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COVID-19 infection rates, hospitalizations and deaths have been dropping around Iowa and the country. However, the United States will soon cross a grim milestone of 1 million COVID-19 fatalities, and the overwhelming majority of hospitalizations and deaths have been among unvaccinated individuals.
Dr. L.J. Agostinelli is a graduate of the University of Iowa Medical Science Training Program. She's a physician, scientist, neurologist, and, right after receiving her M.D. and Ph.D. in the spring of 2021 from UI, she began her residency at a University of Pennsylvania hospital in Philadelphia. Recently, River to River host Ben Kieffer spoke with Agostinelli. She reflected on the past year working on the front lines of this health care crisis in an intensive care unit, often with COVID patients.
This transcript has been edited for length and clarity. You can find the full interview here.
Agostinelli: “I will say that it has gotten a lot better. When I first started — I started last June at this hospital. At any moment, I would say on the weekdays, I would have up to maybe ten patients to take care of, I was the primary covering physician. On the weekends, you can have up to 20, and on the nights you can have 40 to 50. It was always greater than 50 percent of my patients would be here for COVID. It was not unexpected. Sometimes it was eight out of ten that were here for COVID — not here and also had COVID, but here for COVID. They were here because at home they became very short of breath, very lightheaded, trouble walking, trouble breathing. They come into the emergency room and their chest x-ray looks horrific, like one with COVID would, and then they'd test positive for COVID. I initially started to worry— will I not learn much about liver failure and kidney failure because everybody here is here with COVID? And it has gotten much better over the year.”
"You just get used to it. And it's quite similar patient to patient. It's like, well, here we go again. I've seen this 25 times now. I've seen this 35 times"
Kieffer: “So patients in your care, have died of COVID?”
“Oh, yes.”
“How many?”
“I don't even know at this point.”
“Are there weeks, like in a typical in a week, when it was at its worst, what would you say? How many would have passed?”
“So the worst is definitely when you're working in the ICU, many more patients pass away in the ICU. I remember right before I started, I remember hearing, depending on the size of the ICU — let's pretend in an average ICU, maybe in a good week, one patient passes away in that ICU. Then you have a bad week where three or four patients pass away in the ICU. I remember one day where eight patients passed away, all from COVID.”
“A single day?”
“A single day. And this was, like I said, this is actually past the height of the pandemic at this point. So I don't even know what it was on the worst day in the pandemic. And it's never a fun thing to go into a room and pronounce a patient dead. But you do have to have a physician go in and perform what we call a death exam and confirm that the patient is indeed dead. And those are obviously the ones that I remember, because you have to intimately examine your patient, and then you have to fill out a death certificate. And the amount of times that you have to say this death was due to COVID-19 — that obviously sticks with you. So, yeah, it's happened many, many times.”
“When you pronounce deaths, how do you know it's due to COVID?”
“There's a condition, ARDS which is Acute Respiratory Distress Syndrome, where your lungs develop a certain pattern on an x-ray and on a CT scan. And then the course of the disease, how it progresses, what it requires on the ventilator … COVID has been pretty unique and very aggressive in a pattern that is quite distinguishable from other reasons that somebody would pass away from like a horrific asthma exacerbation or a COPD exacerbation or a lung cancer. The course of their hospitalization just looks different.
“And you get used to it. You just get used to it. And it's quite similar patient to patient. It's like, well, here we go again. I've seen this 25 times now. I've seen this 35 times, and it just sort of follows the same projection and pathway and how sick they get, and you watch their oxygen saturation just get lower and lower despite everything you're doing, you do the same things — it's called proning, where you kind of flip a patient from their belly to their back and back to their belly. And you try to just get their body to use all of the possible lung tissue that's left to try to help them breathe. And as soon as their oxygen status just gets lower and lower, you know that you've crossed a point where they will likely die from this.”
“What's that atmosphere like? It must be really hard to take — I mean, you're a professional, you're a doctor, but you're also a human, right? And you may have family members there in the hospital. I don't know if they're able to be with someone in their last moments, because we know from this pandemic those are some of the most challenging situations where — the last goodbyes are said under some really abnormal circumstances.”
“Right. So at the height of the pandemic nobody was allowed to have visitors, and that's really tough. People — doctors and nurses were doing the best they could to put family on a speakerphone or on Facetime or something like this. Then we in the hospital felt more comfortable allowing each person to have one visitor. Sometimes now we're able to get two up there, depending on the situation. And it's really tough. It's really tough to tell patients and then to tell families like, hey we think that you're probably going to die from this. And usually at that point, it's surprising to me, but a lot of patients know, or they'll actually before I even tell them, they'll pull me into their room and say, ‘I think I'm dying.’ And then, we'll say, ‘I think so, too.’”
"It’s never easy, but it has gotten easier because of just the sheer volume of conversations that go around like this."
“It's exhausting to try to breathe like that. And they just, they look so tired and so fatigued. And as you become more fatigued, it's tougher to breathe. You don't really get rid of your CO2, the carbon dioxide. And as that builds up in your body, you get sort of loopy and sort of confused. And before that happens, you want to give people the chance to say goodbye to people, or if they have some finances they need to get in order, or they want to find somewhere to take care of their pet or their kids or whatever. You really want to let them know the best you can that ‘hey, maybe before you get worse, you should sort of try to wrap things up.’ It can be a hard conversation, of course, and we have teams and palliative care doctors help us through all of this. But, it is a tough conversation that unfortunately, especially during COVID, we have way too many times.
“It’s never easy, but it has gotten easier because of just the sheer volume of conversations that go around like this.
“Now it's to the point where we can have people come up and visit. But our hospital's policy is that you either have to be vaccinated to come up and be a visitor or you have to have a recent negative COVID test, like within two days or so. And you'd be shocked at the amount of family members who do not fall into this group. They will not get vaccinated, even though their sister or spouse or parent is dying in the ICU.”
“And we know the statistics … the vast majority of — since the vaccines were developed, people became vaccinated, the vast majority of hospitalizations due to COVID and deaths are unvaccinated. I mean, vast. It's not even close, right?”
“Not even close. It's like a tougher conversation for me to, almost, have with families than with the dying patients sometimes, because you just you get so frustrated. You're exhausted from what's been happening at the hospital, and then it's devastating for you. You've gotten to know this patient. They've been here for days and they're dying. And then there's a family member at home who's still well, and they don't care or don't believe or don't want to get vaccinated, and you just want to scream at them ‘your family member is dying,’ —or is dead, sometimes I have the conversation after the fact and sometimes it results in change. Sometimes there is a change. And but a lot of times there's not.”
“In the patients themselves, before their deaths, have you had unvaccinated patients who you have this conversation with? Are some of them saying, I, I should have gotten a vaccination?”
"It's a heart-wrenching thing to hear, because I knew it could get this bad. Everybody who works in the hospital knew it could get this bad. "
“Well, yeah, of course. I mean, I of course, try not to pressure them, by any stretch of the imagination, because they know what's going on. I would say that there are some patients who don't always believe it. There's like a few that will just say that it's something else, that it's probably not COVID. The large majority, though, know it's COVID. And a handful of them will say something like, 'I just had no idea I could get this bad.' And it's a heart-wrenching thing to hear, because I knew it could get this bad. Everybody who works in the hospital knew it could get this bad. We see it every single day, and I talk about it often with friends, families, etc. just because I can't imagine somebody passes away by accident because they just didn't know. That seems like a very senseless way to go, but it happens.”
“And if you do survive, if you are hospitalized or even people who are asymptomatic, we know now you can come down with COVID and have some very serious long-term implications for your health.”
“Oh, yeah. This whole idea of, like, long COVID is frequently talked about now all of the — you can have heart issues and obviously long-term lung issues. I don't know if your lungs will ever return to normal after that. But neurologic disease, there's a lot of things that definitely happen as a consequence of COVID.
“But the thing that's frustrating, and a lot of family members will say, ' Well, I have a friend who got vaccinated and they still got COVID.' Yes, of course you can still get COVID if you get the vaccine. You know, not at the same rate as if you're unvaccinated. But I don't really — I'm not trying to stop you from getting a flu or getting a sniffle or having one day of a fever. That's fine. It's that if you don't get vaccinated, your chance of ending up in an ICU or dying from COVID is just so much higher. So that's the thing. When a family member says, well — I say ‘your wife is going to die from this, sir, are you vaccinated?’ 'No.' ‘Well, you should probably get vaccinated because it's serious, and you should protect yourself and others. Your wife is dying from it.’ 'Well, I have a friend who I have a friend who got COVID, even though he's vaccinated.' But the thing I'm trying to stress to them is that, yes, you can still get COVID, but your chances of ending up in an ICU or dying from COVID if you're vaccinated, are just much, much lower. Much, much lower. I think the data is now that greater than 90 percent of patients that die of COVID are unvaccinated. It's basically the vaccine is helping you fight off a very serious course of COVID.”
I've heard many patients say. ‘Doc, I carry guns.’ And so they think to themselves as, since I'm somebody who carries a gun, what else would one who carries a gun do? Well, it turns out it means I would also not get vaccinated.
“Right. You're a neurologist. You're an M.D. so maybe this is outside your expertise. Maybe a sociologist/ psychologist needs to address this. But I'm interested in your thoughts, having had those conversations with patients who have then died or been near death or families of patients who died. What do you think is going on there? The resistance to what seems like a black and white decision, black and white science saying do this. What is going on in these people's heads, do you think?”
“Right. I think that it definitely seems like multifactorial and not one explanation can wrap up everyone or most patients, because the conversation, the resistance seems different. There's many different reasons. I think there are people typically it's just like an ideology thing. Everyone's looking for an identity. And if they identify as somebody politically or socially, as, I don't know, maybe their word is conservative or whatever it is. Then they look to leaders or public figures in their group to sort of help them make a lot of life choices. And one of these choices would be whether or not to vaccinate. So I've heard many patients say, ‘Doc, I carry guns.’ And so they think to themselves as, since I'm somebody who carries a gun, what else would one who carries a gun do? Well, it turns out it means I would also not get vaccinated. And nothing I say is going to penetrate them because they so strongly want to be somebody who carries a gun, that therefore they also see themselves as somebody who cannot get vaccinated, would not get vaccinated. That's a tough one because it's almost like an impenetrable conversation at that point, even though I tell them 'fine, carry your gun, but please get vaccinated.' They see them as like it is a package deal.
“And then there's just a lot of patients who it's just I think it's so terrifying, it's a denial thing. Like it's just so overwhelming to accept that this is a thing and that it happens and it really is sweeping the nation and there is a pandemic and humans might be taken out by a virus is just too much. They just need to ignore it, and they don't even want to begin to like think about that. It just needs to be like a horror movie that they just don't want to watch and they do not even want to talk about it. It's so overwhelming to them.”
This transcript has been edited for length and clarity. You can find the full interview here.
