What are "COVID toes?"

- Jennifer Middleton, MD, MPH

Anecdotal reports are emerging of patients with COVID-19 presenting with purplish patches on their toes. Sometimes, these findings are the only sign of otherwise asymptomatic COVID-19, and sometimes they are the initial presenting sign in advance of fever and upper respiratory symptoms. These skin findings (more details here and here) look remarkably similar to pernio (chilblains):

Purple discoloration of "COVID toes" (source)

As described in this 2019 AFP article on "Hypothermia and Cold Weather Injuries," pernio is a "nonfreezing injury characterized by localized inflammatory lesions that most commonly affect the hands or feet within 24 hours of exposure to damp environments....Lesions may persist for weeks to months before resolving spontaneously." Some dermatologists hypothesize that the immune response to the SARS-CoV-2 virus may contribute to an inflammatory response that mimics pernio. Another theory posits that these lesions are the result of small blood clots, noting that SARS-CoV-2 infection has been linked with elevated D-dimer levels and microvascular clots in other organs; 31% of patients with COVID-19 from one intensive care unit in the Netherlands had a thrombotic complication such as a pulmonary embolism, stroke, or myocardial infarction.

None of these "COVID toes" reports have been formally published yet, but the American Academy of Dermatology has a registry to report skin manifestations of COVID-19. Family physicians presented with a chief complaint of skin changes in the feet or hands may wish to consider COVID-19 infection on their differential. We still have much to learn about SARS-CoV-2, and no organ system seems to have been spared across the spectrum of patients with COVID-19 illness. As our collective understanding continues to evolve, you can access a wealth of COVID-19 resources at the top of the AFP website, including research briefs, published articles from FPM and the Annals of Family Medicine, and AAFP CME opportunities. 

Mitigating the effects of school closures during the pandemic

- Kenny Lin, MD, MPH

Excepting a few countries like Denmark that have managed to flatten their infection curve, primary and secondary schools around the world have now been closed for a month or more due to the public health imperative to slow the spread of COVID-19 through physical distancing. Parents and guardians, many of whom have lost jobs or recently transitioned to telework themselves, have struggled to keep track of and connect their children with online educational activities designed to replace in-person learning.

Unfortunately, evidence suggests that distance learning, no matter how carefully designed, does not fully replace in-person instruction. A 2016 report from the National Alliance of Public Charter Schools found that students who attended full-time virtual public charter schools had consistently lower engagement, academic gains, and performance than those in traditional public schools, regardless of demographics. Worse, a considerable proportion of U.S. students have not participated in online learning due to not having personal computers or home Internet access.

Extrapolating from studies of summer learning loss, the educational nonprofit Northwest Evaluation Association recently projected that relative to a typical academic year, students returning to school this fall may only retain 70 percent of reading gains and 50 percent or less of math gains. To make up for these losses, some school districts are planning to extend school into the summer, shrink their curricula, or repeat some of last year's lessions next year. Another controversial idea for high-poverty schools is having all students repeat their current grade, given the potential for further interruptions due to a second or third wave of COVID-19.

Prior to COVID-19, chronic absenteeism (defined as missing at least 10 percent of the academic year, or about 18 days) already affected about 14% of American students from kindergarten through 12th grade. According to an AFP article on school absenteeism, it not only has negative effects on academic performance and graduation rates, but also worsens future social functioning, health status, and life expectancy. Reasons for absenteeism vary from chronic or serious illness (including mental illness) to academic challenges, parenting problems, bullying and victimization, and other social stressors such as food insecurity and homelessness. Family physicians can help by performing an assessment of students with frequent absences and referring students and families to one or more appropriate interventions.

Family medicine resident perspectives on COVID-19 (March 30-April 10)

- Enkhee Tuvshintogs, MD, AFP Resident Representative

This post picks up where my previous post left off on the experiences of residents at my program during the pandemic.

“Where are you getting reliable sources of information?” asked a physician in a group tele-meeting. This, indeed, was the most imperative question. At this point, like the general public, we were being inundated. Over the past several weeks, my sources have varied from local and national news broadcasts, to organizational briefings, to first-hand accounts from friends and colleagues, as well as COVID-19 updates from American Family Physician (AFP), the Centers for Disease Control and Prevention (CDC), JAMA, and The New England Journal of Medicine - just to name a few.

As a whole, coronaviruses (CoVs) are not new to our medical education. As a JAMA article stated, CoVs “have long been considered inconsequential pathogens [until] 2 highly pathogenic human CoVs [SARS-CoV and MERS-CoV] emerged from animal reservoirs to cause global epidemics.” Three years ago, the “World Health Organization (WHO) placed [the CoVs] on its Priority Pathogen list, hoping to galvanize research and the development of countermeasures.”

The medical community is trying its best to rapidly produce valid and peer-reviewed information on diagnosis and management of COVID-19. Early on, I received posts, private messages, emails, and texts from concerned friends and colleagues, hoping that these bits of relayed information would help us all in some way. I am now seeing similar information come through the pipeline from well-known medical journals, including AFP's daily COVID-19 Research Briefs.

Thanks to community members who are practicing social distancing and “flattening the curve,” we have been able to “buy time for science to catch up.” We have gained time to discuss disease markers, symptomatology, patient populations, and medication trials.

Resident physician, Dr. Kim Le (KL) reminded me of important ethical questions: “How would we ethically and objectively chose who gets a vent and who does not? How can we accurately predict who is going to survive this or not, when there are even reports of young people dying?” Offering a different perspective, Dr. William Guthrie (WG) hypothesized about “ways to boost [patients’] immune systems” with micronutrient supplementation, rest, exercise, and other macro level methods to strengthen inherent body defenses.

Other residents, like Dr. David Hubbard (DH) and Dr. Sherry Liao (SL), are thinking about the future.

“We don’t know how this virus will evolve and how it will continue to behave in the community,” observed DH. Similar to influenza, coronaviruses can mutate: “From genetic sequencing data, it appears that there was a single introduction into humans followed by human to human spread. This novel virus shares 79.5% of genetic sequence with SARS-CoV.” The influenza virus changes or “drifts” every year; flu vaccines that are offered annually represent our best guesses about an ever-evolving endemic pathogen. In addition to the annual flu vaccine, will we need to develop an annual CoV vaccine?

On a planetary scale, the challenges we are facing now could be a sign of more to come. SL shared her concerns that “this could keep happening. Instances of crossover from animals to humans seem to be happening more and more often. Urbanization, deforestation, globalization, and climate change will probably cause more contact between animals and humans. We’ll probably have more events like this.”

Air pollution may contribute to COVID-19 disparities

- Jennifer Middleton, MD, MPH

African-Americans comprise a disproportionate share of COVID-19 illness and mortalities, and emerging data regarding the potential effect of air pollution exposure and COVID-19 severity may explain why. The study, conducted at Harvard and not yet peer-reviewed, correlated PM2.5 (air pollutant particulate matter less than 2.5 micrometers in diameter) exposure with COVID-19 mortality in the United States; for every 0.001 mg increase in PM2.5 per cubic meter, COVID-19 deaths increased by 15%:

“If you’re getting COVID, and you have been breathing polluted air, it’s really putting gasoline on a fire,” said Francesca Dominici, a Harvard biostatistics professor and the study’s senior author.

African-Americans are more likely to live in areas of the United States with worse air pollution. Air pollution exposure is linked to a myriad of health conditions, including cardiovascular disease, pneumonia, asthma, urinary tract infections, Parkinson's disease, diabetes, and sepsis, even when controlling for other environmental and socioeconomic factors. Even short-term exposure to PM2.5 can have significant health effects. It's possible that the correlation between particulate matter pollution and COVID-19 merely reflects the increased prevalence of these underlying health conditions in African-Americans, but it's also plausible that both are insidiously working together to intensify the severity of COVID-19.

Air quality has dramatically improved in many places since shelter-in-place orders have gone into effect; I've certainly noticed the difference in the metropolitan area where I live. These improvements in air quality may even be helping to "flatten the curve" of COVID-19 transmission. Sustaining these improvements may be challenging once we all return to our prior routines, but given that air pollution contributes to over 100,000 deaths per year in the United States, perhaps this might be an opportunity to push back against efforts to deregulate environmental protections on air quality.

Physicians can and should advocate for improved air quality along with other environmental changes that can positively affect our patients' health. This 2017 AFP editorial and this 2016 ACP position statement both outline practical ways physicians can contribute to these efforts.

Family medicine resident perspectives on COVID-19 (March 24-29)

- Enkhee Tuvshintogs, MD, AFP Resident Representative

In the following weeks, I will share the experiences of residents at my program from interviews as we live through this pandemic together.

“[You] have to take it day by day. ... We signed up to be doctors knowing that there may always be a disaster,” said Dr. Ashley Rubin (AR), a resident rotating in the Intensive Care Unit (ICU). “You either have to embrace it or you freak out. ... You have mixed feelings about it. Right now it’s not that crazy, but it could be at any time.”

In California, Governor Gavin Newsom issued a Stay-at-Home order on March 19. We were one of the first states to implement this public health measure. The gravity of the announcement prompted an onslaught of changes in hospital policies, set-up, supplies, and personnel.

Daily interdepartmental virtual meetings continue to tackle the “moving target” of the pandemic and create real-time operational changes. The personal protective equipment (PPE) discussion is ongoing. Given the limited supply of PPE nationally, hospital systems are seeking creative in-house solutions, such as finding ways to sterilize masks in-house and choosing to limit patient contact by moving IV poles outside of rooms. Entire hospital wings have been reorganized for patients under investigation for COVID-19.

Still, COVID-19 can feel somewhat abstract at times. Dr. Natalie Morgan (NM), one of our incoming chief residents, said it only “becomes more real when a patient suspected of COVID-19 in the hospital suddenly goes in respiratory distress in front of you.” She lamented that in these moments, family members have to make decisions about intubation and goals of care over the phone or through a video call. “It doesn’t feel real until then.”

Given the confirmation of community spread and gray areas of initial symptomatology, AR admitted, “it is scary; we don’t know what we’re getting ourselves into.” As family medicine residents, we are familiar with the various illness processes that can present to the Emergency Department, inpatient pediatrics and adult medicine, obstetrics, and ICU floors. However, now, we have to be “more thoughtful about which [illnesses] are COVID and which are not.” The constant vigilance can be emotionally and mentally challenging for all.

Personnel in our hospital system support one another. Our attending physicians have set up Facebook support/wellness groups and are individually reaching out to residents to support them. Even during large scale “tele-meetings,” facilitators try to take a moment to reflect on the positives they’ve seen.

“We do find things to be thankful for in this situation,” says AR. As family doctors, we draw strength from the breadth of work we do. “We know the hospital system as a whole.” We are able to help different departments recognize supplies and resources that each area can contribute. We also ”know how to talk to families.” As family medicine residents working in all parts of the hospital, dedicated to the breadth of human experience and life, we are able to provide the attention and care that families need in these difficult times.

Applying evidence-based medicine concepts in a pandemic

- Allen F. Shaughnessy, PharmD, MMedEd and Andrea E. Gordon, MD

A medical student recently asked, “The take home message regarding COVID-19 is that we don't have the evidence, we don't have the randomized control trials we all wish we had, but doctors need to make decisions now about patient care. I'm very curious about how to be discerning in times of crisis and how to keep that [evidence-based medicine] lens even when the specific rules of the [evidence] pyramid can't be followed."

Given the lack of evidence to support our approach to the COVID pandemic, how should we think about it from an evidence-based medicine (EBM) point of view? Here are ten points to consider when making decisions.

1. EBM is about managing uncertainty.

In this time when we have less than optimal evidence, we want to use the best available evidence to make decisions. We can't wait until we get the best, top-of-the-information-pyramid evidence. To do so, we need to realize that the evidence is continually changing. We will need to make decisions based on indirect evidence, realizing that some of these decisions will be wrong. There may be better decisions than the ones we make now, but we won't know until after all of this is over what the right decisions are.

2. Not all information sources are created equal.

Some sources are more valid than others, and some sources will provide more relevant information. “Medical gossip” abounds, with many people suddenly considering themselves to be amateur epidemiologists. Fancy graphics does not mean there is good science behind them. Be discerning in the information you use. Avoid wide-sweeping characterizations of prevalence. Try to find information that applies best to your situation. Decide what you want to know and look for that; more information is not better, and we can avoid information overload by not trying to take in everything. It is easy to get overwhelmed by too much information. When viewing models of spread, realize they all contain assumptions that may not be accurate. Much information about treatments is preliminary, based on lab or animal research, or is based on a few subjects. How we interpret these will reflect our framing bias, with some of us seeing the glass half full whereas others will see it as half-empty.

3. Every intervention has the potential for harm.

We have to realize that any intervention, no matter how seemingly small, has the potential for harm as well as the potential for benefit. All the additional hand washing will likely increase the prevalence of hand eczema, for example. In other words, the common phrase, "you can't be too careful" is wrong. Take a moment to acknowledge the risk of any intervention, try to identify the possible harms, their magnitude and likelihood, and weigh these estimates against the possible benefits of the intervention.

4. Test results are not the same as an infection.

Don't confuse test results with the presence of infection. At low likelihood of infection, positive tests can be falsely positive. In contrast, at high likelihood of infection, negative tests can be falsely negative.

5. Infection symptoms will be different.

While the worst cases make the news, remember that there will be patients with moderate symptoms, mild symptoms, or no symptoms. This realization has implications for both containing the spread and understanding one's own possible experience.

6. Beware your cognitive biases. . . and those of others.

Cognitive biases rule our decisions and the decisions of others. There is no such thing as being strictly rational. But not all cognitive biases are bad, since they often work. Availability bias (basing decisions on examples that come readily to mind), confirmation bias (believing new evidence that supports one’s existing beliefs), belief bias (believing evidence based on its plausibility rather than how strong it is), the ostrich effect (ignoring dangerous or negative evidence), the Dunning-Kruger effect (over-estimating one’s knowledge or cognitive ability), action bias (the preference for action over inaction), and many others will color our decisions and the decisions of others. Learn about these and other cognitive biases to understand how we usually make cognitive errors. But realize that simply knowing about them will likely not protect us from these biases, especially the emotional ones (see “blind spot bias”).

7. Remember the goals of medicine.

Keep some perspective. Broadly speaking, we have three goals in medicine. Most important, we want to relieve or prevent patients’ suffering. Second, we want to maintain or provide hope. Last, we want to prevent, treat, or cure disease. Our goal with using evidence is to serve all three goals.

8. Get used to saying “we don’t know.”

We – science, medicine, politicians, everyone – don’t know the answers. Some people, with great confidence, will claim they do. When asked, get used to saying, “we don’t know.” Use “we” instead of “I” since all of medicine is not sure. When arguing a particular point, simply point to your information sources and let your dissenter evaluate it.

9. Read the Serenity Prayer.

For your own sanity, decide what you can and can’t influence. Focus on what you can change. When talking with friends and family, respect their values and preferences. Change your mind when new evidence comes along or when your own values and preferences change.

10. Be kind to yourself and to others.

**

Dr. Shaughnessy is an AFP Assistant Medical Editor and tweets from @Info_Mastery. Dr. Gordon is Director of Integrative Medicine at Tufts University Family Medicine Residency at Cambridge Health Alliance and tweets from @agordpj. This post first appeared as a preprint in the Annals of Family Medicine's COVID-19 Collection.

Preparing for the COVID-19 surge: a resident's perspective

- Enkhee Tuvshintogs, MD

The last two weeks of January, I was working nights in the ICU. We had just started to hear about COVID-19 and its quick spread in Wuhan, China. It was unclear at that time if the virus could be contained within China, or if it had already made its way to outside countries.

A low-lying sense of unease about patients who came in for respiratory symptoms existed in the Emergency Department (ED) and the ICU. Comments about when or if we should assess for COVID-19 came and went based on possible risk factors.

Just before the end of my night float rotation, I was called to the ED to admit a patient to the ICU for respiratory distress. There was some question if the patient had recently been to China. Our hospital had received guidance to follow guidelines similar to tuberculosis rule-out in these cases. The emergency medicine physician and I donned PPE hoods, N95 masks, and gowns. Given the acute nature of the symptoms, we entered the room, intubated the patient, and placed a central line in preparation for the move to the ICU.

By the time the patient was stabilized and admitted, it was time for morning sign-out to the day team. I wasn’t sure if the patient had COVID-19, but we were all concerned. We needed to notify the public health department and get testing done.

Driving home, I thought about what had just transpired. Had I been exposed to a patient with COVID-19? There were no cases reported in America yet. I tried to put it out of my mind, reasoning that the patient's history didn’t fully support the diagnosis. Still, until the test came back negative, I continued to check in daily.

By late February, the first case of COVID-19 in California had appeared and community spread was suspected. There was a lot to learn about this new strain of coronavirus.

As March began, more news came out about possible community spread. All of the reported cases in Sacramento were sporadic cases in the suburbs. There were no large outbreaks like those in Seattle just yet. Discussions among our faculty and administrative staff began about changes that our residency needed to make to tackle this emerging problem together. Swiftly, they jumped to the task.

Our program director and faculty decided to forgo time with their families to be part of the hospital's response. They placed themselves in the Emergency Department and on inpatient teams. Within one week, resident schedules changed to reflect the needs of the hospital. With the breadth of our family medicine training, we were well-equipped to work in the ICU, the ED, Labor and Delivery, and on inpatient teams. In the same week, faculty and residents on the outpatient side transitioned for the first time to telemedicine visits, while continuing some in-person visits in clinic.

We have not hit the surge yet, but we know we will. Our training has prepared us well to care for patients in all parts of the hospital. We have never encountered anything like COVID-19 before, but we are ready and willing to rise to the occasion.

**

Dr. Tuvshintogs is Chief Resident of the Methodist Family Medicine Residency Program in Sacramento, CA. and AFP's 2019-20 Resident Representative.