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As Abhishesh Pokharel carried his 3-week-old daughter into the emergency department, her fingers and toes were turning blue.
Other parts of her tiny body were yellow.
Something was very wrong.
The triage nurse at Greater Baltimore Medical Center knew it, too. She took one look at baby Ayra and gave her father an order:
Across the building he sped, his wife right behind him – to the pediatric emergency department.
By then, Ayra was sometimes not breathing at all, clinicians later told CNN.
The rapid response team went to work.
Still, “she was not responding to anything that they were doing,” Pokharel recalled.
“My mind just froze and thought I may not get her back.”
Ayra – born a preemie at just 36 weeks and 6 days – had already proved to be a fighter: Her first day on Earth was spent in the NICU because of fluid in her lungs.
Since then, she’d been healthy, her father said.
But now, her fragile body was caving to one of several respiratory illnesses spreading across the US: respiratory syncytial virus, or RSV, which often is most severe in young children and older adults.
While for most it causes a mild illness that can be managed at home, RSV – alongside flu, the coronavirus that causes Covid-19 and other common respiratory viruses – has driven an increase in hospitalizations nationwide. And pediatric hospitals are feeling the strain, with more than three-quarters of their hospital and ICU beds occupied for the past few months.
More than half of US states report high or very high respiratory illness activity, and US officials are begging people, including kids, to get the flu shot and Covid boosters ahead of Thanksgiving.
But for RSV, there is not yet a vaccine – nor an antiviral or specific treatment.
As baby Ayra’s blood oxygen level hit 55% – far from the 95% or better it should be – her parents could only watch, tears filling their eyes as they overheard clinicians say their newborn wasn’t responding.
“I was lost,” recalled Ayra’s mom, Menuka KC. “It was a nightmare.”
The staff at the pediatric ER in Towson, Maryland, was already overwhelmed by a crush of respiratory illnesses so severe it had for weeks claimed virtually every pediatric ICU bed in the state.
But as Ayra lay before them, they knew they had to act.
Knowing Ayra could have gone into respiratory arrest right there in the waiting room “sent heart palpitations through all of us,” said Dr. Theresa Nguyen, the center’s interim chair of pediatrics.
The infant was lethargic, breathing quickly – sometimes not breathing at all. Thick mucus filled her nose and went down as far as her lungs, Nguyen said.
Her prematurity “increased her risk of how her body would react to the RSV virus,” the doctor explained.
It had been just 10 days since the older Pokharel daughter, 4-year-old Aavya, had gotten sick with a fever and runny nose that her pediatrician diagnosed as viral and ear infections, their dad said.
Five days later, on October 13, the couple noticed Ayra started having a runny nose and mucus that they had to remove with a suction ball, Pokharel said. They took her to her doctor for a scheduled check-up and were told she had a viral infection, though her lungs were clear and she had no fever.
But monitor her, they were told.
Three days after that, they took Ayra back because she had a bad cough, and the couple could barely hear her cry.
Two days later, here they were in the pediatric emergency department, with doctors now telling them intubation was Ayra’s best bet.
Inserting a tube into Ayra’s airway and attaching a breathing machine would give the infant the oxygen she needed, the doctors explained.
Ayra was on the brink of death.
She needed to be intubated immediately, the doctors said, before she stopped breathing.
Her parents waited just outside the room and prayed for God to save her and bring her back to them as the medical team carefully and swiftly intubated Ayra.
Immediately, her blood oxygen bounced back to a safer level.
But more hurdles lay ahead.
Greater Baltimore Medical Center could not keep Ayra – or any intubated child who needs to be on a ventilator – because that level of care requires a pediatric ICU, Nguyen explained.
The discussion quickly turned to where to send her for more care.
Hospital staff took to the phones.
Sending patients to other facilities for treatment is common during the height of flu and RSV seasons, Nguyen said.
But this year, the need had started rising much earlier.
Greater Baltimore Medical Center last month had to transfer twice as many pediatric patients as it did last October, hospital data show. And October transfers were double what they were in September, with respiratory transfers accounting for 80%.
“My doctors are seeing patients in the hallways every day,” Nguyen said, adding some have waited up to 16 hours to be seen.
And this was far from the only facility squeezed by the surge in child respiratory illnesses.
“There haven’t been pediatric ICU beds available in the state of Maryland since mid-September,” Nguyen said. “We’ve had to send children out of state.”
Searching out a landing spot for Ayra, they dialed hospitals in Washington, DC, and Virginia and Delaware, Pokharel said.
“‘Worse comes to worst, we have to airlift her and take her to another state,’” he remembered a clinician telling him as they called facilities as far away as Georgia and Florida.
It didn’t dawn on Pokharel to even think about how his family would get to wherever Ayra was sent.
She needed care, and it didn’t matter where.
An hour passed.
Then, a single phone call changed everything.
“There was one bed available,” Pokharel said, “at Children’s National Hospital in DC.”
Ayra was transferred in an ambulance, her father seated beside the driver. Pokharel stayed the night with his ailing daughter.
The next morning, KC was ferried 90 minutes from Perry Hall, Maryland, to the hospital by Pokharel’s brother, who also cared for Aavya while the girls’ parents focused on her sick sibling.
In the pediatric ICU, Ayra lay on a tiny, heated hospital bed. She was connected to blue and white ventilator tubes, her miniscule feet and wrists restrained so she wouldn’t pull at anything. Doctors pulled fluid out of her lungs and gave her an antibiotic, her dad said.
On each of the next two days, Pokharel’s brother chauffeured his sister-in-law home, then back to her vigil at Ayra’s bed.
All the while, their tiny fighter battled for every breath.
Her parents didn’t know how long they’d have to wait.
Then, on the third day: a breakthrough.
Less mucus filled Ayra’s lungs, and she was getting only minimal support from the ventilator, Pokharel said. So, the doctors extubated her.
She still needed a CPAP machine – the kind adults sometimes use to deal with sleep apnea – to get enough oxygen, her father said. And she later would require a nasal cannula – the tube outfitted with prongs going into the nostrils – to help administer lower amounts of oxygen.
But Ayra was pulling through.
Even as the doctors started talking about discharging her, KC grew nervous and started checking and rechecking to make sure her daughter was breathing.
Soon, though, Ayra’s fever broke and she began drinking again from a bottle.
On the fourth day, a friend drove KC to see Ayra – and the whole family went home together.
Being back home has been an adjustment.
The family of four is isolating until Ayra is at least 2 months old, said Pokharel, who works a hybrid schedule and goes out for errands.
“We haven’t allowed any visitors to come home,” he said. “My wife hasn’t left home since then. She doesn’t want to go anywhere.”
They also pulled Aavya out of day care, hoping to keep the germs at bay – and posing an extra challenge for everyone.
“We have a baby who is sick, just came out of the hospital. We are giving 100% focus on the little one,” Pokharel said. “And on another side, I have a 4-year-old who needs my attention, like, 24/7.”
Pokharel, while working some days from home, gives Aavya pre-K workbooks so she can draw, trace or paint, he said. When he’s off work, they go for a walk or a bike ride.
KC spends her days caring for Ayra. Sleep, she said, comes in two- or three-hour stints.
Back at Greater Baltimore Medical Center, the throngs of children with serious respiratory symptoms keep coming, Nguyen said. “Our staff, our physicians, advance practitioners and nursing staff are, for a lack of a better word, they’re overwhelmed.”
“They’re burnt out because this has been ongoing for two months,” the doctor said. “And there’s no end in the near future because … you start seeing RSV and then you see the flu,” which can stick around until April.
“This is really the children’s version of the Covid crisis in adults,” Nguyen said. “I don’t think it’s gotten as much attention as it needs because it’s kids, they’re little. It’s the pediatricians who advocate for them, but we’re actually really, really busy taking care of the kids.”
As Ayra’s parents keep vigil at home over their tiny fighter, their want other families to know: With this virus still surging, be ready for anything.
“I didn’t think RSV would go to this extent,” her dad said. “I never thought I would see a baby intubated – and not my baby intubated.”
“I’m glad she’s doing OK and she’s feeding and sleeping well,” added her mother. “Thank you to all those doctors and the nurses who saved her life.”