“What are you seeing on autopsy?” That’s what Dr. Amy Rapkiewicz, head of pathology at NYU Long Island School of Medicine and chief of pathology at NYU Winthrop Hospital, was continually hearing from anyone taking care of the initial influx of COVID-19 patients. But she wasn’t able to say, at first: In the early stage of the pandemic, the Occupational Safety and Health Administration recommended suspension of postmortem or autopsy procedures on patients with confirmed or suspected COVID-19 infection.
Nobody understood what was making COVID-19 patients so sick. Other respiratory viruses do plenty of damage, but the novel coronavirus seems to have a particularly vicious effect on the lungs and other vital organs. Without fully understanding the path of destruction wreaked by COVID-19 in the body, clinicians found themselves treating patients in the dark.
In an abundance of caution — and adhering to early recommendations from U.S. health agencies like OSHA — Rapkiewicz’s hospital system initially put autopsies on hold for people who died of COVID-19. The issue was the possibility of virus transmission to the pathology team.
“You have to let us do autopsies.” That was the plea from Rapkiewicz and her counterpart, the autopsy director at Tisch Hospital, also part of NYU Langone Health. The pathologists joined in lobbying their hospitals for the right to perform autopsies on patients who died of COVID-19.
With their persistence and a special safety protocol they developed, Rapkiewicz and her colleague prevailed. By early June, they were using autopsies to investigate the lethal effects of COVID-19 throughout the body.
Body-Wide Blood Clotting
The presence of blood clots wasn’t entirely unexpected as Rapkiewicz and her team began doing autopsies for COVID-19 cases. Reports were trickling in from a handful of countries in Europe that blood clots were being found in the lungs of COVID-19 patients with severe pulmonary disease, Rapkiewicz says. The magnitude and extent of blood clotting was the revelation.
“We knew that clinical people were finding clots in these patients,” she says. “So although I knew that that was going to be there, I didn’t expect it at the microscopic level to the degree that I saw it.” Her autopsy study found blood clots in small vessels of the patients’ lungs, hearts, kidneys and livers.
Brains were the only organs her team could not inspect, for lack of the specific infection-precaution equipment needed to enable brain examination in their lab.
“Everything” is more extensive in terms of COVID-19’s effects, Rapkiewicz says. “Like, if flu was a ‘5’ then COVID is a ’10.'”
Spreading the Word
With the COVID-19 pandemic raging, there was no time to waste in sharing these important new findings. “We started doing the autopsies and turned around the information really quickly,” Rapkiewicz says. “I did maybe five grands rounds a week, to where I just basically collated what I found and scheduled talks with medicine and ICU (clinicians) both at my hospital and Tisch Hospital.”
Soon, a cardiologist who works with platelets — the tiny blood cells involved in clotting — connected with Rapkiewicz and started a clinical trial to determine the best way to use anticoagulation (blood-thinning) therapy to prevent or treat COVID-related clotting. Blood clots in vital organs can lead to severe breathing problems, heart attacks, stroke and also disrupt treatment by clogging cathethers used for IV blood tests or kidney dialysis.
Other physicians also applied her newfound knowledge to their medical practice. “I’ve had clinicians call me up later to say and say, ‘I still have that picture in my mind of your slide with capillaries with clotting in the heart — and I’d think of that when I had a COVID patient and they were complaining of chest pain,'” Rapkiewicz says.
After Rapkiewicz reported the autopsy results in the journal Lancet on June 25, her findings went from being personally shared with hospital colleagues to dissemination worldwide, putting her work in the spotlight.
A Beginning, Middle and End
Rapkiewicz loves her work. “I never really wanted to do anything else other than be a physician,” she says. “And then, once I learned more about pathology, there wasn’t really anything else that interested me.”
With pathology, the storytelling, investigation and “a sort of idea that there’s a beginning, middle and end” came naturally to Rapkiewicz.
“My dad worked for the American Museum of Natural History my whole life, and he traveled a lot for the museum,” she says. “I spent a lot of time in the museum. My mother was a teacher — a really excellent public school teacher — and I would go to her class. So I grew up in a storytelling house, in a science-focused house.”
Are the new COVID-clotting findings the most significant of her career? “There are a lot of small moments that I think of as big that maybe the world doesn’t,” Rapkiewicz says. “But, in general, I would have to say yes.”
Although these findings shed light on a vexing worldwide outbreak, Rapkiewicz stays focused on any case she takes on. “For me, it’s more about the individual patient — the individual decedent,” she says. “It sounds kind of corny, but it’s just as satisfying having a complete understanding and answer in every single patient versus the pandemic. Because in the end, it’s the same outcome: You get the answer; you provide information to the family; you close the loop. And you’re really able to satisfy the scientific trajectory that way.”
For pathologists, because of the nature of their work, the occupational risk of contracting COVID-19 is not particularly high. Part of that is due to how the virus typically spreads, through respiratory droplets released by an infected person who is sneezing, coughing, yelling or talking.
In general, autopsy pathologists follow universal precautions and wear personal protective equipment — N95 masks, gowns, gloves and face shields — with every case.
At first, Rapkiewicz proceeded with an abundance of caution with her family. “Early on, we were overly cautious,” she says. “When I came home, I would come in through the basement. And I would take off my clothes and put them in the wash. Then I went right to the shower.”
Until it became clear that the risk was really low, her family life changed. A photo Rapkiewicz now keeps in her office captures a telling moment. “One night, the kids kind of just laid on me because they needed the physical connection,” she says. “And at one point, they realized it was OK to be with me.”
With continued care at home, and a strong culture of safety where she works, Rapkiewicz feels confident in her protection from COVID-19. “I had my antibodies tested a couple times,” she notes. “I feel good that I didn’t get it.”
Importance of Autopsies
During a severe outbreak of an infectious disease, it’s essential to seize the moment for observation and information-gathering, Rapkiewicz says. Otherwise: “The fanfare dies down and you never really get ahead of it.”
With COVID-19, she says, “There was an incentive, from our point of view, that we need to do what we can now, because if we don’t find out about it now, we’re going to lose our opportunity and it’s too late.”
The extensive clotting found in patients who died of severe COVID-19 likely exists to a smaller degree in patients with more moderate illness, Rapkiewicz says. “I tend to think they have lesser forms of clotting that are affecting their organs, maybe not enough to put them on a ventilator. But it seems there’s definitely downstream damage in many patients that are infected.”
Autopsies will continue to help the medical community find answers and improve treatments for COVID-19.
“There’s a bit of stigma still associated with autopsy,” Rapkiewicz acknowledges. “It’s a sensitive subject for some families. But what I’d like for people to see is that when it’s done respectfully and by a trained person, it can offer information for thousands of years to come. And the benefit is so enormous that they should consider it when their loved one passes away. They should know that the autopsy pathologist is really someone who is truly dedicated to improving medicine for the living patients.”
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Pathologist Discovers Coronavirus Causes Extensive Blood Clotting originally appeared on usnews.com