“Rationing” — a form of decision-making to allocate scarce resources — is something health care providers hope they never have to do.

But already the Covid-19 pandemic has forced doctors and nurses around the world — in Italy, the UK, and South Korea — to ration lifesaving equipment and interventions: who gets a ventilator when there aren’t enough for every patient who needs one, for instance. And now, reports from overwhelmed and under-resourced hospitals across New York City’s five boroughs indicate that doctors and nurses there expect to begin rationing soon — if they haven’t already.

“These decisions run counter to everything that we stand for and are incredibly painful,” wrote Meredith Case, an internal medicine resident at Columbia/New York-Presbyterian Hospital, in a March 25 Twitter thread. “Our ICU is completely full with intubated Covid patients. … We are rapidly moving to expand capacity. We are nearly out of PPE. I anticipate we will begin rationing today.”

A worst-case scenario that epidemiologists have warned of — patients dying because the system is too overwhelmed to care for all of them — looms for New York City as a growing number of patients with severe cases of Covid-19 seek emergency medical care, and hospitals run low on ventilators. Hospitals are also running low on beds, intensive care units, personal protective equipment (PPE) to protect their frontline staff, and staff themselves. And after being ordered by the state to increase capacity by a minimum of 50 percent, hospitals are working rapidly to prepare for an even greater influx of patients in the coming weeks.

Because as bad as things are right now, they’re predicted to get worse. In a March 27 announcement, New York Gov. Andrew Cuomo said that the peak in the city’s epidemic curve — when the number of Covid-19 cases top out before declining — could be as many as 21 days away. It’s based on the fact that people infected with Covid-19 can go for days before they show any symptoms and weeks before the most severe cases require hospitalization.

There’s still uncertainty in how the outbreak will play out in New York, since it is impossible to know the number of residents who have already contracted the virus. Though the testing rate here is the highest in the country, the city still doesn’t have the capacity to test everyone with and without symptoms. But officials and medical professionals agree the official counts — as of March 27, there were more than 25,000 reported cases and more than 350 reported deaths in New York City — don’t reflect the true extent of the outbreak.

“The number of patients with severe enough illness to need hospitalization and ICU-level care is expected to rise faster than our ability to fully meet the demand,” wrote Vicki LoPachin, the chief medical officer at Mount Sinai Health System, in a letter to the hospital staff on March 25. “This is the humanitarian mission of our lifetimes. And we won’t win every battle.”

Hospitals are reaching capacity and workers on the frontlines are falling ill

With more than 4,700 Covid-19 related hospitalizations as of March 26 in New York City, about 850 of which have been intensive care unit hospitalizations, hospitals are in crisis mode. Many of them have been for days.

“Even for my senior attendings, it is the worst they have ever seen,” wrote Fred Milgram, an emergency medicine resident physician, in the Atlantic. “Here, the curve is not flat. We are overwhelmed.”

Nurses and doctors have been reusing masks and other personal protective equipment, or PPE meant for single-use since last week, and some health providers are continuing to care for patients even while they experience symptoms of their own. “I am ending my night by delivering acetaminophen to a co-resident who spiked her first fever today,” Case wrote in another tweet. “She is one of many in recent days.”

While New York City officials have not provided an official tally of how many health care providers have tested positive for Covid-19, data from other countries hit hardest by the pandemic, including Italy, reveal that providers are at a high risk of contracting the virus — especially in the absence of adequate PPE.

“As I’ve sat in a room full of coughing patients for 60 hours a week, I have worried about my own safety,” wrote Rachel Sobolev, another of NYC’s emergency resident physicians, in a letter to President Trump published on HuffPost.

On March 24, Kious Kelly, an assistant nurse manager at Mount Sinai West hospital died of Covid-19. According to social media posts from his family members and colleagues, the 48-year-old Kelly was otherwise healthy, but he had not had adequate PPE while caring for his Covid-19 patients.

Gov. Cuomo said in a press conference March 26 that there was “no question” that New York at large would exceed its hospital bed capacity. According to data from the Harvard Global Health Institute, the city has roughly 1,400 ICU beds total. For several hospitals in NYC, including Elmhurst Hospital in Queens, where 13 patients died of Covid-19 in 24 hours, this has already happened.

“I don’t think it’s a question of ‘when’ hospitals are out of space anymore,” says Ani Bilazarian, an ER nurse at one of New York City’s major trauma centers. “It’s happening now.”

The measures that NYC hospitals have taken to extend capacity and care for critically ill Covid-19 patients are extreme and unprecedented. Hospitals have begun to convert pediatric units into adult ICU rooms, transferring the children who previously occupied those rooms to other hospitals. Operation rooms previously reserved for surgery – left vacant in the wake of cancelled elective procedures – have also been converted to ICU rooms at many hospitals.

The equipment shortage is “becoming dire”

In addition to dwindling physical space and hospital beds, NYC’s hospitals are running dangerously low on critical equipment. “The shortages of resources is becoming dire even outside of the news reporting of ventilators,” says Bilazarian. “We are on critical shortages of multiple medications, protective equipment, cleaning products, and space.”

To intubate patients, hospitals need ventilators, the crucial machines that pump air into the lungs of patients unable to breathe properly on their own. In the face of a virus that attacks the respiratory system, these machines can be lifesaving. And yet, as of March 26, Cuomo said that New York had only about 12,000 ventilators total, just over a third of the projected 40,000 ventilators required to accommodate the inevitable increase of patients.

A shortage of ventilators would be a dire situation in the face of any respiratory pandemic, but the drawn-out nature of Covid-19 illness exacerbates the problem.

“Non-Covid patients are on ventilators two, three, or four days,” Cuomo said in his March 27 press briefing. “Covid patients are on ventilators from 11-21 days.”

Bilazarian adds: “The challenge with ventilator resources is not just the high numbers of patients we are intubating but the length of time they are required to remain on a ventilator. We have been keeping patients on ventilators for about 14 days before we decrease ventilator support in a process called ‘weaning’.”

In other words, patients with Covid-19 are staying hooked up to these scarce ventilators for long and indefinite periods. Accordingly, the equipment cannot be recirculated fast enough for use in newly-admitted patients.

Solutions are arising – but hospitals need more help now

New York City’s hospitals aren’t fighting Covid-19 alone; they are working alongside the state and local health departments and the private sector to address the shortage of space and resources. The Jacob J. Javits Center, a convention space on Manhattan’s west side, is being converted into a 1,000-bed temporary hospital. A 1,000-bed hospital ship, the USNS Comfort, is expected to begin admitting NYC patients in mid-April. Nationally, several manufacturers in the auto industry have converted to making ventilators, but the progress has not been adequate.

In a tweet on March 27, President Trump said that General Motors, the automotive company that had previously promised to manufacture 40,000 ventilators “very fast,” has since backtracked, promising 6,000 ventilators by late April.

As usual with “this” General Motors, things just never seem to work out. They said they were going to give us 40,000 much needed Ventilators, “very quickly”. Now they are saying it will only be 6000, in late April, and they want top dollar. Always a mess with Mary B. Invoke “P”. — Donald J. Trump (@realDonaldTrump) March 27, 2020

New York City’s hospital systems need resources immediately and cannot wait for these national solutions; accordingly, several are taking matters into their own hands.

Northwell Health, for example, the New York health care system with 23 hospitals, has begun 3D printing equipment to use machines that they already have in their own facilities as opposed to waiting on companies. Northwell Health has partnered with the 3D printer company Formlabs to expedite production of nasal swabs required for Covid-19 testing kits as well as 3D-printed nozzle-like devices that allow ventilator machines meant for single patients to be split between two patients.

The 3D printed nasal swabs for the Covid-19 testing kits, which are modeled after swabs that already existed, have gotten the green light for production and are currently being dispersed throughout Northwell’s hospitals and testing centers.

But 3D printing ventilator splitters — which are essentially T- or Y-shaped nozzles that hook onto a single ventilator tube and redirect the oxygen flow from the ventilator into two tubes as opposed to one — is not quite so straightforward, because these designs are unchartered territory and need to be tested for safety and efficacy.

“Splitting ventilators is really a last-ditch effort,” says Todd Goldstein, Northwell Health’s director of 3D design and innovation. “The ventilators are made for one individual patient, and even though it’s been done before, it’s complicated to split them. There are a lot of factors you have to control, and there are a lot of issues that can arise.”

Several other hospitals have already begun splitting ventilators between multiple patients.

“We are also trying to be more flexible in how we support patients ... to try and prevent patients from needing vents at all,” Bilazarian said of her hospital. In other words, hospitals are trying to use less invasive electronic breathing devices first (such as the mask-like BIPAP machines, which are sometimes used for people with sleep apnea) to stave off the need for full intubation.

Expanding the frontlines

Nowhere does the wartime rhetoric of the Covid-19 pandemic seem starkest than in the draft-like call-to-action for volunteer health providers in New York. The state’s department of health has added a form on its website for any qualified health providers to join a volunteer reserve workforce. “We are looking for qualified health, mental health, and related professionals who are interested in supporting the state’s response,” the site reads.

On March 24, New York University announced that it would allow fourth-year medical students to graduate early so as to join the frontlines of the Covid-19 response in New York City as soon as April. By March 25, nearly 70 medical students had decided to graduate early; they made the choice to enlist in the frontlines in spite of the risks.

If nothing else, New York’s health workers’ dedication to the work they’re doing — saving as many lives as they physically can — is clear in their remarkable reports from the front lines.

“We feel honored to continue serving our patients to the best of our abilities,” says Bilazarian. “This pandemic will require citizens to make real sacrifices. We need you to stay at home. But as our ER says, ‘we never close, we are always open, we are here for you.’”