By Dhruv Khullar

Travelling nurses have been moving from one hot spot to another. What happens when the hot spots keep multiplying?

Just how big is the coronavirus’s winter wave? It can be hard to get your mind around it. One way to try is to note that, right now, more than a hundred thousand Americans are in the hospital with covid-19—which is roughly as many people as can fit into the country’s biggest stadiums for the Super Bowl, and nearly twice as many as were hospitalized during the pandemic’s worst days in April and July. Another is to note that, around the U.S., hospitals are running out of nurses and doctors. At least half of all states are now facing staff shortages, and more than a third of hospitals in states as varied as Arkansas, Missouri, New Mexico, and Wisconsin are simply running out of staff.

Ordinarily, an I.C.U. nurse might care for, at most, two critically ill patients at a time. Now, some are caring for as many as eight patients simultaneously. Recently, North Dakota’s governor issued an order allowing asymptomatic but coronavirus-positive health-care workers to continue seeing patients. (People without symptoms can still be infectious.) In most of California, I.C.U. usage now exceeds eighty-five per cent—the threshold above which new stay-at-home restrictions kick in. Since the beginning of the pandemic, the nation’s hospitals have developed protocols and purchased ventilators, and the mortality rate has fallen. But now the spread of the virus is so extreme that a shortfall of clinicians is becoming an insurmountable barrier in the fight against covid-19.

Alexi Nazem is the co-founder and C.E.O. of Nomad Health, a medical-staffing company based in New York City. Nomad fills physician and nursing needs across the U.S.; it sends nurses, in particular, to hospitals big and small, urban and rural, from coast to coast. Nazem has marked the evolution of the pandemic by the scale of the job orders he’s received, which have shifted, more or less, with the seasons. “It’s been a remarkable roller coaster,” he told me recently. In the spring, it was a “five-alarm fire.”

There were unprecedented needs in New York and other early epicenters, but hospitals around the country felt compelled to staff up, too. “No one had ever experienced anything like it,” he said. “Hospitals looked around and saw that the covid light switch could flip overnight. They thought the same thing would happen to them. There was an explosion of job orders from all over.” For the most part, though, covid-19 patients didn’t materialize; many hospitals, having postponed elective procedures and non-urgent visits, sat empty and ended up cancelling their staffing requests. “It was complete whiplash,” Nazem said. “They said, ‘Actually, we don’t need all these extra people. We can’t even afford to pay our regular staff.’ ”

In the summer, when the coronavirus surged across the Sun Belt—in Florida, Texas, Arizona—Nazem’s company sent clinicians to affected states. But hospitals elsewhere didn’t feel the need to bolster covid-19 staffing. “Hospitals were more experienced by then,” Nazem said. “They weren’t over-ordering.” The composition of new job requests also shifted. Many hospitals were staffing not for coronavirus wards but to help in operating rooms and procedural suites that had postponed cases and were now running overtime to work through huge backlogs of colonoscopies and knee replacements. “These specialties were the worst hit in the spring,” Nazem said. “They were among the hottest in the summer.”

Now the need for clinicians has erupted again. “It’s been insane,” Nazem said. “Orders are coming from everywhere. There are no hot spots. It’s crazier than we’ve ever seen.” In the past, Nomad Health has provided hospitals with nurses who will work specifically on covid-19. “It’s now impossible to distinguish by job,” Nazem said. “Hospitals are saying, ‘Just come. Who knows what we’ll need you for.’ ”

Given the current wave’s persistence, hospitals are renewing contracts for travelling nurses at unprecedented rates, effectively taking them out of circulation. “The number of extension requests tripled from summer to fall,” Nazem said. “The market is getting tighter and tighter. Hospitals are saying, ‘Let me hold on to whatever I can.’ ” In the past, they were picky about whom they would hire. “They used to say, ‘We need the perfect person,’ ” Nazem told me. “Now they say, ‘If you find someone, anyone, send them over.’ ” (Nomad Health thoroughly reviews credentials for each clinician; Nazem was at pains to say that quality has not been compromised.)

In normal times, there are some fifty thousand travelling nurses in the United States. Most are full-time gig workers who move from job to job, usually staying in one place for thirteen weeks. (That length is a holdover from old maternity-leave policies for nurses; the staffing industry evolved, in part, to fill such gaps.) According to Nazem, travelling nurses generally fit two profiles. One group consists of early-career nurses who want to acquire a range of clinical experiences—academic, urban, rural—and to travel the country. Another includes nurses at the end of their careers: “They say, ‘Hey, the kids are out of the house. I’d like to make some extra money. Wouldn’t it be fun to go to Alaska for the summer?’ ”

The pandemic has diversified the pool. Severe staff shortages have brought more nurses into the travelling workforce. Many clinicians, especially those with critical-care training, feel an obligation to help. But, because demand has far outpaced supply, pay for travelling nurses has also skyrocketed. “Traditional nurses look around and say, ‘Hey, that travelling nurse is making double what I am,’ ” Nazem said. Before the pandemic, hospitals might have offered a travelling nurse seventy-five dollars an hour; now, in many places, that rate has tripled. “High pay draws more supply into the market,” Nazem said. “But at some point you reach a limit. Even if you were willing to pay a thousand dollars an hour, there just aren’t enough nurses. All you’re doing then is shuffling people around. You’re robbing Peter to pay Paul. We’re dangerously close to that.”

Gary Solesbee has an understated manner and an easy Texas drawl; he has been a nurse for twenty-seven years. Last year, he and his wife, who is also a nurse, decided to travel. It would be a chance to explore the country and to spend time with their adult children, who were scattered in different states. In December, they started an assignment in Webster, Texas. In March, they left for Walla Walla, Washington, where their son lives, and where, shortly after they arrived, coronavirus patients began to trickle in. Over the summer, when cases exploded in the Southwest, they signed on with an academic hospital in Albuquerque, New Mexico.

“When we started travel-nursing, we had no idea we’d be doing covid nursing,” Solesbee told me. “But that’s pretty much what it’s become.” Solesbee, who now works in a step-down unit—the rung between a regular medical floor and the I.C.U.—is one of several hundred travelling nurses his current hospital system, in Albuquerque, has hired to contend with the surge. Solesbee’s hospital, like many around the country, has had to refashion many floors into covid-19 units. “It’s weird to go to an orthopedics floor and see it transformed for covid care,” Solesbee said. “Then you go to gynecology, it’s half covid. Outpatient services, all covid. Everywhere—it’s covid, covid, covid.” Last month, the New Mexico health department opened another hospital nearby to house recovering coronavirus patients who had no place to go.

I asked Solesbee if he saw any signs of cases abating. “It feels like it’s picking up, actually,” he said. “We’re bracing for a surge on top of a surge during the holidays.” In recent weeks, he has been asked to pick up additional shifts as the need for nursing care has grown further. Each shift lasts twelve hours, sometimes more. “You get very fatigued,” he said. “Patients are incredibly sick. You’re on your feet all day, going in and out of rooms, putting on, taking off P.P.E. When I get home, I take my scrubs off and collapse. It’s like nothing I’ve experienced before.” Still, he agreed to the extra shifts, mostly out of a sense of duty. He’s decided to stay on through the winter.

“It’s disheartening that much of the public still isn’t taking this seriously,” Solesbee said. “I want to tell them, ‘Come to work with me one day. See what it’s like.’ ” Caring for coronavirus patients is exhausting, but it’s their intense isolation, not clinical complexity, that bothers Solesbee most. “That’s the worst thing,” he said. “They can’t have family or visitors come in. We’re the only contact they have, and we can’t be with them as much as usual. We’re supposed to bundle care, limit exposure, do what you need to do and get out.”

Still, there are moments when compassion trumps protocol. Recently, an elderly patient’s blood-oxygen levels dipped to dangerous levels despite maximum support. After declining a ventilator, he prepared to die. A nurse sat in the room with the patient, calling each of his family members on FaceTime, one by one, so they could said their goodbyes. “Sometimes, it’s the only thing we can do for people,” Solesbee told me. “But, in some ways, it’s the most important thing.” The other night, Solesbee sat with a dying man who had no family. With no one to call, he simply held the man’s hand as the patient’s breathing grew ragged and intermittent. Finally, it stopped. Solesbee stood up. Another patient needed his help.

Terri Newland is a critical-care nurse from Greenville, North Carolina, but has been on the road for much of the past two years: Mesa, Arizona; the Chesapeake Bay; Charlottesville, Virginia. In January, she started work at a twenty-five-bed critical-access hospital in Berlin, Wisconsin, a town of some six thousand people about twenty-five miles from Lake Winnebago. In the spring, as the coronavirus started to spread, the hospital delayed elective procedures and sent staff to larger hospitals to gain extra critical-care training. Soon, patients started presenting with cough, fever, and trouble breathing. At that time, Newland’s hospital sent its coronavirus swabs to an external lab; it took up to three days for the results to return.

“In the meantime, we wore full protective gear with anyone who might have covid while we waited for their test to come back,” Newland said. “It was very disorienting for older patients. They can’t see your face. They can’t hear what you’re saying. They needed human contact, and we couldn’t give that to them.” Newland recalled a patient in her seventies whose room overlooked the parking lot. Each evening, the woman’s family would gather outside the window, call her phone, and mime through the glass. One evening, Newland walked in during the ritual. She helped the woman take a selfie with her family. “I still cherish that photo,” she said. She intended to leave when her contract ended in May, but by then the pandemic had deepened such that she felt uncomfortable travelling. “I was stuck,” she said. “It didn’t feel right getting on a plane and flying home.” So she stayed.

In August, Newland took a job in an I.C.U. in Greensboro, North Carolina, about two hours from home. The local health system has tried to restrict covid-19 care to a single hospital to prevent the coronavirus from spreading because of medical care. Newland works mostly in a “clean” hospital but is sometimes asked to help in the covid-19 hospital, which is staffed primarily by travelling nurses. The sense of camaraderie there is palpable. “The pandemic has really pulled us together,” she said. “Everyone is doing what they have to do. We try to help each other because we know what it’s like when things get crazy.” Newland, who works night shifts, also makes it a point to serve as a conduit for patients’ families. “I want them to know that just because they can’t come in doesn’t mean we’ve forgotten them,” she said. “I give them my number and say, ‘If you wake up at 3 a.m. and want to know what’s going on, call me. I will talk you through this.’ ”

Some staffing companies offer housing, or make referrals to agencies that help travellers secure accommodations. Newland prefers to do her own thing. She’s currently staying in a trailer at a campground near her hospital; in Wisconsin, she rented space in a basement, which she found through a travelling-nurse Facebook group. Many nurses she knows stay in hotels, but, “personally, I need more of a home feel,” she told me. “I can’t imagine staying in a hotel for months on end. Work can be hard; it’s nice to have some space to relax and enjoy the days off.” She likes the travel, but worries about what will happen as more nurses choose to hit the road. Desperate hospitals are offering high-paying contracts to lure nurses into the travelling workforce. “I think a lot of nurses will end up paying for it with their mental and physical well-being,” Newland said. There is also, of course, the unavoidable distribution problem. “I’m seeing lots of core staff leaving for travel gigs. And I wonder, are we filling some holes by opening up others?”

As a clinician, there is perhaps nothing more demoralizing than the sense that you’re providing substandard care. That feeling, however vague, nags at the core of your professionalism, until it ruptures into what the writer Diane Silver has called “moral injury”—“a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.” The term was originally coined to describe trauma suffered by soldiers at war, but it’s since been adapted for the struggles of health-care workers contending with a system that often hinders their ability to do what’s right for patients. It’s an outcome that becomes unavoidable when, as now, the flood of patients far outstrips the capacity of people to care for them. Despite the best efforts of the most dedicated clinicians, medical care grows disorganized. You start to miss things. Often the overlooked things are insignificant—a delayed dose of stool softener, for example—but sometimes they’re lethal: an undiagnosed blood clot, or a patient who, on his way to the bathroom, removes his oxygen mask, collapses, and is found dead forty-five minutes later.

In the spring, disparities in covid-19 deaths arising from inadequate staffing levels were among the ugliest aspects of the pandemic’s first wave. At some overwhelmed hospitals during New York’s surge, the patient-to-nurse ratio quadrupled in I.C.U.s; on the coronavirus floors, some nurses cared for as many as twenty patients at a time. The covid-19 death rate at poorly resourced hospitals was two, even three, times that of well-resourced ones, owing partly to gross inequities in staffing. This is to say nothing of the suffering not captured by statistics: patients isolated, lonely, disoriented; families going without updates on their loved ones; health-care workers who reach the brink of burnout, then cross over. We’re now approaching, and in some places passing, the threshold at which patients, families, and clinicians suffer the preventable consequences of a health-care system beyond its limits.

There’s always been a need for staffing companies like Nomad Health, but the pandemic has pushed them into a more central role. The government has been able to mobilize some medical personnel, but the vast majority of emergency pandemic staffing has been organized by companies like Nomad. “It’s like we’ve been training for the Olympics, and they’re finally here,” Nazem said. “We’ve been doing all this in the background for years. We were practicing archery when no one was watching. Now it’s the Olympics, and all of a sudden archery is really important.” Before the pandemic, few staffing agencies saw themselves as so directly in the business of saving lives. Now the crisis has elevated their work. “It feels different now,” Nazem said. “We’re asking so much of our staff—long hours, complex work. But I think they truly feel that when they work hard, it makes a difference in people’s lives. We’re getting clinicians to the bedside, and, as a result, patients are getting the care they need.”

For now. There will come a point—likely soon—when supply won’t meet the demand. The infection curve will overwhelm the most efficient planning, the most creative C.E.O.s, and the most committed clinicians. Murky as it may be, there is, in fact, an upper bound, defined by the ruthless logic of biology and math. “If and when we hit the limit depends entirely on our national public-health response,” Nazem said. “But people should know: there is a hard limit. Every day that something doesn’t change, we get closer to it.”