I'm the only physician working nights in an urban emergency department during a pandemic. It doesn't feel safe.

• David (not his real name) is a physician who works night shifts at a busy emergency room in an urban area of the US.
• After the onset of the COVID-19 pandemic, David says that his hospital cut down on staff to save money, leaving some doctors to run entire emergency departments by themselves.
• David says that being the only doctor on his shifts has led to the most challenging moments of his career, and he's been forced to make tough calls for patients without any support or second opinions.
• This is his story, as told to freelance writer Missy Wilkinson.

The subject of the article chose to be anonymous due to concerns about workplace retaliation. David (not his real name) is an emergency medicine physician who works night shifts. After his hospital weathered an early peak of the COVID-19 pandemic, management cut staffing as a cost-saving measure. David is frequently the only doctor on his shift. His recent shifts have been among the most difficult of his career.

In emergency medicine, there's no such thing as a typical shift.

A typical shift in an emergency department (ED) is hard to describe. By definition of the work, everything everyone comes in with is an emergency. I might see someone who was in a car accident, someone who was stabbed, someone who was shot. We see sick old people, heart failure patients who can't breathe, young people who took much heroin, and homeless people who just want a place to sleep.

During the pandemic, it's the same, but you also have COVID-19 patients, who are typically older than 50, have a high fever, and usually some element of hypoxia, depending on how severe their disease is or how advanced it is.

During the peak (in mid-April), everyone had COVID-19. Every single patient, no matter what they came in with. Even patients coming in for other stupid s--t had COVID-19.

When the pandemic started, the emergency department stopped bringing in as much money, and hospital staff was cut.

(At that time), volumes across all hospitals fell. Hospitals were bringing in less money, so they cut nursing across the board. Nurses everywhere, in every hospital setting — nurses that work on the floors, in the operating rooms, EDs, ICUs — were cut because of COVID-19, and money.

EDs lose money, always. EDs depend on people who have insurance to come in, and the majority of people who come to EDs don't have money or insurance. Elective surgeries make money, not EDs.

During the peak, our ED volumes fell to 40% to 60% of our typical volumes. I'd be sitting there in the middle of the night, and nobody would show up. I spent whole nights playing solitaire on my phone, and studying COVID-19. I read papers on the virus and listened to internet podcasts. Keeping up with the latest news felt like a full-time job.

Then all of a sudden (in June), our volumes came back, but I didn't have the nurses or respiratory therapists I needed because (hospital management) cut staffing. They expected to get (the volumes) they were getting after the COVID-19 peak, and what they were getting was about 80% of the normal ED volumes. But we had 40% of the nursing staff or less.

Now we're busy again, but still understaffed, so I'm left to make tough medical calls by myself.

I was triaging patients myself. If I needed to intubate patients, I didn't have the staff to do that. I had to be very selective about the patients I intubated. There are patients I would have intubated that I didn't, that I put on Bi PAP (a breathing machine) instead.

I don't like doing that at all, it feels really unsafe. I don't want to be put in that position of having to guess what the ED is capable of taking care of. I've never been in a situation where I was worried about myself, but I've had lots of situations where I was worried about not having the staff I needed.

There have been times I didn't have the resources I need to do my job. There were times where I was really scared. There's almost nothing I can't handle, but if the surge comes too fast and I don't have hands, I don't have nurses, what the f--k am I supposed to do? I've conscripted paramedics to help me with patients, help me with this code or that patient. I've even gotten medications from paramedics, because they're another pair of hands.

How do you do the job of a full ED's worth of nurses with half that number? I don't know. You can't, really. I can go fast, bounce between beds, take care of as many patients that come through the door. As scared as I have been for me alone, lots of ED jobs for physicians are solo jobs. Nursing jobs aren't supposed to be. It doesn't matter how many doctors you have if you don't have nurses to do what the doctors are telling them to do.

I had a conversation with my charge nurse one night about that. She said that after a certain time, she's required to send one of the nurses home. At this point, she will refuse to send that nurse home, because since COVID-19 started and volumes have returned, we've had nights where we were so inundated with patents that she didn't feel they had nurses to provide adequate care. The same way I feel.