Over the last year and a half, the world has been faced with several challenges, the likes of which society has not seen in years. When we began as co-Editors-in-Chief 3 years ago, little did we know how the skin and wound world was about to change!
In the US, July holds the promise of lifted restrictions as more and more persons are vaccinated and small group gatherings are permitted. However, a third wave of COVID-19 infections with new variants associated with increased transmission rates affected Canada this spring, delaying such freedoms as the country sought to establish herd immunity before reopening its borders. Sadly, we believe the crisis in the developing world will continue to cause death and suffering for many more months to come.
Oprah Winfrey said, "turn your wounds into wisdom."1 Clinicians have had to do that quickly (and literally) to provide care for persons with COVID-19. During isolation or when working from home, potential authors and researchers have connected with others by writing about their experiences and observations, generating that wisdom for us all. For some, written communication became an alternative to clinical connection. Along this journey, clinicians have had to rely on their expert skills of observation and subsequent reflection.
Reflection on practice experience is not new. Florence Nightingale, and more recently, other clinicians have used this technique in their professional education programs. The Schon theory of adult learning2 explains the "surprise" that COVID-19 presented to clinicians in practice settings and the importance of reflecting on the lessons learned to compile diagnostic and treatment options. Given the power of knowledge arising from contemplation, the journal is starting a new department titled Practice Reflections (see Publisher's Note). These peer-reviewed articles will appear from time to time in the journal. We hope you find this addition helpful.
This month's issue has many offerings reflecting on COVID-19, including the continuing education article. For many of us, "chilblains" brings to mind a condition more common in cool, damp climates without central heating facilities. This is not a common diagnosis in regions where winters are more likely to be cold and dry. However, chilblains-like lesions such as "COVID toes" are now recognized to be a late manifestation of COVID-19 especially in children. Dr Sachdeva and colleagues have reviewed this new observation and ways to distinguish its signs and symptoms from other cold sensitivity disorders of the feet. So-called COVID toes are often edematous, red, and violaceous. In this late phase of the disease, a COVID-19 test may be negative, but the skin biopsy can show spikey, circular structures from the virus. The Hospital for Sick Children in Toronto has seen more than 100 patients with COVID toes that needed to be distinguished from the less common lesions associated with lupus or idiopathic chilblains.
Personal protective equipment such as masks are associated with medical device-related injuries in several of our recent publications. In this issue, the article by Jiang et al provides data from 145 hospitals in China and outlines the association between protective masks combined with goggles and skin injury among medical staff. Further, Levine et al report on an ear pressure injury in a care setting among patients who need to wear COVID-19 protective masks almost all the time. For even more COVID-19 data, we recommend you periodically review our articles that have been published ahead of print: https://journals.lww.com/aswcjournal/toc/publishahead. Currently, the offerings include a report of a patient with COVID-19 who developed sacral pressure injuries associated with pyoderma gangrenosum, as well as a facial pressure injury that occurred in a patient with COVID-19 from prone positioning.
Many of the clinical observations of COVID-19 have arisen from the challenges of virtual care and pandemic precautions. We must recognize that COVID toes are probably a local clotting abnormality that is a much more likely result of the disease than any reaction related to a preventive vaccine. We must achieve herd immunity to protect societies worldwide. Please act as an advocate for vaccination for all, and let us hope that July brings the opportunity for safe in-person gatherings around the world.
Elizabeth A. Ayello, PhD, MS, BSN, RN, CWON, ETN, MAPWCA, FAAN
R. Gary Sibbald, MD, DSc (Hons), MEd, BSc, FRCPC (Med Derm), FAAD, MAPWCA, JM
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