On a normal day, helping sick people cope with the most serious, life-threatening illnesses is a given at the medical intensive care unit at University of Iowa Hospitals and Clinics. Lung failure, liver failure, kidney failure – the list goes on.
Dr. Gregory Schmidt sees a little more than a dozen of these patients during morning rounds, then works with other healthcare givers at the hospital to map a plan to save each person’s life.
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Dr. Gregory Schmidt: Well, in normal times, the MICU (medical intensive care unit) has a very broad and varied population of patients and problems. You know, typical things would include severe life threatening infections, shock, bleeding, pneumonia, lung failure, emphysema.
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Schmidt is director University of Iowa Hospitals and Clinics’ critical care programs and associate chief medical officer for critical care at UIHC. He also is a professor of internal medicine at the University of Iowa, specializing in pulmonary, critical care and occupational medicine.
In mid-January, when we caught up with Schmidt, one-half of the 25-bed intensive care unit’s patients had COVID-19. There was a post-holiday blip but numbers settled down. The COVID-19 patients were isolated from the outside world, including their families.
Iowa managed the blip but a lot of health care workers were wondering if Iowans understood how brutal dealing with COVID-19 in the hospital is, for patients and healthcare workers.
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Schmidt: Well, I would first say that it’s not always clear where someone acquires their infection. I think there often is a temporal association with things like holiday gatherings. And, of course, those are also quite poignant, because they’re the, they really reveal that tension that the pandemic confronts all of us with, which is trying to understand how to reduce our risk, and yet live our lives. So, when someone is being overall, generally very careful with how they conduct their life and keeping themselves safe, and then they break that care, for a holiday gathering with family that’s important to them, and then have a life threatening, and in a couple of these instances, fatal course of COVID-19. It’s just quite painful to watch that happen.
IowaWatch: Do you think the general public has a full understanding of just what type of suffering goes on, that you get to see on a daily basis at work?
Schmidt: Not a chance.
IowaWatch: Why do you think that is? Is it just because of some being so far removed from it?
Schmidt: I think it’s a combination of things. I think, first of all, even clinicians historically have, when a patient survives an ICU stay, we have always celebrated that, you know, life threatening illness you get them through. And, then it’s, you know, hooray, success. And sometimes that actually is completely true.
But I think what we underestimated for many years was the post ICU consequences of having been critically ill, and I’m talking now pre-pandemic. And it’s really been, maybe over the last 15 years, maybe 20 years ago, we started to really appreciate the toll of post-ICU illness in terms of challenges. Especially with cognitive functioning, executive functioning, the ability to make decisions, or to do a job, to handle finances, a lot of physical durability limitations. And, being able to, you know, use hips and shoulders or muscular strength to carry out activities of daily living.
So, the first thing is, I think that, in general, the public probably has, maybe, our prior sense of what ICUs are about, which is that if you make it through in your survive, it’s like that’s, that’s great. And, of course, it is great, but it’s incomplete. It’s an incomplete story. And I think most people don’t understand how much subsequent burden in terms of quality of life there is for many of our patients. So I think that’s one factor. I think what you said also makes sense. They don’t see what I see. They simply don’t see the suffering.
They don’t see the death.
And I would also add, I think we’re all aware that there’s been a lot of misinformation and disinformation, to try to make the impact of the pandemic maybe less evident.
IowaWatch: What type of misinformation or disinformation are you talking about?
Schmidt: Well, for example, the notion that, ‘well, I’ve heard it commonly stated that this disease is similar to the flu,’ for example. I mean, medically that’s just simply absurd. It’s just not true. Or, that it only kills very frail, fragile, elderly patients. And, while it’s true that older patients with comorbidities and other serious illnesses are at greater risk of death.
I’ve seen numerous young patients die of this illness patients in their 20s patients in their 30s.
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Families end up watching all of this play out remotely. The ability to grieve naturally, bedside with a love one, is taken away in order to keep COVID-19 from spreading.
The worst cases become death from a distance.
People like Schmidt and other frontline healthcare workers treating patients with COVID-19 get to deal with it, and not just as care providers. They become surrogates for families.
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Schmidt: I’ve never been awakened on a breathing machine so I can’t tell you from personal experience that, because I care for these patients all the time. It’s quite routine for patients on breathing machines to have pain, to have shortness of breath, to be unable to effectively communicate their needs and wishes and fears and discomfort. We work hard to try to facilitate communication but it’s often not possible. A lot of our patients are deeply sedated. They’re effectively in a medical coma. They may be paralyzed with paralyzing drugs because they are so close to the edge of death that if we did not do that they would get sicker and be at risk of death.
… One of the real tragedies of this pandemic is the isolation of critically ill patients, isolation from the people they care about and care about them.
IowaWatch: What type of mental drain is that? It seems predictable that it would be tough.
Schmidt: I think it’s tough up and down. And it’s tough for the patient because they derive comfort from the people they know and love. And instead, they’re in an environment with people who surely care about them. But we’re clinicians, and we’re not their family. So it’s hard for the patients.
It’s in some ways, maybe even harder for families who are at a distance and who are often getting news over a telephone or, maybe, FaceTime. But they can’t actually see what’s happening. And it’s, it’s hard enough, I think, to go through the critical illness of your loved one when you can actually experience what that means for them by being there, by seeing, ‘Oh, yes, here’s how they are. Yes, I see that they’re sick. Oh, my goodness, they look sick.‘”
To not be able to see that just creates all kinds of challenges of not knowing what’s going on or being worried about what’s happening, or feeling that you’re missing, the involvement with what’s happening or that journey of that shared journey of patients and their loved ones. It’s becoming a much less shared journey.
And then, of course, for us clinicians, for the doctors, the nurses, the advanced practice providers, the respiratory therapists who are dealing with this illness, we’re seeing this happen. We’re watching our patients, ill but separated. We’re talking with these family members and hearing them at the other end of a telephone line with their incredulous at their distress, their questions, their concerns, and having to answer that over a telephone is just gotta’ be awful.