Tyler McGuire, MD, is a Portland area emergency department doctor.

In February, during an overnight shift in the emergency department, I cared for a young man found in a snowbank in Portland. He was not intoxicated and had no known drug history. He was unhoused and had tried to make a snow “shelter” to stay warm.

Although his body temperature was near normal, he could not stop shivering. His speech was slow, and his fingers were gray and painful, though he could still feel and move them. He had not come seeking medical care. Someone saw him in the snow and called 911.

Two hours later, it was clear he was physically stable and ready for discharge. We often provide a bus pass to a shelter, but despite the 18-degree temperature that night, the 60-bed emergency warming shelter was not open. When I explained this to him, he quietly told me that if he had to go back outside, he would jump in front of a bus.

Hypothermia occurs when the body loses heat faster than it can produce it. Evidence indicates that frostbite and hypothermia are common cold-related injuries treated in emergency departments and can lead to permanent disability or death. Nationwide, more than a thousand Americans die each year from excessive cold exposure.

Maine experiences this danger every winter. Public health data suggest that around 20
Mainers die from hypothermia each year, and emergency departments and EMS crews routinely treat cold-related illness, particularly among residents without stable housing.

Portland’s emergency warming shelter opens only when forecast nighttime temperatures fall to or below 15 degrees Fahrenheit, or when a major snowstorm is expected. These thresholds reflect budgetary constraints and difficulty with staffing the shelter on short notice as the weather forecasts change.

Human physiology, however, does not recognize budget shortfalls or staffing challenges. Wind, wet clothing, exhaustion, chronic disease and hunger lower tolerance to cold, making exposure dangerous well before temperatures reach shelter activation thresholds.

When shelters are closed, the emergency department becomes the backstop. People sit in the waiting room not because they need medical care, but because they need warmth. Staff offer a sandwich and a cup of coffee, but eventually, they must leave. Often it is nurses who must explain that there is no medical reason to keep them in the ED. They face the pleading, frustration and occasional violence of people who cannot meet their most basic needs, shelter and warmth.

Recent reporting indicates that Portland’s 60-bed emergency warming shelter costs about $7,700 per night to operate, meaning that keeping it open nightly from November through April would require roughly $1.4 million each winter. That investment would provide a warm place to sleep for dozens of vulnerable residents every night.

A public-private partnership could help close the gap. Donors could fund the shortfall needed to keep the shelter open every night during the coldest months, reducing dangerous cold exposure and strain on EMS crews and hospital staff. With reliable funding and a consistent seasonal plan, Portland could create a dependable backstop for people who have nowhere to go on a cold night.

Every winter, Maine prepares for the cold. We pull out heavy coats, and cities service their
snowplows. Our response to dangerous cold exposure, and our support for those most vulnerable to it, should be just as deliberate.

By morning, the patient I cared for had been evaluated by psychiatry and discharged with a bus pass and a list of local resources. He was safe for the moment, but without a clear plan for where he would sleep that night, or the next, the same cycle was likely to repeat.

This idea will not solve homelessness or cold exposure, but it is a practical initiative toward ensuring that no one in Portland is left without protection from the cold.