Skin Changes with Covid 

I decided I needed more information to discuss this with any semblance of knowledge. This posting is an opinion piece, with some validated resources for your review as well. 

Initial Thoughts 

Before I read this article, Cutaneous signs in COVID-19: A review, I thought it was funny in an ironic way, that the authors of this article are all associated with dermatology. The Covid-19 disease process is not a “surface organ” problem – it is an immune response and hematological problem involving inflammation and coagulation challenges, and therefore the resulting skin changes that come with compromised circulation. The coronavirus causes swelling of endothelial cells. The swelling of the endothelial cells has a huge impact on circulation, as every vessel in the human body is lined with these cells. "Endothelial cells form a single cell layer that lines all blood vessels and regulates exchanges between the bloodstream and the surrounding tissues" (Alberts, et al., para. 15). 

Insults to the integumentary system that originate from circulatory deficiencies, are not typically – well, not ever – a dermatology concern, rather these insults call for the interventions by a wound care, vascular, or general surgeon or medical provider that specializes in wound care, vascular diseases, or infectious diseases. The exanthems that occur with Covid-19 would be more of a petechial presentation rather than a confluent, a sporadic, or a satellited, pinpoint, macular rash.   

According to Starkman (2022), when writing about the ‘Covid toe” skin condition, “These skin changes have shown up in people who’ve tested negative for COVID” (para. 5).  Additionally, symptoms just like those found in “Covid toes” have actually been around for quite some time, referred to as chilblains. Chilblains present as itchy red patches on the toes (sometimes fingers too), as a result of cold temperatures (NHS 24, 2020). Additional risk factors for chilblains include: poor circulation, poor diet or low body weight, exposure to cold, Lupus, and Raynaud's phenomenon (NHS 24, 2020).

Rochman (2021) quoted the lead author of a study as saying, “Like other dermatologists, we began to see an increase in patients with chilblains during the pandemic” (para. 3).  

My Experiences with Covid Skin Issues 

I have only provided care for two patients with “Covid toes” as I stopped working in acute inpatient care in March of 2021. The skin changes were like any of the pictures you will find when you “Google” Covid toes images. See Image 1 and Image 2 below. 

         

 Image 1 Skin changes seen with Covid-19 (Rabin, 2020)  

  

   Image 2 Skin changes with Covid-19 (Rochman, 2021) 

Type of Rash  

There was no rash present for either of my patients. They both had nonblanchable discoloration and the presence of swelling and intermittent pain on areas of the toes of both feet that did not feel "itchy" until 12-24 hours after initial onset. Both described the pain as a burning or stinging sensation, which occurs in chilblains (NHS 24, 2020). After reviewing several different publications, all symptoms are present for some, and for others, only the discoloration is present. Some will have other symptoms including blisters and raised, painful red bumps (Starkman, 2022). The American Academy of Dermatology (AAD) (n.d.-a) reports, “If you have swollen, discolored toes or fingers, you may have chilblains instead of COVID toes” (para. 16).  At my recommendation, both of these patients were treated with a moderate strength topical corticosteroid (Triamcinolone 0.1%) to reduce the itching and swelling, and the symptoms resolved within 72 hours of onset.

Manifestation Timeline 

In children, the “Covid toes” may appear in the fingers actually and may be the only sign of a Covid infection (AAD, n.d.-b). The two patients I had were in the late stage or over the virus, and were ready for discharge soon after the condition appeared. For many, according to Noakes & Majoe (2020), the toe issues occurred post-Covid infection. Discolored “Covid toes” are reported to typically occur in children, teens, and young adults, as the only indication that they may have been infected with the SARS-CoV2 virus (Starkman, 2022). Other sources suggest this odd set of symptoms occurs in the early stages of the virus as well as in the late or post stages of acute viral infection (Ketchum, 2021). 

Severity of Associated Illness 

Both patients had been in the ICU, but that is where all of the Covid patients went, in our hospital. One of my patients had been intubated for a portion of his hospitalization and the other had mask and/or CPAP oxygen only.  

Cutaneous Signs as Indicators of the Disease 

As stated previously, some publications indicated that this may be the only sign in children, teens, and young adults. I do not think that this discoloration is an appropriate indicator of the Covid-19 virus or severity.  

Conclusion 

Ultimately, I have not seen any conclusive data that supports "Covid toes” or cutaneous rashes as a Covid-19 disease indicator or indicator of Covid infection severity. As I stated previously, Covid is a disease process that affects the immune system and has hemotological implications. The swelling of the endothelial cells in response to the SARS-CoV2 virus, has a huge impact on circulation, because every vessel in the human body is lined with endothelial cells. As a Certified Wound, Ostomy, Continence nurse, I see this as acute tissue changes resulting from the impairment in the circulatory system, which can happen in those that were infected with SARS-CoV2, but can also occur in other inflammatory, circulatory conditions. 

In my opinion, this is in no way an indicator of Covid severity, nor a finding that would prognosticate a Covid-19 infection.  

References  

Alberts, B., Johnson, A., Lewis, J., Raff, M., Roberts, K., & Walter, P. (2002). Blood Vessels and Endothelial CellsVersion (4th edition). In Molecular biology of the cell: A problems approach (4th ed.). Garland Science. Retrieved May 19, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK26848/Links to an external site. 

American Academy of Dermatology. (n.d.-a). Covid toes, rashes: How The coronavirus can affect your skin. Coronavirus Resource Center. https://www.aad.org/public/diseases/coronavirus/covid-toesLinks to an external site.  

American Academy of Dermatology. (n.d.-b). Rash: Sign of coronavirus in kids. https://www.aad.org/public/diseases/coronavirus/coronavirus-rash-signs-kidsLinks to an external site.  

Ketchum, D. (2021, March 39). Are covid toes and hands an early sign of covid-19? https://www.getbrio.com/post/purple-covid-toes-and-handsLinks to an external site.  

NHS 24. (2022, November 25). Chilblains. https://www.nhsinform.scot/illnesses-and-conditions/skin-hair-and-nails/chilblainsLinks to an external site.  

Noakes, A., & Majoe, S. (2020, June 24). Understanding the role that “covid toe” has in recognizing the potential extent of covid-19 infections: A case study. Pathogens and global health. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7480604/Links to an external site.  

Rabin, R. C. (2020, May 1). What is “covid toe”? maybe a strange sign of coronavirus infection. The New York Times. https://www.nytimes.com/2020/05/01/health/coronavirus-covid-toe.htmlLinks to an external site.  

Rochman, S. (2021, June 23). “Covid toes” were likely not caused by covid-19, in most cases. NCAL Research Spotlight. https://spotlight.kaiserpermanente.org/covid-toes-not-caused-by-covid/Links to an external site.  

Starkman, E. (2022, December 24). Covid toes: What you should know. https://www.webmd.com/covid/what-are-covid-toesLinks to an external site. 

Wollina, U., Karadağ, A. S., Rowland-Payne, C., Chiriac, A., & Lotti, T. (2020, September). Cutaneous signs in COVID-19 patients: A Review. Dermatologic therapy. Retrieved May 6, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7273098/Links to an external site. 

Hurricane Katrina: A Response Worse than the Disaster?

In August 2005, Hurricane Katrina hit the southeast coast of the United States, causing loss of life and damage to property in excess of $100 billion (Gibbens, 2019). This Category 3 storm took the lives of at least 1200 people, and countless others suffered years of destitution as a direct result of the damage, which increased with the failed response efforts by the government (Gibbens, 2019). The common theme emerging from each of the sources reviewed - and many that are not referenced in this work – is that although the Katrina storm was a natural disaster that did a great deal of damage on its own, the true devastation and resulting catastrophe was caused by the disastrous response by government authorities, specifically the Federal Emergency Management Agency (FEMA).  

The National Response Framework contains 29 different federal agencies that have a role in disaster relief (Edwards, 2015). There is also a National Incident Command System, so there may be too many “nationally” focused systems, and these may not be as effective in a local or state-level response need. Is it possible that the delay in federal response and subsequent dysfunctional coordination of relief, was driven by the race or socioeconomic status of the residents? Is it conceivable that local and state response systems would provide more successful outcomes than the national or federal red-tape-laden agencies? Let us further explore the inequities of this disaster response.  

Minimizing or Preventing the Disaster in Advance 

The first failure lies within the warnings about the strength and design of the levees, that we now know were dismissed repeatedly for several years prior to Katrina. The southern border of Louisiana was supposed to be safe from flooding because of a network of levees that made up the federal flood protection system. This system, though, was redesigned and a rebuilding process began in 1965. After years of budget cuts and diversion of funding to other projects, the rebuild was only 60-90% complete when Katrina hit (Pruitt, 2020). When levees broke in more than 50 locations, almost 80% of the city of New Orleans was under water (Pruitt, 2020). The city sits uniquely below sea level already, according to McMahan (2022). This was not the first time for severe flooding though, as hurricanes had previously flooded New Orleans five times since 1915, according to History.com Editors (2022).  

A population of roughly 100,000 remained in the city during the storm despite evacuation orders, but one must consider how many residents were physically unable to evacuate, could not afford to evacuate, did not know to evacuate, or did not have the transportation necessary to evacuate (McMahon, 2022). According to the History.com Editors (2022), over 110,000 of the New Orleans residents (approximately 500,000) did not have access to a car.  

Weaknesses in the Response 

In a catastrophe of this magnitude, there are so many working parts that need to be addressed and yes, it starts with prevention, but beyond that there should be a process in place as soon as possible to mitigate loss of life and property. These are just a few considerations that come to mind: 

• Is there a warning/alert/announcement system in place? Is it accessible to all members of the public? Is it audible/visible without power supply? Who would potentially not receive the alerts? 
• What is the evacuation need? Is there a plan for evacuation? What is the timeline? How quickly can residents be evacuated? Where will they be directed to go? 
• What search and rescue resources are available for those who did not, could not, or would not evacuate? Where can those affected go after the fact, to gather? Where can the remaining residents commune for food, shelter, water, clothing, supplies, and medical aid?  

Suggested disaster risk management steps include components of prevention, mitigation, transfer, and preparedness (United Nations Office for Disaster Risk Reduction [UNDRR], n.d.). During Katrina, there were extreme limitations in assistance available to the victims, and tragically, the response by the federal government was also delayed. The government response turned out to be too little, too late. The worst of the disaster came not from the storm itself, but from the response (or lack thereof) by the government. It should be noted that much of the damage from the storm was unavoidable, but the ripple-effect disasters that followed could have been prevented.  

There was plenty of time to begin evacuation efforts prior to the storm and subsequent flooding. Because of the confusion and lack of proactive engagement by officials, faulty information was provided to the public (Edwards, 2015). Edwards goes on to report that “there was general confusion over mission assignments, deployments, and command structure” (2015, para. 3). Despite simulation exercises performed the prior year, officials failed at learning and implementing the key lessons from that drill (Edwards, 2015). During Katrina, there were breakdowns in communication, supply chains, and decision making (Edwards, 2015). Those put in key leadership positions for FEMA were inexperienced in disaster management (Edwards, 2015).  

In the aftermath, there were instances of excessive fraud and abuse regarding distribution of relief funds (Edwards, 2015). Millions were left homeless and more than 400,000 ended up leaving New Orleans for good (Pruitt, 2020). Probably the most appalling aspect of this entire disaster response system is reported by Edwards in his 2015 article. He notes that FEMA blocked relief from the people of New Orleans and he provided examples of actions taken by FEMA. The following bullet points are directly quoted or minimally altered from the Edwards (2015) article, depicting actions taken by FEMA (para. 9):  

• repeatedly blocked delivery of emergency supplies ordered by Methodist Hospital in New Orleans 
• turned away volunteer doctors because they were not listed in the government records as emergency volunteers 
• actively blocked flights intended to emergently evacuate residents and offered no assistance in coordinating evacuation services 
• refused Amtrak offers for evacuation assistance and would not return calls from the American Bus Association or even the Motorcoach association, who were offering evacuation assistance 
• denied necessary access for the Red Cross to deliver emergency supplies to the Superdome 
• turned away trucks from Walmart loaded with water for New Orleans and prevented the Coast Guard from delivering diesel fuel  

This list is not exhaustive but depicts the abhorrent inequities of this disaster response. So again, is it possible that these actions occurred because 69% of the New Orleans population is black (Sastry, 2009)? Was it race or socioeconomic status of the New Orleans residents that caused those in power to dismiss the emergent nature of the disaster? It must be considered based on the extreme negligence and inequity that anathematized the city of New Orleans. 

What Went Right 

Despite all the atrocities listed in the previous section, many things went right with some of the response to Katrina. The local Coast Guard response was integral to the rescue of more than 30,000 people, after they deployed 4,000 service members (Edwards, 2015). The state-commanded National Guard was there to establish and reinforce law and order, when the police force was incapacitated by the storm (Edwards, 2015). The strength of the private sector was revealed with the Red Cross, The Salvation Army, Walmart and its employees, and the Home Depot, all coming through with provisions and supplies for food, shelter, water, clothing, and support (Edwards, 2015). 

Preventing Future Occurrences 

In looking at the potential for preventing or minimizing a disaster like this from happening again, certainly community risk assessments could be performed. For this Katrina disaster, the well-studied failures offer more insight than anything else on how to prevent or respond in similar situations. For New Orleans, a rebuild was required for hurricane defenses and “...cost $14.6 billion...” to complete by 2018 (Gibbens, 2019, para. 19). Federal, state, and local governments spent more than $20 billion to construct new levees along more than 350 miles of coastline (Pruitt, 2020). Prior to Katrina, funding for the United States Army Corps of Engineers (USACE) which would have allowed for the addition of safety measures in their design and upkeep of the levee system was not provisioned (McMahon, 2022). This funding decision was made based on a risk analysis that was conducted, which weighed the costs of installing new levees against the cost of coping with the after-effects of a major disaster (McMahon, 2022). The risk analysis performed in this instance did nothing to benefit the community when it came to the Katrina disaster. 

Conclusion 

All-in-all, Hurricane Katrina was a terrible natural disaster that garnered a slow, dismissive, and poorly constructed federal response effort that failed to help the people who needed help the most. As if there were not enough lessons from other past failures, this disaster set the bar at an all-time-low for government response in the United States.   

References  

Edwards, C. (2015, August 27). Hurricane Katrina: Remembering the federal failures. Cato.org. Retrieved December 30, 2022, from https://www.cato.org/blog/hurricane-katrina-remembering-federal-failures Links to an external site. 

Gibbens, S. (2019, January 16). Hurricane Katrina facts and information. Environment. Retrieved December 30, 2022, from https://www.nationalgeographic.com/environment/article/hurricane-katrina Links to an external site. 

History.com Editors, H. E. (2019, August 9). Hurricane Katrina. History.com. Retrieved December 30, 2022, from https://www.history.com/topics/natural-disasters-and-environment/hurricane-katrina Links to an external site. 

McMahon Last Modified Date: December 21, M. (2022, December 21). What caused the levees to break in New Orleans during hurricane Katrina? UnitedStatesNow.org. Retrieved December 30, 2022, from https://www.unitedstatesnow.org/what-caused-the-levees-to-break-in-new-orleans-during-hurricane-katrina.htm Links to an external site. 

Pruitt, S. (2020, August 27). How levee failures made hurricane Katrina a bigger disaster. History.com. Retrieved December 30, 2022, from https://www.history.com/news/hurricane-katrina-levee-failures Links to an external site. 

Sastry, N. (2010, August 1). Tracing the effects of hurricane Katrina on the population of New Orleans: The Displaced New Orleans Residents Pilot Study. Sociological methods & research. Retrieved December 30, 2022, from https://pubmed.ncbi.nlm.nih.gov/20161061/ Links to an external site. 

United Nations Office for Disaster Risk Reduction (UNDRR). (n.d.). Disaster risk reduction & disaster risk management. PreventionWEB. Retrieved December 30, 2022, from https://www.preventionweb.net/understanding-disaster-risk/key-concepts/disaster-risk-reduction-disaster-risk-management Links to an external site. 

Thoughts on a College Education

Found this quip in my iPhone notes, it was dated October 5, 2014... exactly 5 years ago today. Just think it is interesting to review prior thoughts and writings every once in a while to see how you may have grown or how you may have departed, from past thoughts. Or in this case, how the past 5 years in my growth and experience has validated my thoughts from 5 years ago. I hope to expand on these thoughts in the future, developing a practical metaphor to convey the true spirit of learning in a college setting.

I believe that college is a place, a lifestyle, an action, and a mode of transportation. 

Place

attend

participate

learn

grow

Lifestyle

way of life

absorb

expose

enrich

Action

be

do

see

think

feel

experience

Mode of transportation

past

present

future

Kristie Hartig

10/5/14

What kind of nurse are you?

I believe the world needs nurses, nurse educators, and nurse leaders who are idealistic motivators, leading the way for the future of nursing, through education, support, collaboration, and service.

I think I am one of them. My passion for authenticity, integrity, transparency, ethics, advocacy, and tolerance, drives my desire to motivate and encourage new nurses along a similar path.

If we reach nursing students early in their nursing program and hold onto them in a mentor-to-mentee capacity throughout the curriculum, we may be able to introduce them to a world of professional nursing where they still have a solid grasp on compassion and equity in practice and peer relationships. (Image credit: Forbes.com)

There has to be some way to circumvent the cynicism of well, so many nurses. For those who are cynical new grads, maybe you have been mistreated and have experienced what it feels like when "nurses eat their young." Maybe you aren't to blame for your negative, judgmental attitude.

Maybe you are among the misguided who somehow believe that RNs, you know, real nurses, only work in hospitals. Ha! Good grief, give me a break. Real nurses take care of people. All people. No matter the facility, no matter the person. How are you missing that? All I can say is walk a mile, sweetheart, walk a mile!


Cynical nurses are like a vortex...the Coriolis force leading to an infinite abyss of broken spirits. These cynics purloin energy from nurses who believe and practice as I do. They drain the life force of others and even push some to burnout. Since many can't beat you and your nasty attitude, they join you, only to find that there is nothing sweet about the energy created at a negative nancy convention.

Redirect your energy. It's never to late to change your attitude. Life already sucks most of the time, don't make it worse by feeding into the negativity. #EmbraceTheSuck

Where your thoughts are,
your energy is.
Where your energy is,
you will be.
What you think about,
you bring about,
automatically!