COVID-19 has no doubt changed many facets of laboratory medicine. But not a lot of people have talked about exactly how cancer management and workflows have changed. Are these changes permanent? Are they temporary? I don’t think any of us know for sure yet. So, we decided to spend some time and ask physicians what they think about changes they experienced. In this series, we are sharing these stories with you. So many of us have shared similar challenges and many have found creative solutions to adapt to new workflows. It is our hope that this series shares the collective learning experience about navigating the pandemic and strategies about how to move forward.
The first blog post in our series, Scoping COVID-19, features Dr. Raquel Yokoda (@yokoda_md), a 14-year Transplant Hepatologist turned Pathology resident at Montefiore Health System in the Bronx, New York. To say her workflow changed due to the pandemic is an understatement. In early March, she found herself not behind the microscope, but rather on the frontlines. “I was feeling that my place was not in the lab. With all the clinical background experience I had, I needed to go to the frontlines,” Dr. Yokoda told us. “I first worked at night, as the need for people who could do night calls was overwhelming, then I went to the day team for one week, and then back to the night shift again.”
With NYC at the epicenter of COVID-19, the need for hospital organization under mounting pressure was paramount, and departments came together as a team to meet the challenges they faced. Dr. Yokoda explained, “The logistics involved Internal Medicine coordinating their operations, including intensive care and rapid response teams under the direction of Critical Care Medicine, all in collaboration with a core leadership resource group overseeing all of the needs for professional deployment. All of the professionals that were not Internal Medicine were under the “allied health” team. I worked with intermediate care and cardiology intensive care. Most of the time, we were in units that used to be telemetry and reshaped into ICUs, including the PACU units turned into intermediate care. We had patients intubated in all units; at the peak, we had around 400 functional ICU beds, beyond the regular original 88 ICU beds. And therefore, the perspective was that at some point, Medicine would deactivate those units.”
Dr. Yokoda’s responsibilities ran the gamut. “At night, I would function as a regular physician. I would see patients, write the transfer notes (as they were coming from the floors/ER) or progress notes and do the initial prescription from admissions and all the miscellaneous notes for a stat medication or procedure. I performed several clinical procedures. I placed peripheral venous lines and central lines. I managed vasoactive drug drippings and infusion pumps, as well as sedation pumps, when indicated. I started early oxygen therapy with a non-rebreather mask, progressing to the high flow nasal cannula, incorporated the proning maneuvers, and had a few intubations. I read EKGs, followed up enzymes, set amiodarone and performed defibrillation--all the intensive care work-up that I was used to from my clinical years. I quickly learned how to deal with all models of ventilators we had available, and we were seeing an increased number of patients with tracheostomy as well those who were waiting for a vent facility, as discharging became challenging due to lack of availability in those units. I also had close interactions with palliative care medicine and end of life care, especially pain control protocols that require close monitoring of dosage titrating, along with the clinical pharmacists.”
One of the most moving experiences she shared was serving as a link between the patients and their families. “I would talk with families over the phone and update them every time a patient was deteriorating. I would also talk with families/health care proxy when the patient was eligible to be enrolled in a clinical trial. It was difficult because I could not predict how anyone would react, recover, or how the drugs would work. And ultimately, I would call the family for one last video call with the patients if they wished to see their loved ones for the last time. I think this was the most challenging part of the job. I felt the art of practicing Medicine above medical science during those days.” Pathologist-patient interaction due to the coronavirus was also taking place at NYU Langone Health. Dr. Yvelisse Suarez (@Dr_Y_Suarez), a GI pathologist, was part of a program called NYU Family Connect created by Dr. Katherine Hochman (@KHochmanMD), where pathologists called patients’ families to give updates on how their family members were doing. “For a certain time, no visitors were allowed so patients were by themselves. Pathologists became the bridge between patients and patients’ families. Being involved in patient care was a really rewarding experience. As a pathologist, I don’t have any patient interaction at all, so speaking to family members and doctors on the frontline really made me feel a part of the medical community and a direct participant in patient care,” Dr. Suarez explained. From our interviews, we find that most pathologists view interacting with patients as rewarding and ponder if we will see more patient-pathologist interaction in the future of medicine.
Amidst all of the frontline work by IM and allied health, a new responsibility emerged: Dr. Yokoda began sharing her knowledge and love of Pathology. It all happened very organically. “I introduced myself as a current pathology resident from the beginning and I explained my background in Medicine and Gastroenterology. In most people’s minds, all I was doing in Pathology was autopsies. Overall, at night, we were too busy for any further talk about our professional choices.” But during the day, the dynamics changed. “There are more residents around and more space for teaching and learning. During the day, I would function as a resident, talking to an IM attending and discussing the cases, even if very briefly. And the residents were really curious about me. The question of ‘why are you in Pathology?’ was there from day one. They were intrigued because I wasn't someone who only did Internal Medicine, but I also had further specialization. And they never thought about Pathology in that sense, as a cutting-edge experience in Medicine in defining pathobiology and helping to progress the current medical knowledge.” Dr. Yokoda also had the opportunity to reframe the image of a pathologist. “The fact that I like patients, and I am good and comfortable with clinical Medicine, puzzled them. They expressed their surprise and their bias as they would never picture a pathologist who could also be a clinician and be good around patients. They told me how they’ve pictured pathologists over the years as someone who averts people and patients and hides in a lab! I was completely outside of the box for them.”
Dr. Yokoda continued, “There were several IM residents around me during that week and their program maintained all of the lectures and conferences going on, and I interacted with several of them. I like Radiology-Pathology correlation, and I would open the chart, the image, and some Pathology websites and explain all associations for them every time they asked me something about their patients. The level of correlation was something they had never seen before. Quickly, they were asking a lot of things, from lung histology to gross heart pathology and autopsy findings to differentials. Then, the residents and attendings asked me to give a lecture after their didactics in the afternoon. They set the service in a way that I had more than one hour to talk. During the lecture, I presented two articles with the early autopsy descriptions in the US in COVID-19 cases. The diffuse alveolar damage, and diffuse microthrombi and even glomerular thrombotic microangiopathy were appealing to them. Also, I talked about why we were trying the drugs that we had on clinical trials based on HLH behavior as a cytokine storm. I mentioned the longer gastrointestinal virus shredding, and our project of validating the stool test for COVID-19, while I also clarified the validation process of a new laboratory test as it becomes available when we were starting the antibody testing for all employees. After that week, two of the residents sent me texts telling me they had learned a lot and they would always think of Pathology from now on. Some residents in their senior year also asked if they could see an autopsy or participate in a radiology-pathology conference. They were mesmerized, as everything was making sense. A PGY-3 told me, ‘We should take all questions to Pathology, and they would explain and help us to understand the disease." Another statement I heard was, ‘Wow, you guys are way up in the medical science power chain; we should interact much more.’ They were hungry to connect the dots, and on that week, I was the connector for them. I was proud to discover how interactive our Pathology knowledge can be and how much they needed it and appreciated it. Internists have much more interactions with Radiology as their primary diagnostic specialty, as they do not see clinical pathology personified. Pathologists interact with surgeons daily, infectious disease doctors, and oncologists frequently. But there is room for much more if we step up.”
Not only did Dr. Yokoda bring her skill and experience as a clinician to help on the frontlines, she shined a light on how crucial Pathology is to practicing medicine. Dr. Yokoda made a lasting impact not only on the patients she cared for on the frontlines, but on her colleagues by using pathology to connect many dots during the early stages of COVID management. Even amidst a crisis, she still helped residents from other specialties fill gaps in Pathology knowledge that may not have occurred under normal interactions. It’s these interactions which will propel the practice of pathology to the frontlines and beyond. Dr. Yokoda showed pathology is up to the challenge--to act, to serve, to educate.
We’d like to thank Dr. Raquel Yokoda and the Montefiore Einstein Department of Pathology for this interview as well as Dr. Yvelisse Suarez from NYU Langone Health. In the coming weeks, we will be sharing more COVID-19 stories from pathologists, oncologists and interventional radiologists including the rise and fall of case volumes and the positive impact the pandemic has had on education. Stay tuned for more Scoping COVID-19.
Built on the vision of better patient outcomes, Instapath was founded in 2017 by engineers and scientists to enable patients to immediately know their cancer diagnosis. Our team made it our mission to develop fast and easy digital pathology technology so diagnosis can be made in minutes instead of days. To learn more about Instapath and our technology, visit www.instapathbio.com or contact us at info@instapathbio.com.