MDBehind the frontlines – life in the COVID Lab

Wars are fought not only with arms and ammunition. Behind every successful general is an intelligence corps gathering vital information for successful decision making. Where will the enemy strike next? Are we being infiltrated by spies and advance troops intending to sow terror and chaos among the populace? Where should we deploy our armies? What will they use in combat?

This is essentially the scenario in the ongoing war with the SARS-CoV-2 virus. What is more intimidating is it is an invisible enemy. It seemingly strikes anywhere and everywhere at the same time. The terror the populace feels is palpable. What we have not been doing is enough intelligence gathering about the enemy. This is where testing comes in. Basically, testing exposes the presence of the virus that causes COVID-19. Thus unmasked, it can be prevented from further infecting others by isolating the infected.

The intelligence corps in this instance is the COVID testing lab. Its advance guard is the army of swabbers who gather the raw information (the nasopharyngeal and oropharyngeal swabs from suspect persons) and transmit them to the laboratory. These swabbers must be trained well not only in the technique of swabbing people safely but also for safety measures to prevent themselves and the swabbees from infection. The amount of information they can gather is proportionate to the success or failure of the campaign against SARS-CoV-2. Thus, it is important that we have many trained swabbers to gather as much samples as they can get. They need not be healthcare workers as long as they are properly trained and equipped (with PPE).

In a war movie, the intelligence room is full of people hunched over their desks, hard at work in deciphering the raw data brought in by the intelligence-gatherers (swabbers). Their equivalents are the medical
technologists who are garbed in full PPE, literally sweating it out in the stifling confines of their bunny suits in a negative pressure room designed to exhaust the air 12 times an hour in order to prevent them getting infected. They swelter in the heat created by this environment that no amount of air conditioning can correct. The cool air is almost immediately sucked out before they can feel it. These medical technologists
with seemingly normal names like Noel, Jovell, Eunice, Kim, Ken and Elle, do an incredible amount of work in a very hostile environment, braving heat, stress, hunger, fatigue, lack of sleep and rest as well as the ever-present danger of infection. They work intimately with the enemy in hand to hand combat as it were, first neutralizing them with a deadly move (inactivation), extracting vital information by intense interrogation (RNA extraction) and then subjecting the information to processing (RT-PCR). They often come out of the laboratory soaked in sweat and thoroughly drained. They do this day after day, sometimes working long hours straight for two weeks or more. This elite corps of medical technologists must first be trained in Biosafety and Biosecurity as well as Molecular Biology with special emphasis on Reverse Transcription Polymerase Chain Reaction (RT-PCR). They are in very short supply due to limited training being conducted which is being done only by two overburdened reference laboratories.
We desperately need more of them if we are going to gain the upper hand in this struggle with the virus.

The processed information is handed over to the pathologist, the chief intelligence officer who has the task of deciphering the processed information and singling out the positives. The pathologist, a doctor rarely seen outside the confines of the laboratory, is another unsung hero of the war against COVID-19. After basic medical education, he/she must train in laboratory medicine for 4 more years which require an exhaustive
review and more intensive study of the basic subjects in medicine like anatomy, histology, biochemistry, microbiology and physiology which must be correlated with the clinical information of individual patients. Then they have to pass two specialty board examinations (Anatomic Pathology
and Clinical Pathology) to make them the compleat laboratory experts, bar none. The pathologist must also manage the laboratory, dealing with quality assurance, personnel movements, validations etc.

The most important role of the pathologist is in clinical decision making, making determinations if laboratory results mirror the true state of the patient or the nature of his/her illness. Nowhere is this more apparent than in COVID testing. Lay people often see the result as black or white, negative or positive. But before the result is sent out, the technical output either in numbers or in qualitative terms (meaning positive vs negative) is subjected to scrutiny by the pathologist to ensure that first, the technical aspect is valid and then if the result is clinically relevant.

The pathologist must also be a strategist, designing methods to increase
the amount of data that can put out by the medical technologists. This is where pooled testing comes in. Imagine that instead of one result
coming out from a single determination or kit, we can produce the equivalent of ten? Then our medical technologist can be more productive
Raymundo W. Lo, MDBehind the frontlines – life in the COVID Lab
and the pathologist can identify more positives.

This vital information must be quickly relayed to the generals on the frontlines, which is not really the emergency rooms or intensive care units as imagined by many. The frontlines are the general population where the battle with the virus is waged on a minute by minute basis. Everyone must be wary of being infiltrated by the enemy, which may not harm most of those infected but silently lurk until the infected asymptomatic comes in contact with a person who once infected, suffers a major illness landing him/her in the hospital.

The asymptomatics are the unwitting spreaders (think Trojan horses) of the dreaded virus but once identified by the expanded testing strategy formulated by the pathologists, they should be quickly quarantined to let them wait out the infection. If this is done well enough, the enemy starts withering from within. It is now up to the public health experts, the generals in the field, to step up their game and rout the enemy.

Well behind the frontlines lie the bases (hospitals) where the doctors and nurses care for the fallen. They battle day and night to save the lives of those who suffered gravely from the illness, casualties of the battlefield
where the unwitting or unwilling, aid the enemy by not protecting themselves through mask wearing, physical distancing and hand hygiene.

The pathologist also gives them the information to distinguish between
COVID-19 and other diseases for the enemy is a great mimic. Likewise, the clinical laboratory churns out the data necessary to manage the patients who must be monitored with laboratory exams every now and then. This is the last line of defense that must not be breached or overwhelmed by the enemy.

While the clinicians’ doctors and nurses are rightfully hailed as our heroes in this war against COVID-19, there are the unsung heroes of the battles behind the lines, doggedly supplying the intelligence without which wars can’t be won: the swabbers, medical technologists and the pathologists. You don’t see them often since they are behind the scenes. Without them though, the war is all but lost.

This war is being fought by the public health care workers, doctors, nurses, medical technologists and radiologic technologists and other hospital workers who keep the hospitals running. The war can’t be won by tanks, bullets or other military means. Soldiers, you are out of your league in this war. Neither can it be won by sweet words, enticements or coercion. Politicians, please let the medical profession speak. And listen, for all our sake. Else, this war will be lost on your watch.