No U.S. city suffered more in the first wave of the coronavirus pandemic than New York City, where more than 24,000 people died, mainly in the spring. Medical workers in New York learned exactly how difficult and dangerous things can get when hospitals are overwhelmed, and now they are bracing themselves as infections begin to rise again.

Around the New York City metro area, public health leaders and health care workers are warily watching the trend lines, as intensive care units fill up in other parts of U.S. and around the world. They say it gives them flashbacks to last spring, when ambulance sirens were omnipresent and the region was the country's coronavirus epicenter.

There is wide agreement that hospitals and care providers are in much better shape now than then, because there is more clinical knowledge about the disease and how to handle it; larger stockpiles of personal protective equipment; and much more widespread testing.

But at the same time, many front-line workers remain nervous about hospital preparedness, and many in health care are more skeptical than elected officials about the effectiveness of the city's testing and tracing infrastructure.

"I think there's a lot of anxiety about doing this a second time," said Dr. Laura Iavicoli, head of emergency preparedness for New York City Health and Hospitals. With 11 hospitals and dozens of clinics, it's the country's largest municipal hospital system. Iavicoli also works as an emergency room physician at one of the system's hospitals: Elmhurst Hospital, in Queens, which came to be called "the epicenter of the epicenter" back in April. Still she has enormous confidence in the system's staff.

"They will rally, because I know them," she says. "I've worked with them for 20 years, and they're the most amazing people I can possibly speak of, but there's anxiety and there's COVID fatigue."

Some of the system's hospitals are at capacity, but Iavicoli quickly adds that she's not talking about "COVID capacity," meaning the beds and recently reconfigured spillover spaces for COVID-19 patients. Rather, two of the network's 11 hospitals have had to transfer out ICU patients to other hospitals, to make room for an expected influx of COVID patients.

"We are doing a little bit of redistributing around the system to give them COVID capacity, but it's very manageable within the system," says Iavicoli, whose name is pronounced EYE-vuh-koli.

"The increase is definitely typical in flu season, but knowing that we have just entered upon the second wave [of COVID-19] and predicting what is to come, we're a little even more cognizant than normal to make sure we leave capacity in all of our facilities."

'We're afraid we're going to have to go through this again'

Many nurses, however, feel unprepared for a new surge of COVID patients, saying their hospital administrators have not done enough to apply the lessons learned in March and April.

"We're scared," says Michelle Gonzales, a critical care nurse at Montefiore Medical Center, in the Bronx, "We're afraid we're going to have to go through this again."

Gonzales is also a union representative for the New York State Nurses Association (NYSNA).

Nurses in her unit typically handle one or two intensive care unit patients at a time — but now have to handle three, she says, even as the number of COVID-19 inpatients is creeping up once again. During the peak of the pandemic surge last spring, it was common for one nurse to be in charge of four or more patients, Gonzales says, and that's overwhelming, If one patient crashes, several nurses need to converge at once, leaving other patients unmonitored.

"When we start to get triples with the frequency we're seeing right now, we know it's because we're short-staffed, and they're not getting ICU nurses into the building," Gonzales said during a recent nurses' protest outside Montefiore Medical Center in the Bronx. They and local elected officials — including Carl Heastie, the powerful Speaker of the New York State Assembly, who is from the Bronx — demanded that managers increase hiring at Montefiore and other hospitals in the network. Then, a phalanx of nurses marched from Montefiore to a nearby cemetery, carrying floral wreaths for fallen comrades. A band and bagpiper played "When the Saints Go Marching In" and "Amazing Grace."

A union spokeswoman, Kristi Barnes, says that Montefiore, by its own reckoning, has 476 nursing vacancies — a number that has climbed by nearly 100 since 2019.

"Management is not living up to their promise to fill vacancies and hire nurses," Barnes says. "As of last week, they have 188 full time nursing jobs they have not even posted, so there is no way they can be filled."

The Montefiore administration disagrees.

"We have a contractual agreement with the union, and we meet the contractual obligations of that agreement," says Peter Semczuk, senior vice president of operations. "We tailor our staffing in such a flexible way to meet the needs of the patient."

Like many hospital systems, Montefiore relied heavily on temporary staffing agencies to provide "traveling nurses," who came to New York from around the country at the height of the pandemic earlier this year. Hospitals are preparing to hire traveling nurses again — but now there is demand for them all over the country.

"They got us travelers in April, but that was four or six weeks in, and until that we were on our own," recalls Kathy Santoiemma, who's been a nurse at Montefiore New Rochelle for 43 years. "I don't even know where they're going to get travelers now — everyone around the whole country needs travelers."

NYSNA led a two-day strike at Montefiore New Rochelle on Tuesday, after contract negotiations — which had been going on for two years — stalled on Monday.

At NYC Health and Hospitals, Iavicoli says each of the network's 11 hospitals have already submitted their specific staffing requests to system leaders, so that they could place a preliminary order with nurse staffing agencies.

Health planners are hoping New Yorkers won't flood into emergency rooms this time. They point to the modest climb in COVID-19 hospitalizations over the past two months compared with other areas, including New Jersey and Connecticut. One of the things they hope will keep the curve relatively flat is testing, which is more pervasive than almost any place in the country.

Across New York state, about 200,000 people are getting tested each day, roughly one-third of them in New York City.

"It's the first step to actually interrupting further spread," says Dr. David Chokshi, the city Health Commissioner.

Mass testing works on two levels, Chokshi says: Tests highlight which areas are hot zones, so health workers can target residents with "hyper-local" messages about COVID-19 spread, to get them to change their behavior, and tests also allow contact tracers to communicate with newly infected people individually.

"Once someone tests positive, we very quickly help them isolate," Dr. Chokshi says. "We do an interview with them to know who their close contacts are, and then we call those contacts and make sure they're quarantining as well."

However, the city's contact tracing program has had a mixed record. The people it reaches say they're staying put — but fewer than half of them share names of people they might have exposed. Dr. Denis Nash, an epidemiologist who previously worked for the city's health department and the Centers for Disease Control and Preparedness, says contact tracers aren't asking people enough questions about their behaviors and possible exposures. That means the city hasn't been able to drill down into the data to learn how coronavirus actually spreads.

"During the summer and early fall, when things were slowly ramping up, there were missed opportunities to use contact tracing to talk to 80 or 90 percent of all newly diagnosed people, to understand what their risk factors were and what kinds of things they did, and they were exposed to, that could have potentially resulted in them getting the virus," he explains.

"You can never know with 100 percent certainty [where they contracted the virus], but if you ask these questions, you could begin to understand what some likely patterns were, for example, of public transportation use or working in office buildings that didn't have rigorous safety protocols or indoor dining."

This knowledge, though imperfect, could lead to better informed public policy decisions, Nash says, about whether to close businesses such as indoor restaurants, beauty salons, or fitness centers. Without that data, leaders are just making guesses.

Other critics fault the city's testing and tracing program for not doing enough outreach to poor communities of color — which suffered disproportionately during the first COVID-19 wave. Dr. Chokshi, the city health commissioner, says getting testing sites to these neighborhoods has been a priority — but a recent analysis suggests it's not working as well as the city intended.

"There's clearly a disparity in providing widespread testing across New York City," says Wil Lieberman-Cribbin, a graduate student and environmental health researcher at Columbia University.

He looked at how many people are getting tested, by neighborhood, and correlated those figures with race, income level, and positivity. In wealthier areas, people are getting many more tests, and have much less illness. In poorer neighborhoods, people are getting many fewer tests and are much sicker. More testing in those low-income areas would help identify cases sooner, when people are contagious but haven't yet developed symptoms.

"Testing is really, really needed, not only to protect the most vulnerable, but to collectively try and get a handle on COVID and reopen New York City," Lieberman-Cribbin says.

Personal protective equipment, or PPE, is also much more available than last spring but, similarly, remains a source of contention.

New York state health authorities are requiring hospitals to stockpile a 90-day supply of PPE, and nursing homes, 60 days' worth. Many have complied with September and October deadlines, but others have not.

Montefiore, NYC Health and Hospitals, and other large hospital networks say they have at least that much, if not more.

Nurses, though, say they should be able to don fresh N95 masks each time they see a new patient, to limit the risk of contamination. Many administrators counter that isn't feasible, given the precariousness of the supply chain. They note that CDC guidelines permit "extended use" of some types of PPE.

"[Nurses and other care-givers] change their gloves between every patient, but they might wear the same N95 mask for one shift and put a surgical mask over it just to preserve it and only switch it out if there's some integrity issue or it gets contaminated," says Iavicoli, of the city hospital system. "But definitely, at the next shift, they're getting a new one."

Iavicoli acknowledges the challenges as the pandemic rolls on. She says there are four kinds of days: "blue skies, or normal," "busier than normal," "a little stretched," and "extremely stretched."

"I think we're at the top end of 'busy normal' bordering on 'a little more than overstretched,'" says Iavicoli.

This story is from a reporting partnership that includesWNYC,NPRandKaiser Health News.

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