Raquel Teixeira Yokoda, MD, is a trained gastroenterologist / transplant hepatologist. After 14 years in clinical practice, she joined Montefiore Einstein in 2019 as a first-year resident in the Department of Pathology, specializing in Anatomic and Clinical Pathology. Her research interests include: GI/Liver pathology, hepatobiliary tumors, cholestatic diseases, liver regeneration, liver iPSC, organoid models, gene therapy, normothermic perfusion ex-vivo technology, and oncolytic virotherapy. She is a strong advocate of efforts to address healthcare disparities.
In what ways did you become involved in Montefiore’s response to the COVID crisis?
I volunteered to help on the frontline by seeing patients and providing direct patient care in any settings that would be in need. I was re-deployed to Internal Medicine as an allied health staff. I started helping in the semi-intensive and ICU at the new extended facility at the Hutch [Montefiore’s Hutchinson Campus], then with the floor patients at Northwest [Montefiore Medical Center, Moses Campus], orange team, and later at the cardiology/telemetry arrhythmia unit at Weiler [Montefiore’s Einstein-Weiler Hospital] with the purple and aqua team.
How did the teams react when they learned you were from Pathology?
When I worked at the Hutch and Weiler, I did mostly night shifts, and they had me solely as a clinician. But, my time with the orange team at Moses was during the day, and I was able to take part in their teaching rounds. One of the Internal Medicine attendings asked me to explain the pathological features of the first COVID autopsies published in the US. I ended up doing a small lecture on essential lung histology. Then from the two articles they gave me, I did the clinical correlations for a group of Internal Medicine residents. They were hungry for the smallest understanding of the microscopic findings of COVID19. After that, I got daily questions from residents about Pathology, and also about Anatomy, much more than GI/Liver questions. Ultimately, my clinical background gave me a quick fit-in on the frontline. Still, the Pathology perspective was necessary for the team, almost like a breakthrough to shed some light on our daily struggles in understanding the disease.
What did you learn from working with COVID patients?
It was an extraordinary experience, emotionally and medically demanding. Every day, we were learning about the disease, and protocols and guidelines for clinical management could change daily. The level of uncertainty about any efficacy in treatment gave us a different challenge when supporting our patients and their families.
For the first time, we learned how to share scientific uncertainties while holding to the compassionate art of Medicine. The level of stress and anxiety was also unique, as we were faced with our limitations while risking exposure to a virus that has the potential to kill.
Fear permeated the teams every day. We were facing death and seeing it happening much too often in an unusual situation -- when you are all that the patient, and the family, has. We learned to be the connection between love and loss, every time we were there to hold a patient's hand while the family was saying goodbye over the phone. Every time we were the ones to deliver the last messages, the very last thank you; the ultimate “they love you very much.”
I learned about fear and grief when the family is forced to be absent. But I also learned about kindness and courage shining in our darkest time of death, when love permeates all barriers. We contemplated our mortality, and I could see professors expressing the best of their humanity, acknowledging our fragility in trying to protect the ones we loved. The pandemic brought us humbly into the role of providers without all the necessary answers. Our questions and compassion kept us in the moment for the patients and our teams.
What were the greatest challenges? The greatest rewards?
The medical challenge has been establishing goals of care early on, getting the healthcare proxy name and contact, and dealing with the indication of palliative care in specific settings. Also, learning to postpone intubation, and keeping close monitoring on a patient that could rapidly deteriorate, using maneuvers instead of non-invasive ventilation for the risk of aerosolizing.
The emotional challenge was dealing with our limited knowledge of the disease. The overall uncertainty of prognosis in the long term for patients who were discharged on oxygen therapy is a challenge. And ultimately dealing with increased volume of patients and challenging PPE availability in the first couple of weeks.
The greatest rewards were seeing the unparalleled collaborative spirit running in the teams. The presence of several specialists acting in the role of an intern was heartening. Still, they shared all their knowledge and offered their best when their best was called into action.
This is an extraordinary time in Medicine, when grace is under pressure, but it moves forward each day at a time.
How did your medical training, past and present, prepare you for this crisis situation, or not?
This crisis is unique, and I believe no one was prepared for what we faced. I was a clinician for 14 years; I have a background in Medicine, Gastroenterology, and Liver Transplants. I also received training in Outbreaks and Global Emergencies, when I was part of Doctors without Borders. I did several missions in poor-resource settings in Africa, coordinating HIV hospitals, as well as explore-missions after a cyclone or cholera outbreaks.
None of those settings is comparable to this one, of a new virus. In those settings I knew the risk, the treatment, and the outcome, and ultimately my own exposure risk was under control. But I can say that my experience prepared my soul as a volunteer in challenging situations. I did not doubt that my place was on the frontline, and I volunteered as soon as I recovered from the infection myself, as I had the mild form of the disease early in March.
How did your life experience prepare you, or not?
Dealing with the emotional challenge from the patient suffering and family grief is always demanding. Everyone will give us a different shadow that will follow us forever.
I experienced loss early in my life; my father had passed when he was only 56. Knowing the pain of grief helps me to connect with families at this moment. But social distancing has made it all different. I could never anticipate that I would connect families through FaceTime for a last goodbye. Knowing how important is the final touch or hug, and to witness the tears, it was heartbreaking.
This crisis also teaches about life and priorities. Usually, we take everyone for granted, and most of the time, life and work steal the proper amount of time we have with those who are truly important. We should always make the most of our time while we have it.
You are a highly trained and experienced clinician. What made you want to do a residency in Pathology?
Pathology is a very different specialty. It took me a while to fully appreciate it. Every medical student should be aware that there is a commonality for the bests in Medicine. It could be the best surgical group or cancer center, it could be a reference transplant center, or endoscopic facility, or even that fantastic minimally invasive surgical center -- they all need one thing to have the quality title: the best pathologists!
Every medical specialty sees the disease from the outside to the inside. They can do most of the anatomic assessments. Still, they need pathologists to assess the ultrastructure, in the cutting edge of the individualized Medicine, from the microscope to the cytogenetics and molecular profiles that will change everything. We pathologists see from the inside out, from the structure to the clinical history. It’s similar to choosing the red pill and being able to see the Matrix. Pathology gives gravity to all Medicine, and despite not being the perceived as the leader, it rules the gold standards of the complicated navigation system, allowing the best practice and choices to thrive. I wanted to see the Matrix! And I am in!
Posted on: Wednesday, May 20, 2020