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It’s a cliché but the horse is out of the barn. There is no doubt that coronavirus is widespread in the United States and the situation is getting worse. No one — not the government, not hospitals — are addressing the elephant in the room. There are not enough nurses to care for a worsening coronavirus outbreak in the U.S.

With decreased reimbursement, hospitals run a tight ship. Hospitals don’t even staff for full capacity. They staff for their average census throughout the year. When there is a surge, they count on nurses to work extra: overtime. Many offer bonuses in this situation. For example, in the ER I worked in, there is a program called the capacity alert. When they are desperate, they put out a page to nurses. If you come in, you receive double pay. There was rarely a day that one of these pages didn’t go out. I doubt nurses will come in extra during the peak of this crisis.

The same capacity alert system exists in the ICU. Few people in this country realize the complexity of nurses’ jobs these days. Nurses literally hold patients’ lives in their hands. An example of this is the advent of ECMO (extracorporeal membrane oxygenation). ECMO has become commonplace in larger hospitals. Due to its complexity, the standard of care is a two nurse assignment. Consider the fact that every coronavirus patient in an ICU will probably require ventilation and management of multiple drips.

I anticipate the majority of patients in a hospital will be coronavirus patients. Priorities in hospitals will be reordered. Critical care beds will be increased. Some nursing stations will be closed and nurses reassigned. You really can’t reassign medical/surgical nurses to ER or ICUs. If this gets as bad as anticipated, other facilities outside hospitals will be set up to care for patients.

This is where we get to the bottom line: Who will care for all of these patients? There are not enough nurses in the workforce to staff this situation. How about the military? Will they step in? Probably. The problem is most nurses in the military staff military hospitals.

How about the reserves? The problem is most nurses in the reserves have civilian jobs. There is something called the Medical Reserve Corps, a volunteer organization that sends health care personnel to help in a disaster. I venture to guess most of these nurses are already employed elsewhere.

So where do we get the nurses? Retired nurses? It’s a possibility. In Italy, there was a plan to try and recall retired nurses and doctors. They may be the only way to increase staffing numbers.

It is estimated there are 200,000 nurses in the country right now. Nurses will become sick and therefore unavailable. I do not hear any plan to address staffing shortages in this situation. It puzzles me. It is at the very core of the pandemic. It will determine life and death. Why is it not being talked about? Why are doctors not anticipating this? It is a devastating mistake. I can assure you nurses are thinking about this and they are scared to death.

Susan Shannon is a retired nurse who blogs at madness: tales of a retired emergency room nurse.

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Trusted clinician commentary on COVID-19 coronavirus from the KevinMD community.