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An Intrepid Speech Pathologist Confronts an Implacable Foe

Julia Agosto during a respite from working in the COVID ward.

By David DeFusco

For Julia Agosto, a speech-language pathologist and Katz School clinical assistant professor, life on the front lines of COVID-19 has been an unrelenting series of challenges that have tested the limits of her strength, patience and resilience.

The stress of being thrust into a chaotic and sometimes maddening environment can be all consuming. There is the physical exhaustion of lifting and turning patients on their bellies so they can breathe easier, the never-ending evaluations for speech, swallowing and cognition on top of administering treatments for already-existing co-morbidities, the communication difficulties with compromised patients while clad in protective gear, and the mental anguish of making end-of-life decisions.

Then there’s the fear of breathing the same air as the seriously ill and the tears from the sick, their loved ones and her co-workers. Patient after patient, day after day, all the while bracing for yet another variant ready to unleash a fresh wave of infections. Still, Julia tries to put herself in the place of her patients.

“Imagine waking up two weeks after you’ve been intubated, you already have dementia, had a stroke on top of it, speak another language, and there’s this monster wearing a respirator, mask and glasses and you can’t communicate,” said Julia, who works per diem at Westchester Medical Center and Hackensack Medical Center, and part-time at Pascack Valley Medical Center.

Patients who are cognitively challenged or have hearing and vision issues need to see her face and mouth in order to communicate effectively, which is critical to decision-making. "Since the PPE is a barrier," she said, "I try to find creative ways to evaluate and treat them.”

Julia said that she has to find creative ways to communicate with her patients while she is in full gear.

Julia decided to join the Katz School’s M.S. in Speech-Language Pathology Program because of its focus on medical speech pathology, including its commitment to a holistic approach to care. She teaches the courses Cognitive and Higher-Level Language Disorders and Geriatric Dysphagia and Airway Management, and is the lead instructor of the peer-to-peer clinical training program. In addition, she serves as a supervisor in the Katz community clinic, which has provided more than 1,000 free evaluations and treatment sessions for New Yorkers.

“The fact that we are expected to stay in clinical practice while remaining academic leaders was especially appealing because it highlights the value of clinical experience, which remains at the forefront of our profession,” she said. “At Katz, we have a diverse faculty with a myriad of expertise that is all-encompassing and well-rounded. We are passionate about producing students who are highly prepared to deliver the best patient-centered, evidence-based care.”

When COVID hit initially, Julia often covered three hospitals in one day because of chronic staffing shortages. At Hackensack, they had over 500 intubated COVID patients, most of whom would never return home. Because she specializes in acute care, she works predominantly with swallowing disorders, deciding whether patients who have been taken off a ventilator can eat or drink, or need a feeding tube to ensure they’re adequately nourished and hydrated.

If they have facial weakness resulting from a stroke, she teaches them oral motor exercises. For the hearing impaired, she uses an iPad to facilitate communication between virtual interpreters and her patients. Dealing with end-of-life decisions has become routine, especially with patients suffering from dysphagia—the inability to safely swallow. Then there are the patients who aren’t candidates for a feeding tube or reject it outright.

“I spend a lot of time educating my patients and families on their options,” said Julia, “including accepting the risks of aspiration by allowing the patient to be fed by mouth, knowing that this will likely result in death. I can’t tell you how many times that a family member has said, ‘I don’t want to be the one to make the decision that’s going to kill them,’ when they are unable to see their loved ones or say goodbye.”

Julia has worked for 20 years in every health care setting and with every category of patient, from neonates to geriatrics, to hospitals/acute care, to subacute, long-term, outpatient and in-home, and the pandemic has been by far the most challenging stretch of her career.

“My goal is to take the knowledge I’ve gained from the years of clinical practice—including the successes, barriers, problems and solutions—and share it with my students so that they are ahead of the game when they graduate,” she said. “But, as important, I tell my students that to be a good clinician, you have to be a good person—to be empathetic and kind. In doing so, we gain valuable insight not just on the disorder, but how best to treat it and the client as a whole.”

At the height of the pandemic, Julia, a single mom, didn’t see her five children—ages 8, 10 and 12, plus two in college—for a month. “I didn’t let them come home,” she said. “I was in full PPE and changed three or four times a day. I can’t tell you how much laundry I did.”

In order to stay close to them, Julia manages and helps coach three travel soccer teams, and to minimize the emotional toll of her work, she visits her autistic brother in a group home as much as possible. As if she didn’t have enough on her plate, she was inspired to pursue a combined Ed.D. in healthcare and education leadership and doctorate in public health from Nebraska Methodist College to position herself as a voice for needed change in patient care and student training.

“This is what I signed up for,” she said with a rueful smile. “I don’t have time for PTSD.”