As the spread of COVID-19 upends daily life across much of the globe, healthcare workers in the United States find themselves on the front lines of a rapidly escalating crisis. In the continued absence of widespread testing and easily accessible fever clinics, there is real concern the virus could overwhelm the country’s limited medical resources, leading to tragic outcomes that we’ve seen in Italy.

Efforts to “flatten the curve” rest not only on social isolation and hand-washing, but also the acceptance that not everyone who believes they have symptoms may be able to receive immediate care, according to public health leaders. Emergency rooms, in particular, are among the most overburdened and understaffed levels of the U.S. healthcare system. While hospitals have been able to handle the influx so far, the crisis here is only just beginning. Epidemiologists believe hospitalizations won’t peak until May.

On Thursday, Gothamist spoke with an emergency room doctor at a major academic hospital in New York City. When he last worked on Monday, he’d just screened his first patient for symptoms consistent with coronavirus (the final test results remain pending). He described the situation as “painful,” noting that a failure to prepare and questionable guidance from elected officials had created a situation with the potential to rapidly deteriorate. We have agreed to withhold the identity of the doctor so he could speak candidly. The full conversation, lightly edited for clarity and length, is below.

It’s obviously been a stressful few weeks. How are you and your colleagues holding up?

It's been a spectrum. Across the board from doctors to nurses to technicians, some are quite worried on a personal level as well as on a work level. Some people are like whatever, I’ll accept my fate and it can’t be that bad. There are pregnant staff who are scared because no one knows yet how this coronavirus could affect a fetus if they’re exposed. For the most part when I talk to my colleagues they realize that, yeah, this has the potential to be really serious on a systems level. All in all though, I’d say there’s a calm acceptance about how crazy it's going to be.

Last Friday, Mayor Bill de Blasio told New Yorkers who think they may have coronavirus symptoms to “just get to health care,” whether that be “a doctor's office, a clinic, an urgent care, an emergency room.” Many people have said that’s not possible. Was the mayor’s advice wrong?

It was terrible advice in the current context of NYC healthcare at the time he said it. If we actually had a system that was prepared when he was saying these things, then it would be great advice. But there was a lag in citywide action and cultural response to what was happening. In the last week, things are slowly moving in the direction where we are mobilizing and becoming more prepared. It’s important to know that in a busy New York City emergency department, it can be a huge drain on resources to have all these people show up at the ER at once to get tested.

Why is that?

It just isn't feasible or sustainable for someone like me to be doing this in an ER setting the way it was [expected] for me and my colleagues on Monday. Especially for patients who are coming in and are otherwise well. If they’re in respiratory distress or unstable, they need to be in the ER. But if it’s multiple walking people with common cold symptoms, it’s just not feasible unless a new system is in place to address the widespread testing needs.

The other systems issue is that we don't have enough nurses. Basically on a busy night it can be about ten patients per nurse on average, if not more, counting patients who are boarding in the ER and admitted patients who can’t go upstairs due to no vacant beds. That’s just how New York City ERs work. It’s unsafe. When you combine that with a possible COVID outbreak, in which you’re trying to find masks, trying to deal with the patient load, putting on equipment, putting swabs in their nose and mouth, the rest of the ER is just going to stall and explode. I’m hoping the system will adapt, but last week was painful, and I am dreading my next shift.

The President of NYC Health + Hospitals, Mitchell Katz, says that public emergency rooms haven’t seen the sort of rush of patients that could present a serious problem. Do you think we’re ready in the event that changes?

Right now, things are very dynamic, and access to testing I hear is ramping up in-house, meaning even if a patient might not meet criteria for DOH testing, the hospital itself may be able to run the test or send it to a private testing lab. Everything is a bit nebulous with protocols still being formed by the higher-ups. But really, the entire healthcare system should have been ready and set to run, considering how serious the epidemic was on the other side of the world in the month prior and how easily one should have considered NYC to be an eventual landing site.

One of the major fears is that the health care system becomes overwhelmed and difficult decisions need to be made about who can use limited resources. Officials say we have 1,200 hospital beds and 5,000 ventilators across the city. Have you or your colleagues discussed a worst case scenario where those run out?

It's very possible. No one's really mentioned it, that I’ve heard. I will tell you that there's always a shortage of beds. So it's probably going to go that way if the pandemic actually hits like they’re talking about. They do keep some of the beds open for elective surgeries to make money for specialties, like ENT or gastroenterology, which is a whole separate issue. But the hospital is always going to be full if a lot of sick people come in.

In terms of the ventilators, yeah if the ICU is full, then the patients that are intubated have to board in the ER. I've never reached a point before where we ran out of ventilators in the hospital, and I hope it doesn’t happen here. But it's not too far-fetched to imagine, given how this happens to be an extremely contagious respiratory bug. It’s hard to say. With these other areas like Iran, Italy, these are different contexts and environments. The resources may be different. But to my knowledge [no other virus] seems to have done this before in the modern era of respiratory viruses. And it has every potential to wreak havoc here. The most important things are simple personal and public health measures. Social distancing. Hand hygiene. Staying hydrated. Getting rest.

There’s been a lot of confusion about who is even eligible to receive a test. What have you been told?

The main criteria is that you either have to have fever, or subjective fever, or upper respiratory symptoms and have either had contact with a known COVID case or have traveled to one of the places that’s a hot spot. These criteria are being changed, it seems, on a weekly basis. But who knows where the actual hot spots are right now. Westchester should be a hotspot. Community transmission is happening in NYC. It boils down to the fact that it’s hard to get testing. As of last week, there were people coming in who might have COVID and were not getting tested. More and more seem to be now but more progress is needed.

We've also seen questions about how this virus spreads. De Blasio has claimed that it can only survive on a hard surface for a few minutes and that it can’t hang in the air — which contradicts recent findings by scientists, as well as the earlier guidance of the Center for Disease Control and the World Health Organization. Are you concerned about that discrepancy?

Yeah, it's a little concerning. He's trying to temper the panic, but realistically it's a lot longer. I know that a patient who might have been screened for COVID, if they're either discharged or admitted or doing personal quarantine, we’ll leave the room alone for half an hour or longer and then clean it. That’s not a realistic view, especially when evaluating what the data shows.

It's concerning that he's saying that because people are going to treat it as less dangerous than it is.

Officials have been saying for weeks that testing is about to ramp up seriously. So far that hasn’t happened. Do you have any sense about what’s stopping that from happening right now?

It’s hard to say why we can't freely test like they are in other countries. I don't know if it's due to the testing cost or if there's something from high up, where they want to limit the data. There needs to be COVID clinics where people will be directed to these areas with specialized care that can deal with a flow of patients and easily and efficiently test them.

From your vantage point right now, how bad might things get?

There's a lot that we don't know. I like to think we're ready to mobilize if needed, but I would say that our resources in the ERs and the health care system will be incredibly strained. There's definitely a possibility it could get crazy. It doesn't seem like it has quite yet, I don't know if maybe the warmer weather, hopefully, will change the contact of how the bug spreads. I'm just naively trying to be optimistic about it but understanding that it could get bad.

We have people up there thinking about this, and we have the ability to get the right personal protective equipment available at all times for providers to prevent spreading the infection in the ER, which is a true hazard. We have the ability to create a real streamlined approach to a mass casualty incident. But it's hard to tell how things will perform if or when the actual crisis happens. I'm hoping that all that gets sorted out before the shit hits the fan.

This interview has been lightly edited and condensed for clarity.