When the COVID-19 pandemic was at its peak in New York in mid-April, there were about 95 hospitalizations per 100,000 in a region with many large hospital systems. These hospital systems had some excess capacity and had the resources and surge plans to create more capacity by repurposing hospital units to COVID-19 care, freeing up more staff through cancellation of elective surgeries and procedures, and shifting health care workers from ambulatory care settings to hospital work. 
In addition, a significant number of physicians, nurses and respiratory therapists came to New York City from around the country to volunteer or work as paid supplementary staff to help meet the demand for care created by the surge of COVID-19 patients.
Despite these efforts, the hospital systems were pushed to their limits, forced to move from providing conventional care to crisis care.
South Dakota's COVID struggles
In South Dakota today, there are about 65 hospitalizations per 100,000 people. At first glance, it appears that this number is significantly lower than the COVID-19 patient surge New York experienced at the city's peak. But the landscape of emergency services, hospitals and intensive care capacity is vastly different in South Dakota compared with New York City.
Hospital care is delivered primarily in small rural Critical Access Hospitals, often about 25 beds with limited or nonexistent intensive care capability. COVID-19 patients and other critically ill patients who need to be cared for in an intensive care unit are typically transferred to larger regional hospitals, which can be hundreds of miles from the small critical hospitals.
Intensive care physicians, critical care nurses and other specialists are essential to the care of COVID-19 patients, and these health care workers are in short supply in rural health care systems. 
As cases continue to rise, South Dakota is facing the same type of mismatch between resources and demand that occurred in New York City at the peak this spring. If we don’t get control of the cases, people will continue to get critically ill, and hospitals will continue to be overwhelmed in the state. The standard of care needed to battle COVID-19 will not be able to be maintained, and crisis standards of care will have to be implemented in either an organized or less desirable haphazard manner. This could mean, for instance, ”battlefield triage,” rationing life sustaining care for those least likely to benefit.