New Yorkers are bracing themselves for a third wave of Covid as a steady drumbeat of closures — everyone from Broadway theaters to local clubs are canceling or postponing shows, either because of positive tests or out of an abundance of caution. But even though the dramatic escalation has many recalling the twilight before the first wave — when the city became “the epicenter of the epicenter” — many emergency physicians are “cautiously optimistic” that their departments will not regress to April 2020, when critically ill patients overwhelmed the city’s hospitals and hundreds died each day. Yet some worry that in less-vaccinated communities across the country, this new surge could threaten to once again devastate exhausted local health care systems.
“New York City, in general, I think has done actually a pretty darn good job of getting vaccines into arms and getting people to mask in appropriate locations, and so I am really optimistic that hopefully the surge can get mitigated even more than last winter’s because of that,” says Dr. John P. Marshall, chair of emergency medicine of Maimonides Medical Center in Brooklyn. “But I think we’ll all find out.”
The past week has been filled with anxiety-inducing Covid developments. For the third day in a row, New York State reported on Sunday a single-day record of 22,478 new cases, with 12,404 in New York City. According to city data, the 7-day average positivity rate jumped from 4.2 percent on Sunday, Dec. 12, to 7.68 percent on Friday. Hospitalizations in the city however totaled 1,046 — still a far cry from those at the peak of the first wave last year.
At Staten Island University Hospital, Dr. Nicole Berwald, associate medical director of emergency medicine, says that the increases in Covid cases among patients over the past couple of weeks have largely unfolded as she would have expected: Patients started coming to her hospital’s emergency department for viral-like symptoms at higher rates several days after the Thanksgiving holiday, with another peak a few days later that she attributes to the Omicron variant. “It almost feels like there isn’t such a surprise,” Berwald says. “We have some sense of what we’re watching and what it might do, which allows us to make plans for the emergency departments, for the hospitals, to be able to take care of the volume.”
That the unvaccinated are suffering more severe Covid symptoms didn’t shock the departments, although the number of breakthrough cases in recent weeks has caught some by surprise. Dr. Rahul Sharma, emergency physician-in-chief for NewYork-Presbyterian/Weill Cornell Medical Center, says that data in many ways reflects how the virus continues to mutate. The new Omicron variant so far has proven highly transmissible and reduces the effectiveness of vaccines compared to the Delta variant. Still, Sharma noted that “the good thing is in these breakthrough cases the symptoms are milder and fewer people are being hospitalized,” compared to those who are unvaccinated.
The timing of the latest Covid surge could prove challenging for the city hospitals’ emergency physicians. Typically ERs work on a treat and release basis, Berwald explains, admitting patients to the hospital only if their symptoms require further treatment and evaluation. During the pandemic, this process ground to a halt as ERs wound up taking in Covid patients, many of whom needed to be admitted to already-packed hospitals and required longer stays. Meanwhile, others who typically would have sought emergency care over, say, stroke symptoms, were delaying crucial treatment to avoid coronavirus infection. Seasonal illness cases like the flu were also nonexistent, in large part thanks to mask wearing and social distancing. As a result, several hospitals’ emergency departments saw their overall case numbers actually decline last year compared to pre-pandemic levels.
Now, with people back out in the world and Covid prevention policies loosened, ERs are handling routine cases at frequencies more in line with historic norms. Berwald says her department and others are keeping afloat despite the additional rise in pandemic-related patients. Still, it’s not impossible to envision a worst-case scenario, where the Omicron variant proves severe alongside aggressive seasonal illnesses. “If we have a 2019 flu season plus an Omicron season, that could really outstrip our resources,” Berwald says, referring to the harsh flu season that resulted in an estimated 380,000 hospitalizations, and 28,000 deaths in the United States.
Beyond increasing ER cases overall, for some emergency departments, the latest wave is running up against the stress of ongoing staffing shortages, particularly among nurses. This past October, 538,000 health care and social assistance workers nationwide quit their jobs, up from 467,000 the prior year, according to the Bureau of Labor Statistics. A recent survey by Morning Consult, meanwhile, found that nearly a third of health care professionals who have kept their jobs since the start of the pandemic have considered leaving.
Marshall of Maimonides has witnessed the staffing shortage unfurl across his own emergency department. Since the beginning of the pandemic, he estimated that 50 nurses, or more than 25 percent, have left, many as a result of burnout from the past 20 months or the ability to easily make more than double their current salaries as travel nurses. There has been some success in rehiring nurses and even luring new ones, and so far the department has not had to close any of its beds due to shortages, unlike medical facilities in Long Island and upstate New York. Still, amid the uptick in Covid cases, Marshall worries about the vacancies straining staff.
“When you’re challenged on the nursing staffing side, it can be difficult to get the patients triaged in a timely fashion,” Marshall says.
Emergency physicians who spoke with Rolling Stone are reassured by the relatively high rates of vaccination overall through New York City — more than 70 percent of all residents are fully vaccinated — and at the moment feel capable of handling the ongoing Covid surge. But as Omicron continues to spread far beyond the East Coast, particularly to lower-vaccinated locales, and understaffing persists, it’s all too likely to see hospital systems across the country pushed once again to the brink, if not beyond.
“There will likely be pockets of the country and individual microclimates of medicine, individual towns and cities, where the system becomes overwhelmed,” says Dr. Ian Wittman, chief of service for the emergency department at NYU Langone Hospital-Brooklyn. “We’ve been at this for two years and it’s been happening for two years. There have been individual hospitals or individual cities or, in some cases, regions that have become overwhelmed.”