Waiting for their turn in the ER, dazed-looking parents in winter coats bounce crying children in their arms, trying to catch the eye of Dr. Erica Michiels. Us! Pick us next! they seem to plead with tired eyes.

Michiels directs pediatric emergency medicine at Corewell Health Helen DeVos Children's Hospital in Grand Rapids, Michigan. Lips pressed together in a thin line, she surveys what she calls the "disaster" area.

"People have been out here waiting for a couple hours, which is heartbreaking," she says.

Typically, the ER at Devos Children's sees about 140 kids each day, according to Michiels, but on a recent Tuesday in mid-December, they saw 253.

"I hate when we have a wait," sighs Michiels. "But for right now, we can't do it any other way."

Like so many other children's hospitals across the nation, the staff at DeVos Children's has been stretched beyond capacity by waves of patients with RSV and, increasingly, the flu.

This surge of sick kids is coming after years of some U.S. hospitals cutting back on pediatric beds — in part because it is typically more profitable to treat adult patients.

The remaining pediatric beds are increasingly concentrated in urban areas, leaving families in rural areas to travel longer and longer distances to get the care their kids need.

When the local ER can't help

When Staci Rodriguez brought her nine-month-old son into the ER in their small town of Shelby, Michigan, she was desperate. Santi, who has big brown eyes and long eyelashes that everybody gushes over, had been sick for days.

First Santi stopped eating, so she took him to urgent care. Then he started sleeping 20 hours a day, so she went to the pediatrician. Rodriguez says everyone told her Santi was just fighting a virus, and sent them home.

Within hours of leaving the pediatrician though, Santi "was so much worse," she says. "His fever was way too high. I couldn't get it down." She took him to the ER, where doctors told her Santi had RSV, and that his oxygen saturation levels were dangerously low.

Rodriguez says staff at the Shelby hospital told her they couldn't give him the care he needed, that they didn't have the proper equipment.

Out of 130 acute care hospitals in Michigan, only 10 currently have pediatric ICUs, according to the Michigan Health and Hospital Association.

The ER wanted to transfer Santi immediately, but Rodriguez says that first there was an agonizing wait while the medical team deliberated where to send him: Muskegon was much closer, but DeVos could offer more intensive care. "So they sent us to DeVos, and he had to ride in the ambulance."

The trip took an hour. "I thought I was going to be able to hold him," Rodriguez says.

But for safety, Santi needed to be strapped to the stretcher. "Luckily, he just kind of stared at me the whole time, and then eventually fell asleep."

Rodriguez watched the beeping monitors as she recounted their story in the hospital room at Devos Children's, which has been partitioned to make room for another sick infant and his family.

Moments before, six staff members had assembled around Santi's bed, speaking in soft tones as they worked to thread a tiny feeding tube through his nostril. Next they held down his chubby arms, and kept him still even as he wailed, so they could take an x-ray to confirm the tube had been placed properly.

Now Santi lies comfortably on his mother's chest, a small oxygen tube taped to his face. His breathing is labored, and he struggles against sleep, keeping both his eyes on his dad, Saul Botello.

"I hate seeing him like this," Botello says, his hands in his sweatshirt pocket, his own eyes glued to his son. Eventually, Santi's heavy lids close, and he slips into a fitful sleep in the hospital crib. His mom rubs his back, shushing him softly.

"He'll be fine, just have to support him through [this]" says Dr. Andrea Hadley, chief of pediatric medicine at DeVos.

Turn kids away, or stretch staff even further?

Hadley is the one who gets the desperate calls from smaller hospitals or freestanding ERs in rural areas, asking if they can transfer their patients to DeVos Children's. "I have had many calls come in where they said 'We've called 15 other places and they've all said no.'"

Big children's hospitals like DeVos regularly get transfer requests. But in recent weeks, the calls are coming from a much larger geographical area, including parts of Illinois. Patients who live in Michigan's Upper Peninsula typically go to Wisconsin for care, Hadley says. But now, those hospitals are full, too.

In response, DeVos Children's has doubled up their rooms, squeezing two patients (and their families) into rooms meant for one. The hospital is also allowing no more than one parent or guardian to stay overnight. Even with those changes, Hadley says, the hospital only has capacity to care for the sickest children.

"We've had to say, 'We see you, we're going to support you, but we can't bring you here yet.'"

Hadley says that in the past, they'd take all the referral requests.

Across the health care industry, pandemic-era staffing shortages are adding to the strain. Michigan has lost 1,700 staffed hospital beds since 2020, according to the Michigan Health & Hospital Association. That's left children's hospitals scrambling during this RSV and influenza surge.

At the Children's Hospital of Michigan in suburban Detroit, there's only enough staff to cover about 60% of the beds, according to chief medical officer Dr. Rudy Valentini. With 40% of beds unavailable, children who need to be admitted have to wait in the ER until a bed opens up.

"So we have ICU patients in our emergency department that can't get up to our ICU, because either there's no available beds, there's no available staff beds," Valentini said December 6th.

The sheer number of pediatric patients, the bed closures, and the staffing shortages have created a perfect storm for children's hospitals, leaving them with difficult decisions.

"There's also a moral distress associated with the thought of having to turn patients away," Hadley says. "And how do we balance that distress that comes with knowing potentially, if we as a system don't stretch a little more, that there might be patients that are turned away?"

But stretching staff who are already "on the brink of burnout" comes with its own risks, explains nurse manager Jamie West. On her floor at Helen DeVos Children's Hospital, there are enough nurses to safely care for a total of 18 patients. But recently, West says they've had to stretch the same number of nurses to care for up to 33 seriously ill patients. They don't have enough electronic monitors for every patient either, Hadley adds.

"These kids are just so much sicker [than we typically see during RSV season,]" West says. "And when you think about nurses that are already in very large patient assignments, nurses are very worried that their child's going to go downhill very quickly, that they're going to maybe miss something because they're spread so thin."

'You're not going to send us home, right?'

In the emergency department at DeVos Children's, Dr. Michiels is a constant blur of motion. One moment, she's doing a sepsis work-up for a 12-year-old boy whose fever won't break. The next moment, her pager goes off and she's striding down a long linoleum hall to the room that's been designated as the "resuscitation room." Staffers try to keep that one room open, Michiels says, for "the next blue baby" who's rushed in.

In a room at the end of the hall, Caitlyn Houston hovers over her seven-week-old daughter, Parker, as nurses tie a small band around the baby's flailing arm. Parker's reddened face bunches up in distress, her cries filling the small room. We're going to admit her, Dr. Michiels tells Houston, and probably to the pediatric intensive care unit.

Still Houston can't help but ask: "But you're not going to send us home, right?"

No, Michiels reassures her softly. The two of them can stay. Houston says they've spent the last several sleepless nights in and out of the ER.

"There's so many kids in here that they have to take the ones that are really bad," Houston says.

"And even two nights ago in the middle of the night, the ER was packed. So we were there for 2 hours, waiting."

Being told your infant may need lifesaving medical intervention is never good news, but for parents like Houston, being admitted to the hospital brings a feeling of relief. Their child will at last get a bed.

This story comes from NPR's health reporting partnership with KHN (Kaiser Health News) and Michigan Radio. It was edited by Carrie Feibel, with photo editing by Max Posner.