A year into the pandemic, COVID-19 has put an enormous strain on healthcare systems — including the influx of COVID-19 patients, staffing shortages and budget crunches. Hospitals and healthcare workers reflect on living with COVID a year after it came to dominate our lives.

Joel Wells says the worst moments at Iowa’s rural Wayne County Hospital came last fall, when COVID-19 hospitalizations were spiking statewide.

Wells, a family physician in the third decade of his career, says at that time, he had nine COVID-19 patients. That’s a lot for a 25-bed rural critical access hospital in south central Iowa.

“We had to make lots of decisions on the fly,” he recalls. “And we had patients that really — when I say were critical, they were. We had quite a few deaths at that time.”

But Wells says facing surges of sick patients was far from the only challenge his hospital faced in the past year.

Some patients have aggressively pushed back against his public health recommendations. That’s something  he and his colleagues never expected to experience during a pandemic.

“We, as a medical profession, don’t have the trust that I thought we did,” he says. “It just rocked my world. I just said, ‘Oh, man, people really don’t want to listen to me.'”

On top of all of that, Wells said about half of the Wayne County Hospital staff had to be furloughed last summer to deal with COVID-related budget shortfalls.

These challenges aren’t limited to small hospitals like Wayne County’s.

“There were multiple moments that when we were standing on the edge of the cliff, you never thought the cliff could be steeper,” says Suresh Gunasekaran, CEO of the University of Iowa Hospitals and Clinics, the state’s largest hospital.

There were times during last fall’s surge when his region was reporting no available ICU beds. The entire health care system was stressed, and like Wayne County Hospital, Gunasekaran says the university hospitals experienced an economic strain that trickled down to every single hard-working staff member.

“We had folks that took pay cuts.” he says. “And we had folks that gave back vacation and did these things that you know, very much were stressful, and very much were dollars out of their pockets.”

A year of battling the coronavirus has left many hospitals and their workers across the county emotionally and financially drained.

Aaron Wesolowski, vice president of the American Hospital Association, says the organization estimates hospitals lost $320 billion in 2020. “A lot of states imposed really strict bans on certain kinds of services, and people avoided certain services that resulted in reduced revenue.”

He says hospitals also faced increased expenses for personal protective gear and in caring for COVID-19 patients.

He expects hospitals will continue to face pandemic-related challenges for a long time — even with the vaccines now available. He notes this year started with a massive surge in COVID-19 cases.

“They put a tremendous strain on hospitals in terms of, you know, having ICU that were essentially maxed out,” he says. “So we think it’ll be quite a while before we return to any sort of baseline.”

But some hospitals seem to have fared better than others.

Joanne Roepke-Bode, public relations manager for the Kossuth Regional Medical Center in northern Iowa, another rural 25-bed hospital, says support from the federal CARES Act helped the hospital avoid staff furloughs.

Roepke-Bode says the biggest challenge in the past year was pacing and preparing for the virus. She says they were ready last spring for a surge in cases. But that didn’t happen until late fall.

“And then when cases came, I think people were already hitting COVID fatigue, you know, and they were just ready to move on,” she says. “And that’s when we kind of needed to really buckle down and say, ‘Oh, gosh, we need to stay home now.'”

In Wayne County, Wells agrees pacing was a huge issue for many health care workers, who forgot that a pandemic is a marathon — not a sprint — and didn’t stress that important message to the public.

“We had a tendency to paint hope,” he recalls. “There was no hope. This was going to be a long siege, and I think a lot of us saw that and we just [tried] not to talk about it.”

Wells knows the pandemic is far from over. But with vaccines now available, he remains cautiously optimistic that a return to some normalcy is near.

This story was produced by Side Effects Public Media, a news collaborative covering public health.