Donald D. Chang
The University of Queensland - Ochsner Clinical School, MS4
May 10, 2020
New Orleans, Louisiana
From March to April, during the peak of the pandemic in New Orleans, I helped run the COVID-19 diagnostic tests at my hospital, Ochsner Health System. In our hospital we have three different testing platforms. The one I worked on utilized a technique called Reverse Transcriptase quantitative Polymerase Chain Reaction (RT-qPCR) and of all the testing options at Ochsner, this had the greatest capacity for large volume testing as it was high-throughput (up to 96 samples per run) and also had the highest level of analytical sensitivity and specificity.
Interestingly though, while the need to roll-out accurate high throughput COVID-19 diagnostics was self-evident, the pathway for medical student involvement was not.
The personnel who typically run laboratory tests, Medical laboratory Scientists, are post-graduate trained researchers who need to pass a rigorous set of state-mandated requirements. In the hospital, they are responsible for accurately resulting out the lab test of hundreds of patients each day. When 70-80% of medical diagnoses are based on laboratory results, one can appreciate the need to have regulatory processes in place for staff recruitment.
Medical students fall in a gray area. Many of us have extensive research experience and a few, including myself, have doctorate level training. However, none of us were Clinical Laboratory Improvement Amendments (CLIA) certified – the official stamp of approval to work in a medical laboratory. Normally, this certification process takes weeks to process.
But we were not in normal times. Behind the scenes, Ochsner leadership was communicating directly with the Louisiana State Board of Medical Examiners to grant emergency licenses, an initiative which ultimately passed – an extraordinary display of collaboration that underscored the state of urgency Louisiana was in at the time.
The end result was that I was allowed to assist in the frontline efforts of COVID-19 diagnostic testing during the peak crisis days.
My role evolved over time. At the beginning, it was hands-on work. There was no shortcut for pushing a sample through the testing process. SARS-CoV-2 was sweeping across New Orleans at an alarming rate and we needed test results yesterday. We worked around the clock, picking up samples at specimen processing, loading them on the machine, troubleshooting, and then resulting it out, often late at night. At the same time, we helped train some of the newer staff, spreading out the workload so that together, we could pull ahead of this pandemic. Eventually, we caught up and that’s when our roles shifted to a more analytical role. It turned out that due to the breakneck pace of testing samples, we had not actually had time to shift through the mountain of data that we had collected. Currently, our involvement is primarily analyzing our data and interpreting its clinical and epidemiological significance.
Of the many lessons I took away from this experience, there are two that stand out: Learning to adapt.
The arrival of COVID-19 did not come with a manual or a syllabus. Yes, we had the equipment which came with instructions. But to think that was enough to start testing right is naïve. There was a laundry list of challenges we faced. How would we ensure we had the proper negative pressure airflow in the testing center? How would we ensure safe handling of the COVID-19 nasopharyngeal swabs? What’s the best way to approach sample tracking? How do we train staff?
Despite the overwhelming number unknowns, we were able to adjust our approach and organically adapt our workflow to where we started with a few hundred to over 1,500 sample testing capacity – and do it same day was well.
The Clinical Significance Behind a Laboratory Test. While it was easy to get lost in the routine pace of laboratory work, the results we handled were life-changing and as physicians, we must never forget the weight that comes whenever we interpret a diagnostic test. I’ll never forget how at the end of a long workday, probably near midnight, we were reviewing our last RT-qPCR run which, by all accounts, was a “good” one – meaning it had no errors. However, as we were releasing out all the COVID-19 positive results, our lead pathologist solemnly said “Too many positives…”. Through the fogginess of many sleepless nights and long laboratory workdays, his comment sliced through and hit me. I was not doing a bench experiment or research. Our work would be the reason why tomorrow morning there would be tears shed and lives changed. As clinicians, we must respect the weight behind every diagnostic we order as there is no such thing as a trivial result.
My experience here went beyond just the lab. Through connections made between the medical school and Pathology department, we were able to set-up integrated Pathology days, a new experience that was inspired by our interactions with the medical laboratory department. This new initiative involves medical students on Internal Medicine Clerkship spending one day with the Pathology department and touring the Anatomical and Clinical Pathology areas. This allows students to develop a deeper appreciation of the background process behind a diagnostic test while simultaneously enabling them to learn basic principle of pathology. I’ll never forget the call I received from the Pathology Department chair when he first told me about the lab and our mission objective: to become one of the lead testing centers in Louisiana. It was a mix of excitement, nervousness, and at one point, self-doubt. “Could I do this? Am I good enough?” The answer, in hindsight, was a resounding yes. When the calling came, our clinical training and mental fortitude kicked in. There was no hesitation – just doing. As physicians-in-training, we will have to someday make decisions that can change a patient’s trajectory forever. It is something every medical student is nervous about. Yet this experience instilled in me the confidence that I not only had the skill set to execute such decisions, but that I have the training to fulfill that responsibility.