The line of patients outside the emergency room at Elmhurst hospital in Queens has vanished. So has the near-perpetual wail of ambulance sirens that filled the air in this working-class neighbourhood earlier this year when the coronavirus pandemic was bearing down on New York City.
Yet after a summer respite, Dr Eric Wei, the hospital’s chief executive, is again feeling dread. Elmhurst, a public hospital that is one of the city’s oldest and busiest — and whose patients are among its poorest — is once more seeing a rise in Covid-19 cases and bracing for a second wave.
“Even though we expected the numbers to go up as the weather turned, now that it’s actually happening I feel this pit in my stomach like, ‘are we going to go through this again?’” said Dr Wei.
The pandemic’s resurgence in New York was confirmed this week by the Governor Andrew Cuomo, who declared that the state was entering “a new phase in the war against Covid” as he laid out a battle plan to try to contain a surge in cases.
“My biggest nightmare”, Mr Cuomo said, was hospitals being overwhelmed as Elmhurst nearly was in March. The situation became so desperate that refrigerated trucks were brought in to hold an overflow of bodies. The surrounding neighbourhood suffered one of the city’s — and the country’s — highest Covid-19 death rates.
“It’s not just the public who were scared — we were, too,” said Eduardo Santana, an Elmhurst nurse for 38 years who delayed his retirement to help his co-workers through the crisis. Even though cases had declined in the neighbourhood, the fear had remained. “People are panicking every time they have a cough,” he said.
Dr Eric Toner, a senior scholar at Johns Hopkins University, who led an extensive study of New York City’s coronavirus response, said he would be “shocked” if the situation was as bad this time around.
“We just know a whole heck of a lot more about Covid-19 than we did back then,” Dr Toner said. “We know what to expect with these patients. We know what are the indicators of either a good prognosis or a bad prognosis, and we have treatments that are at least somewhat effective.”
In preparation for the winter, the city’s public hospital system has stockpiled a 90-day supply of protective equipment and hundreds of ventilators. It has expanded critical care capacity at public hospitals and fine-tuned computer “dashboards” that allow doctors and data experts to manage an onslaught of patients.
Reflecting on Elmhurst’s experience, Dr Wei believes part of the problem in the early days was that the hospital, which serves one of the world’s most diverse immigrant communities, had been preparing for a different pathogen: the Ebola virus, which reached New York City in 2014.
“We’d done a lot of preparation around the system, and the city and the country. Asking questions about travel to Africa, exposure to other people with Ebola-like symptoms, and getting them into a negative-pressure room and being able to isolate them. So I think that’s how we started with Covid,” he recalled. Before he knew it, they were facing a fire hose of infections — “just so many patients with Covid and Covid-like symptoms that it just overwhelmed the traditional screening and isolating”.
Over the summer, the hospital’s Covid-19 cases dwindled to single digits but never quite went away. At present, Elmhurst is treating just over 30 Covid-19 patients — fewer than 10 of whom have been intubated. By comparison, it was dealing with 150 intubations at a time in the worst days of the crisis.
Current patients tend to be younger and healthier than those infected in the first wave, according to Dr Wei. That suggests fewer will progress to critical care this time around.
The hospital has also learned from hard experience. One counter-intuitive lesson: to refrain from putting patients on ventilators for as long as possible — even when their depleted oxygen levels suggest otherwise.
“A lot of the things the rest of the country has been doing — those lessons were learned here, in terms of proning patients[lying them on their fronts], giving steroids like dexamethasone, giving remdesivir,” Dr Wei said.
Like other hospital executives, his greatest concern now is not about securing enough beds or ventilators but finding enough staff.
“We were unlucky and lucky in the fact that we were the first to surge in New York City, and the rest of the country really came to our assistance,” said Dr Wei. “But now the whole country is surging, and so people who came here in the spring are responding in their local communities.”
Some Elmhurst doctors and nurses retired early or left the profession altogether after their experience in the first wave. In an interview with the Open Forum Infectious Diseases Podcast, Dr Eric Bressman, then the hospital’s chief resident, recalled crying junior doctors calling him after hours, trying to make sense of the loss not of one patient on their shift but 20. “It was traumatic,” he said.
The hospital consulted the military to develop the sort of counselling more commonly given to soldiers in a war zone. It has also hired “travelling” nurses to try to bolster its ranks — although those are now increasingly scarce across the country.
In a crisis, Elmhurst will be stretched. It has developed a plan to surround specialists such as a respiratory therapist or intensive care nurse with a group of generalists to take on as much of the more mundane care as possible. “What can we take off their plate so they can lend their expertise to more patients?” is how Dr Wei described the approach.
“I think we’re in a better position,” one Elmhurst nurse said approvingly of such preparations. She was standing outside the hospital’s community care clinic. A line of people waiting for Covid-19 tests stretched down the block. Signs indicated where the expected wait time was 30 minutes, then 60 minutes and then 90 minutes until there were no more signs but still more people. “I feel like it never stopped after the first wave,” the nurse said.