recalled Sutton.
Now at the hospital, doctors suspected that her daughter had croup, a childhood virus that causes swelling in the upper airway, possibly exacerbated by asthma.
The longtime ER doctor was worried about how many cases like Zariya's could be on the way.
"If beds don't open soon," Reingold said, looking around the busy ER, "you'll see a slow-motion car crash as the day goes on."
7 A.M.: 16 children waiting; only 10 ER beds
At dawn, two days before Thanksgiving, Reingold made his way to St. Christopher's from his Center City home. The sun had not yet risen. He took the Broad Street SEPTA line north, then hopped on the No. 52 bus, getting off five blocks from the hospital.
He walked past a Coca-Cola warehouse, a sign-making plant, and auto-repair garages. Trucks rumbled up and down Erie Avenue. All spewing pollutants that contribute to asthma.
Such environmental factors aggravate asthma, Reingold knows, from soot in the air to crumbling homes with mold and cockroach allergens. Then there are the socio-economic stressors, like poverty, food and housing insecurity, and gun violence. A child's home zip code can often predict their likelihood of getting asthma. Many of the parents of children now seeking treatment at St. Christopher's for a virus-triggered asthma attack also suffer from asthma, which is not hereditary. They grew up in North Philadelphia as well and spent their own childhoods in and out of this hospital.
Reingold, 53, became head of the ER at St. Christopher's this past May. He had never seen asthma sicken kids like this in his more than 20 years in pediatric emergency medicine at other hospitals, including Children's Hospital of Philadelphia in University City. Within two weeks of starting at St. Christopher's, two kids died of asthma in the ER, Reingold said.
"The children here are way sicker. I had several children who truly frightened me, and I do not scare easy," Reingold said. "I would listen to these children breathing and think, 'We maybe have minutes to turn this around or they are going to die right in front of me.'"
Reingold knows many of his patients have few options beyond his ER. About 87% of kids treated at St. Christopher's rely on Medicaid, the federal health insurance program for people with low incomes — the highest of any children's hospital in the country, Reingold said.
As his shift started at 7 a.m., the overnight ER doctor briefed Reingold on patient caseloads. The nationwide nursing shortage had left St. Christopher's ER down by five nurses that morning, and only 10 of the hospital's 34 emergency beds could be used.
In recent days, the ER has reached 100 kids waiting to be seen.
"We'll have more kids just in the emergency department than in the whole hospital," Reingold said. "It's absurdly overcrowded."
Most of the families will wait up to 12 hours without complaint, but late last month, the hospital had to hire armed guards for the ER's waiting room, "because families get so stressed and angry and they start fighting with each other and they start threatening the nurse," Reingold said.
10 A.M.: Number of kids in ER doubles to 32
Reingold scrolled through the individual cases on a computer screen: Cough. Wheezing. Shortness of breath. Fever-cough.
Four kids were waiting for regular beds to open; two of the four had spent the night waiting — one had been there for 11 hours; the other, 10 1/2 . That left six beds in the ER — all taken.
The rest of the children sat glassy-eyed, or slumped over a parent or guardian seated in white folding chairs. In two crowded waiting areas, seal-like coughs, some so violent their parents feared their child would vomit, punctuated the air.
"Everyone out there can't breathe," said Awilda Torres, nurse manager of the emergency department. "We're focused on getting the sickest kids back."
Zariya, Tyshanek Sutton's daughter, was taken back right away. Reingold diagnosed her with croup and eczema, which he calls "asthma of the skin." He prescribed a breathing treatment of steroids and epinephrine to shrink the lining of the toddler's airway.
John Smith, the only respiratory therapist on duty in the ER that morning, rolled breathing equipment, like nebulizers, from one kid to the next. At 8:04 a.m., he stopped in Zariya's room.
"We're going to put this mask in front of your face, and it's going to help get you breathing, OK?" Smith told Zariya.
Hissing steam rose from the infant-size face mask. The 15-month-old began to cry. She pushed it away.
The respiratory therapist guided the mask — shaped like a dragon with pink eyelashes and googly eyes — back over her face.
"Yes, honey, it will make you feel better," he said.
11 A.M.: More nurses arrived; eight new ER beds open
Just around the corner from Zariya, in a curtained-off bay, 10-year-old Leyshlianie Medina sat upright on a gurney with a breathing mask strapped to her face.
The girl, clad in red Snoopy pajamas, was wide-eyed and teary as her stomach rapidly caved in and out like a fish thrown on a dock.
"She gets scared like that when she gets sick," said her mother, Arisdelis Mendez, 31, who had tried to avoid the ER by giving Leyshlianie puffs on her inhaler, filled with albuterol, throughout the night.
Leyshlianie shook her head "no" vigorously when Reingold asked if she felt any better. She should be breathing 20 times a minute, Reingold observed, but her breathing rate was in the 50s, and her oxygen level was way too low.
"It's frightening. It's terrible to feel that way," Reingold said out of earshot.
A flu-like virus had swept through Mendez's home. Reingold checked the breathing of Leyshlianie's 14-year-old sister, Marian, who was there for a cough and chest pain. Their 9-year-old sister Jelianys was there too because their mom didn't know how long they'd be in the ER and she didn't want to leave the youngest home alone after school.
Meanwhile, the ER grew more crowded.
In a bay toward the back of the ER, Valerie Manigat fretted over her 5-month-old daughter, Kamyrah. This was her second trip to the ER within a month.
In late October, Kamyrah got RSV that worsened to bronchiolitis, an inflammation of the small airways. The infant was hospitalized and on oxygen for two days.
Now, she was back with rapid breathing, wheezing and coughing, and a crusty and dry mouth — a sign of dehydration.
Kamyrah sucked on a pink binky in coral-colored footie pajamas. She looked doll-like in the middle of a wide hospital gurney. Lines, hooked up to oxygen and heart-rate monitors, trailed from her tiny body.
Reingold ordered some Pedialyte to help hydrate her, but the staff couldn't find any. "We're supposed to have it," Reingold sighed in frustration. He closed the curtain so Manigat could try to get her daughter to breast-feed.
Manigat, who has three other children, has called out of work at least five times to tend to Kamyrah since taking a new job as a dental assistant about two months ago. Now, she was worried not only about her baby girl, but also keeping her hourly paid job.
Reingold called this the "ripple effects" of the ongoing virus battle. Parents miss work; kids miss school.
And too often, the cycle repeats in a matter of days or weeks.
2 P.M.: The backlog grows to 41 kids
Triage nurse Jeanne Mackley zoomed down the hallway with a little boy and his mom in tow. She escorted them into Room 113, handed the boy a "Purrble," a stuffed bearlike animal that purrs and vibrates, and shut the door.
"Asthma! But he sounds kinda croupy too," she yelled to the ER staff as the sound of the boy's coughs carried through the door.
Mackley sprang into action each time a child and parent walked through the ER door, checking for signs of respiratory distress too dire to let wait: flailing nostrils, caving stomach-breathing, gasping.
She decided which kids were the first priority for medical care, at times angering other waiting parents.
Dressed in neon-yellow scrub pants and "The Flash" superhero costume top, the 52-year-old nurse chased down 4-year-old Abigail Reyes, who didn't want to take oral steroid medication to help open her airways.
"It's nasty tasting. She had it before. She made a run for it," Mackley said with a laugh.
Between evaluations, Mackley handed out blue raspberry Popsicles and apple juice containers in hopes of calming cranky kids.
By midafternoon, the ER was so jammed, some parents lined up in a narrow hallway. Their only option for food came from a vending machine with Lance peanut butter crackers and Kar's trail mix.
As a mounted television tuned to Nick Jr. blared, Jada Ballard sat against a wall painted with a train with animal passengers. Her son, 4-year-old Jayce, leaned against her shoulder, his eyes half-closed.
He never had a problem with asthma until he got COVID-19 at age 2, she said. Now, even the slightest cold triggers an asthma attack.
This time, he woke up at 4 a.m. with a 103-degree fever and cough. Mackley gave him some ibuprofen and a Popsicle as he waited for eight hours to be seen.
By the time Jayce was escorted to an ER room around 3 p.m., his heart rate was elevated and his oxygen was low. But the ibuprofen had kicked in, and his fever broke. The boy scooted around on the floor playing with Lightning McQueen cars.
"He's no longer zombie-fied," his relieved mother said.
4 P.M.: The ER swells with 62 kids
It was late afternoon, and hospital staff knew the night would only get worse, especially with flu cases rising in the Philadelphia region.
In an ER bay, 8-month-old Nasir Hurst had cried for hours, his airways alarmingly tight.
His mom, Nazhay Gaffney, hadn't slept all night. Her nerves were frayed from watching her son's stomach suck in and out like a roller shade beating against an open window on a blustery day.
Finally, Nasir stopped crying and fell asleep in his mom's arms. A breathing treatment had worked.
Reingold poked his head in to check on them. He said he'd send her home with a portable nebulizer. She began to sob softly.
"Now I know he's going to be OK," she told Reingold through tears.
