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On the front lines in Connecticut

DW Weekly talked to Caroline Nelson, MD, from Yale School of Medicine, about her experiences serving in the internal medicine unit during the COVID-19 pandemic.

DW Weekly: I understand that you have been serving in the internal medicine unit during the COVID-19 pandemic. How did you go about getting involved?

Dr. Nelson: At the beginning of the pandemic, the Yale Internal Medicine Department put out a call for volunteers across the health system to assist in taking care of patients with COVID-19 infection. There were 12 faculty members in our department who volunteered — three of us have served as medicine attendings on the COVID wards so far. The majority of our dermatology residents also volunteered and have been working in the hospital alongside internal medicine residents.

DW Weekly: How has the COVID-19 situation been in your area?

Dr. Nelson: We’ve been hard hit in Connecticut. Our numbers are going down, but the current total COVID-positive inpatients in the Yale New Haven Health System is 485 with 137 of those in the ICU. That’s down from our peak. So far, 2,326 COVID-positive inpatients have been discharged.

DW Weekly: What has your experience been as a dermatologist on the front lines?

Dr. Nelson: I was a hospitalist on the COVID wards, so all of my patients had COVID-19 infection. I had an exceptional senior internal medicine resident and intern working with me. We started rounds at 7:30 a.m., discussing the patients in our workroom prior to rounding in-person. During chart rounds, we wore surgical masks. During in-person rounds, we donned PPE including an N-95 mask, face shield, double gloves, gown, and shoe coverings. There was a dedicated stethoscope in each patient room.

DW Weekly: What has the adjustment been like returning to a medicine setting?

Dr. Nelson: One of the things that I’ve thought about a lot is that I became a doctor before I became a dermatologist. This experience took me back to the essence of medicine. It was a really challenging experience, there’s no doubt. A lot of patients hospitalized with COVID-19 have comorbidities that place them at greater risk of complications. I found myself needing to think about things I haven’t thought about on a daily basis for several years — for example – how to evaluate an acute kidney injury. Remembering: When to rely on the FENa versus the FEUrea?

Dr. Nelson volunteers to treat patients on the COVID-19 ward.

DW Weekly: Describe how you have been working with other specialists and physicians.

Dr. Nelson: The collegiality was wonderful. Some of my medicine colleagues and house staff were people who I have interacted with before as a dermatology consultant. I’ve always had an interest in inpatient dermatology. This was inspired by my mentor Dr. Misha Rosenbach during my residency at the University of Pennsylvania. Before joining the faculty at Yale, I completed a Complex Medical Dermatology Fellowship with Dr. Arash Mostaghimi and Dr. Nicole LeBoeuf at the Brigham and Women’s Hospital and Dana Farber Cancer Center. The fellowship combined my interests in inpatient dermatology and supportive oncodermatology. Now, I spend a lot of my time at Yale attending on the inpatient consult service. So it was nice to work alongside my medicine colleagues during the pandemic. It was also humbling. As dermatologists, we’re stepping in to help out, but our medicine colleagues have been on the frontlines since day one.

DW Weekly: How has this experience affected collaboration among your dermatology colleagues?

Dr. Nelson: Early on in the pandemic, we started thinking about how to support each other as dermatologists. I am very fortunate to work with Dr. Jean Bolognia, and we developed a medical dermatology advisory panel consisting of five core faculty members along with pediatric, surgery, and dermatopathology faculty liaisons. The on-call dermatology attending can activate the panel for COVID-positive inpatients in order to provide an additional layer of medical collaboration. Thus, our faculty are volunteering not only to support internal medicine, but also to support each other. It has been a meaningful experience for me to be a part of that.

The panel is also an opportunity for us to share information about dermatologic manifestations of COVID-19 infection. For example, while I was on service, we were consulted on a case of pediatric multi-system inflammatory syndrome in the setting of COVID-19. The panel’s discussion of the published literature was instrumental to the care that our team provided for that patient.

DW Weekly: There have been some reports of dermatologic manifestations of COVID-19. Is that something you’ve come across, and if so, what are you seeing?

Dr. Nelson: There’s been a range of dermatologic manifestations in COVID patients. In addition to pediatric multi-system inflammatory syndrome, we’ve seen a variety of erythematous eruptions ranging from morbilliform eruptions to urticaria and we’ve seen a variety of purpuric eruptions. In the inpatient setting, we have observed significant hypercoagulability manifesting as retiform purpura in some patients with detectable antiphospholipid antibodies as was originally reported in the New England Journal of Medicine. Detecting dermatologic manifestations of COVID-19 infection is an important role for us as dermatologists to play.

DW Weekly: How has your expertise in dermatology helped on the COVID-19 wards?

Dr. Nelson: I didn’t happen to have a patient with a dermatologic manifestation of COVID-19 infection on my medicine service; however, I did have a number of patients with dermatologic conditions that were bothering them. I remember on rounds visiting one patient and asking her how her breathing was. She just kept scratching her hands and asking if someone could do something about her itch. It’s an important reminder that the COVID-19 pandemic has not stopped other skin problems and, in some cases, may be exacerbating them.

Dermatologists also need to recognize that they have something valuable to offer not solely by virtue of their specific expertise and extensive medical training, but also by virtue of their human empathy. I will never forget on my first day of medicine rounds, there was a patient with COVID-19 who was very sick with decompensated heart failure. She was also suffering from uterine prolapse. The intern on our team made the comment, “In this time when my patients have a life-threatening illness and are isolated from their family and friends, what I find to be fulfilling is treating issues affecting their quality of life.” She went to great lengths to get this patient a pessary. Patients are isolated from their family and friends and dermatologists can offer so much in terms of medical care and emotional support that improves patients’ quality of life.

DW Weekly: What advice do you have for fellow dermatologists who may be recruited to assist with COVID emergency efforts?

Dr. Nelson: There’s nothing more meaningful than getting involved on the frontlines of a pandemic. I always felt supported by my medicine colleagues. Every day that we were rounding, the attendings for the other two teams on our COVID floor came by and asked if I needed anything and if I had any questions. I think people should take advantage of the opportunity to volunteer. It’s a privilege. And I think that one of the at-risk groups in this pandemic is the front line health care workers. There’s something valuable for us as physicians in knowing that we’re not in this alone and that everyone is ready to support each other across the house of medicine.

Caroline Nelson, MD, is a medical dermatologist at the Yale School of Medicine. She treats patients at Yale New Haven Hospital and at the Yale Medicine Dermatology New Haven and Branford clinics.

Are you on the front lines managing COVID-19 patients? Share your story with DWW. Email dweditor@aad.org.