Zach Grimes

I grew up in a very small town in a very rural area. And if you were wanting to be a scientist or a biologist, the world was your oyster and because there was so much natural beauty, there were so many things to explore. Neighbors would bring me their animals from their farm to dissect to try to determine how they died. My mom was patient enough to pull over the side of the road to get roadkill for me, so that I could try to figure out how the animal died. She wasn't sure she was raising the next Jeffrey Dahmer or the next surgeon. Yeah, and luckily it turned out to be a doctor.

Aryana Misaghi

I'm Aryana Misaghi and this is Appalachian Care Chronicles, a podcast bringing you stories from every corner of West Virginia's health sector. Join me as we journey alongside a variety of problem solvers, change-makers and daily helpers, who are all working behind the scenes and on the frontlines to care for our communities. Together, we'll explore what they do day to day, the steps that got them there, and the why’s that continue to draw them back. How in the face of some of the most challenging situations possible do they manage to keep themselves and the rest of us from falling apart? Far from predictable, the paths they’ve walked are full of twists and surprises, discovery and purpose. This podcast is for anyone who's ever even thought about going into the healthcare field, or has a passion for caring for others in times of need.

In this episode, we meet pathologist Dr. Zachary Grimes, he graciously gave us a tour of the hospital laboratory and all the medical mysteries inside.

Zach Grimes

So we're coming into the back of the hospital. Most patients don't really enter this way. Just be careful with this. Pathology is in the basement.

Aryana Misaghi

Zach pointed out the perfect symbolism of this. Pathology is the foundation for how most physicians decide next steps in patient care. Pathologists’ workspace looks nothing like the doctor's offices and hospital rooms most people are familiar with. Technicians in lab coats slice and stain tissue samples, document precisely what they've done and prepare the slides for the doctor to examine. Zach took us on a tour of the lab and gives an amazing description of what we saw. He's talking about material from a real patient. So if that makes you uncomfortable, keep ahead a few minutes.

Zach Grimes

These are for shoulders, to protect any splashes on our arms. First thing I'm gonna have you do is put that bucket underneath the scale there. And then I'm gonna hand you the brain. And you're gonna weigh it for me.

So we'll just slice to make sure that there's no tumors. Here's the hippocampus. See? See how it looks like a horseshoe? This is where all this individual’s memory is kind of consolidated and formed. Kind of beautiful, right?

Aryana Misaghi

Zach also let us examine a tissue sample under the microscope, giving us a whole new understanding of a deadly group of diseases.

Zach Grimes

Most of our reality in the world is built around what we can see at 1x. But now you get to see another world where very few people get to see it. And that's at the cellular level. And I think that's a really cool thing about the job.

So what are we looking at here? So I can tell you already, that this is a tumor. Cancer comes from, I think it's a Greek word meaning crab. Why they kind of named it that I think is because like a crab that buries itself under the sand, it kind of edges its way through it right? And kind of infiltrates in between the sand? And that's kind of what cancer cells do. Cancer, by definition, is just an uncontrolled cell growth. You see how busy this is? See how, like, the cells are back to back forming these glands. And it's not respecting each other's boundaries. Normal tissue respects each other's boundaries. But here, it's just kind of growing over top of each other. It looks like a bunch of people in a subway station, right? Trying to catch the last L train. So, like, I can show you as a reference. Here's what a normal breast should look like. See it's kind of fatty. Kind of see some of the glands here you see it? But it's all respecting each other's boundaries. Does that make sense? It’s saying, you belong here, I belong here, right? But then you get to cancer, and it looks like Times Square with Taylor Swift playing, right? It's just so busy. You see how different it looks? So that's pattern recognition. It’s being able to say this looks different than what the normal should look like, right? So it'd be a good pathologist, you really have to know what normal looks like. And then only through understanding normal, can you diagnose the abnormal.

Aryana Misaghi

For a lot of pathologists, cancer is the crux of what they diagnose. According to the CDC, cancer is the second leading cause of death in the United States exceeded only by heart disease. West Virginia is a state with the fourth highest incidence of cancer in the United States, with lung cancer accounting for the most deaths. We really can't underestimate the importance of pathologists to diagnose cancer, and then help guide treatment.

Zach Grimes

It makes you very nervous, at least it makes me very nervous, right? Because if you miss call it and let's say, it's malignant, or cancer and I call it benign, then they're not going to get any surgery. And then it'll metastasize and spread. And I could be responsible for that. Or let's say it's benign. It's not cancer, and I call it malignant cancer. And then that patient goes and has surgery and gets either their whole breast or part of their breast removed. Right? It keeps me very on edge, you know, because you have to make sure that you're right, right, there's no room here to be wrong, because the consequences are too grave.

I compare it to what it must feel like in Mission Control at NASA. The moment you say time for liftoff, that means that you've cleared everything, and everything is ready to go, right? And you've made sure of that. Same thing here, the moment I sign out that case in my computer, and it goes in the patient's chart, I have to make sure that I have considered every option, and that it is cancer, or it's not cancer, and I have to be 100% sure. And if there's any doubt in that, it doesn't get signed out until I can figure it out. So, because this dictates the next course of treatment for this individual. That's going to set in place surgery, radiation, and chemotherapy. And not to mention the fact that you're going to have to live with the knowledge that you've had cancer. It changes an individual, it changes a family, it changes a community.

Aryana Misaghi

Pathologists are like the Sherlock Holmes of the medical world. If anything, like anything at all, is removed from the body, it goes to pathology. Pathologists take a look at samples from the body and detect abnormalities in tissue and blood. They're often on call during surgeries to diagnose cancer in real time. And they're also the people making sure routine lab tests like blood counts and chemistry are available and running accurately 24/7 in the hospital. And of course pathologists are well known as the people who determine the cause of death after someone has passed, like in an autopsy. Zach's initial interest in medicine starts with this last part, studying whatever roadkill and dead animals came his way.

Zach Grimes

I grew up in rural, rural West Virginia in Pocahontas County. So I was always out in the pond looking under the microscopes. I got my first microscope when I was nine years old, you know, the world never looked the same afterwards, and I became obsessed with it, and I was able to have that intellectual freedom that I think fostered that love of science and medicine. And, you know, pathology. You know, I didn't know that's what it was called, was pathology, when I was dissecting a dead animal to try to determine how it died, but I knew that I enjoyed it because you got to see anatomy and you got to use your hands and figure something out. You know, also growing up in a rural area, there's a lot of things you can dissect. I'd write up my own autopsy reports, you know, and I thought this would be a perfect job. So when my mom was in nursing school, I took her white lab jacket, and her stethoscope, and I decided to open my own medical office. My grandmother was my secretary and my grandfather was a patient, and he had these multiple patients that he would make, like, different complaints. One day was his heart, another day was his lungs. And I would write on a yellow legal pad my diagnosis and pretend prescription. And that's kind of where I knew I wanted to be a doctor and I don't think I've ever really deviated from that path.

Aryana Misaghi

Appalachian Care Chronicles is made possible thanks to the West Virginia Higher Education Policy Commission, and Claude Worthington Benedum Foundation serving communities in West Virginia and southwestern Pennsylvania since 1944.

West Virginia needs great mental health professionals. If you're practicing in an underserved area and need help repaying your student loans, apply for the Mental Health Loan Repayment Program, through the West Virginia Higher Education Policy Commission, visit collegeforwv.com to apply. That's collegeforwv.com.

Aryana Misaghi

Zach's office is furnished with a wide range of objects: tools of the trade models of human anatomy, and other artifacts that in some way capture the intricate patterns found in the natural world, like skulls and animal skins.

Zach Grimes

This is where everything gets done. This is the office, I have a lot of weird little things. There's a boa’s malt of his skin, family photos, a piece of coal, actually. And it's a tarantulas exoskeleton, some skulls, a bear skull, and that’s a fox skull, and a coyote skull and a model of a human skull. So yeah, they're really quite lovely. Yeah. Beautiful, right? And I think it's really cool because you can study the difference between, you know, different mammal skulls, like a human skull versus bear skull, and you can almost see where more of the real estate is seeing, you know, the bear’s skull, it's mostly in the back here, because it's where the vision is more important, right? Whereas a human vision is not that important, right? It's the frontal lobe. So you can see the difference in the size of the skulls and how that dictates, you know, what's essential to that organism. Comparative anatomy here.

This is the microscope. This is the instrument that we use to make our diagnosis going way back to the 1600s and it's been advanced in the past couple of centuries. But it has two heads on the microscope so that two people can view at the same time, and that's the instrument of our trade. You know, for a surgeon, it's a scalpel, for a pathologist, it's the microscope.

Aryana Misaghi

While it may sound like a pathologist’s work is only solitary looking under a microscope and making a diagnosis in a room far removed from the patient, Zach actually works closely with other health care professionals who are in charge of sourcing specimens and preparing materials for diagnosis.

Zach Grimes

We're famous. Yeah, we're all going to be famous here. I'll show you how we start the process. Maybe it’s best if we walk around this way. So a surgery is done, right, and the specimen is put into a container, and it's brought down to pathology. And it's brought down here into the Pathology Specimen Drop Off Area. We get all the specimens from the hospital, including an amputation over here, which someone's working on right now. Hello, there's Corinne and Curtis, our two PAs that are here. We're recording for a podcast here. We're just explaining how we bring down specimens from the OR, and then the PAs, predominately the PAs, they gross and prepare the specimen. So grossing means to look, see where the problem is, and take sections and to submit it so that the pathologist can sign out and make the diagnosis. It’s one of the most important, well it is the most important step in what we do as pathologists. So they're the eyes and nose for us in our office. You know, we get to sit in the office and just look under the microscope, and these folks are the ones who stand, you know, for 10 hours a day dissecting the specimen. Every patient sample comes to pathology, anything that comes out of the operating room, regardless of what it is if it's a foreign body, or if it's someone's colon or breast it comes to the pathology lab so we examine everything from the operating room. So even routine things like this, and sometimes they turn out not to be routine, as Corinne said sometimes will, someone will get their femoral head taken out, you know, because they fractured it or broke it. And then you realize there's a bunch of tumor there and that's why they had broken in the first place. So our job as pathologists and PAs is to give an explanation as to why that patient had to end up in the operating room to begin with.

PA

Sometimes it's the first time you see the tumor. Yeah, it's like, oh, boy, all hands on deck. This patient has cancer somewhere else, and we didn't even know it. And then you, you have to start over. Yeah, with the clinician and the patient and try to find the primary. So sometimes we're the first ones to see it.

Zach Grimes

The thing about pathology that I really love is that it's very communal. You know, we all work together very closely to make that diagnosis. You know, you're not really on your own, making that diagnosis, which I really love. You know, we share ideas, we share the cases, and we reach the conclusion. So most of the time when you go and get a biopsy done in a hospital, it's been looked at by multiple pathologists. So that's the good thing about it.

Aryana Misaghi

Zach’s educational path looked pretty similar to most doctors. He completed an undergraduate degree in Biology at Shepherd University. Then he went to medical school at the West Virginia School of Osteopathic Medicine in Lewisburg. All doctors graduating medical school have to complete years of on the job training in the form of a residency program. Basically, students apply to dozens of programs across the country, they hope for a handful of interviews and then make a ranked list of their top choices. The programs do the same, and an algorithm matches them up. Once you're matched, you're in a legally binding contract to go work wherever you are matched to. Sometimes that means moving across the country.

Zach Grimes

When I graduated medical school, I ended up in New York City at Mount Sinai, where I did my residency in Anatomical and Clinical Pathology. And this was really the first time I ever lived outside of West Virginia, I had spent briefly a summer in Boston, but I essentially just got dropped off at New York Penn Station with two bags and took about eight years to get streetsmart. Usually pathologists, their last year of residency, they'll apply for fellowship to get sub-specialized, and I was kind of lazy and didn't really know what I was wanting to do, and that last year happened to be 2020.

Aryana Misaghi

Everyone in the healthcare field, including those of us in training at the time, were obviously impacted by COVID-19. Zach made it part of his education. His contribution to COVID relief was at the epicenter of the pandemic in New York City, and it was at the cellular level.

Zach Grimes

I remember the first day that a patient tested positive in New York City, I was in one of my attending’s office and the PCR came back positive for COVID. Everyone knew at that point, it was just a matter of time that it was going to explode. And so, you know, because I didn't really have any plans for what I was going to do afterwards, I thought, well, maybe I can contribute to understanding this virus. So I ran over to the autopsy director at Mount Sinai, who was Dr. Fowkes who passed away in 2020. And I said to Dr. Fowkes, I think we should do autopsies. And she said, I agree. So she teamed me up with—who ended up being one of my best friends, who at the time was my attending—Dr. Bryce, and we, you know, we had our first patient at the end of March to do an autopsy. And it was scary because it looked like a scene out of, you know, out of Outbreak, the movie, because we didn't know how you could get COVID. You know, we didn't know that it was only respiratory. So we were in this autopsy room with this individual who just died of COVID and we are in these biohazard outfits. And, you know, when the morgue attendants closed and locked the door, you know, in this isolation room, she and I didn't leave. We would do, sometimes, four or five autopsies a day. This would be six days a week on these patients. And what we were able to accomplish with that work—and this is why autopsies are so important—is that we were able to show how COVID affects the body, right? How does it cause lung disease? How does it, you know, damage the lungs? Not only that, but we could also show that, you know, it was being found within the brain. And it was also in the heart and certain places, right? And we were able to show that certain patients who had COVID were more susceptible to forming blood clots. And we published those papers. And those papers were then used to help change how patients were being managed. This is where the autopsy is so fundamentally important to public health, because the dead, the individuals who are dying of that, we're teaching us how to better manage the living.

I love New York, I miss it. But West Virginia is my home. And the people of the state of West Virginia are not only my family, but the schools and everything else have contributed to who I am as a person. And I think it's time for me to go back and to give back. And by pure chance, there's a job available here in Charleston. And I took it.

Aryana Misaghi

Since pathologists aren't working with patients, their schedules have quite a bit of flexibility. That can be a great draw to the profession. But it can also blur the boundary between work and home life. Zach is intentional about using strategies like a long morning walk to work to stay sharp.

Zach Grimes

Yeah, I get up around six o'clock, and I get ready. And it's kind of like Philip Glass’s “Mad Rush” of trying to walk the dog, feed the dog, and get ready to leave by 7am. So that I can walk. I walk about two and a half miles to work every morning from downtown Charleston to Memorial. And that walk allows me to think about, you know, problems that I'm having both personally and professionally. I think about cases. I usually get here by around eight o'clock, and I try to check out at 5:30pm. And I check out, you know? There are times, certain cases, certain phone calls, that you know, you just can't really shake. But I try not to think about that stuff when I go home, you know? Because one of the things that pathology teaches you is that life is pretty short. And you can’t sit there focusing on your job all day long, you should have your other priorities straight in life, you know.

Aryana Misaghi

It can be hard to leave work at work, especially when there's always more to be done. This is exacerbated by the fact that there aren't many pathologists anymore, which contributes to the excessive workload.

Zach Grimes

There aren't enough pathologists to do the work for the living, let alone for patients who have passed away. And you're starting to see that trickle down in the medical examiner system where there is such a shortage of forensic pathologists. And it's a fascinating job. It's just that many people aren't going into it. And the consequence of that is cases are getting delayed, they're not getting signed out in a timely manner, and if that case is something that's going to be prosecuted, that individual who's sitting in prison waiting, they're just sitting there waiting, right. And so their access to a fair and speedy trial is being denied to them, right? So it has huge impacts. And that's why more people need to be going into pathology, just because it is so pivotal in patient care. There aren't enough pathologists, a lot of the pathologists today are older and retiring. There aren't a lot of young people like myself who are going into it. And so in the next 5-10 years, there's going to be a drastic shortage of pathologists not only to take care of patients at the hospital, but also at the medical examiner's office.

Aryana Misaghi

So what does a shortage of pathologists mean for a state like West Virginia? Earlier in the episode, we talked about the extremely high incidence of cancer in this state compared to the rest of the country. We also have unique diseases that are only really seen in this area, like Black Lung. That makes the work of pathologists here even more crucial.

Zach Grimes

Here, in Charleston, there's about maybe one or two autopsies a month in the hospital. And most of those autopsies are for Black Lung disease. Because Black Lung is so prevalent here in the Appalachian area because of coal mining. And oftentimes, in order for family members to get the compensation that's needed, they have to show proof, and the way that has to be done usually, is by autopsy.

Aryana Misaghi

If this was your first time even hearing about pathology, you're not alone. Pathologists' work is typically unseen by patients and their families. The impact however, is tremendous. The information gleaned by the pathologist guides treatment all the way from diagnosis to remission, as Zach showed us through his tour at the beginning of the episode, pathology is the foundation of medicine and what's underneath the surface is often the most important.

Zach Grimes

We’re the doctor that no one in the hospital sees, but who has, in my opinion, the greatest impact upon your care. The pathologist and the radiologist, because those two doctors set the course for everything that happens to you afterwards, whether you go get an Xray, and they find something on your lung, and then you get a biopsy and the pathologist says it's cancer or not cancer, all of that sets in place the next course of treatment for that patient and it's all because of the doctors that you never get to see, the ones behind the screen.

Aryana Misaghi

Appalachian Care Chronicles is a production of the West Virginia Higher Education Policy Commission Health Sciences Division. Special thanks to the Claude Worthington Benedum Foundation and to Vandalia Health. For more information about educational opportunities related to health care in West Virginia, visit appcarepod.com. That's appcarepod.com. I'm Aryana Misaghi and you've been listening to Appalachian Care Chronicles. Join us for our next episode uniquely featuring a married couple Mary and Peter who have served their rural community as family doctors for over a decade. That's next time on Appalachian Care Chronicles.