Evaluating and Treating Foot and Ankle Patients During the COVID-19 Pandemic

Abstract

The fear of becoming infected with the SARS-Cov-2 virus, and developing COVID-19, has driven many of us to seriously consider which patients need to be seen in the office. In our practice, we are following our health system's guidelines so we restricted office visits to only those patients with urgent or emergent conditions, including those with wounds and injuries, infections, and other acutely painful, “limb-threatening” conditions. Because my schedule has been booked solid for many weeks in advance, I have taken to inspecting the upcoming appointments at least a week prior to the scheduled visits, so that I can review the progress notes for some patients and decide who should or should not be seen. In some cases, I have to call the patient to discuss their current status in order to decide if they qualify to be seen as an outpatient. In our offices here in Philadelphia, Pennsylvania, we are reduced to scheduling about 25% of the patients that we would typically see if it were not for the social distancing requirements that we have implemented in response to the pandemic. While these measures paralyze our business in the short term, I believe they have been vitally important in our efforts to impede the spread of SARS-CoV-2 and, in effect, save lives. Despite the reductions we have made in our office schedules, we remain cognizant of the fact that all of the other conditions that we typically treat continue to affect our patients. While we practice social distancing and restrict visits to just those patients that we deem to be urgent or emergent, we have to keep in mind that some patients be reticent to speak up enough about their foot or ankle condition, or they might fear potential exposure to the coronavirus to such a degree, that they allow an urgent/emergent condition to go unattended for longer than is necessary or safe to do so. If my understanding of a particular patient's condition concerns me enough in this regard, I have to decide whether or not to have them come in for evaluation; and, this can be a difficult decision to make, because I have to weigh the risks associated with their foot malady versus those associated with potential exposure to the virus. Of course, in our office, our reduced staff, and the patients that we see, are all at risk for exposure to the coronavirus, so we wear face masks, and we don gloves and eye protection for each encounter. Furthermore, for the first time in my career, I have participated in audiovisual telemedicine visitation with some of my patients. I found this to be useful in regard to one tech savvy patient with whom I discussed her painful pedal paresthesia, inspected her skin as she moved her smartphone camera over her feet, and we ended up adjusting the dose of gabapentin that she was taking and we also added the use of a topical analgesic cream to her treatment regimen. In the case of another patient that I had been seeing for weeks in our wound care center, a telemedicine encounter was arranged to coincide with the time when a nurse was visiting the patient to change his wound dressings. With the help of the visiting nurse, who wore appropriate personal protective equipment as she operated the smartphone camera, we were able to communicate and I could inspect the patient's wound and adjust his wound care protocol. The pandemic has also changed the way we treat patients in the hospital. We have postponed all elective surgical cases, and our Surgery Department's backlog currently involves over 800 such cases. At the end of April, 2020, moreover, we have 107 inpatients with COVID-19, and 35 (33%) of these are on a ventilator. Thankfully, our hospital began to prepare for the outbreak back in January, so we have not run out of supplies and equipment, and we were ready to convert rooms to negative pressure chambers for COVID-19 patients. We have employed strict procedures to contain the virus and to preserve our resources. Of course, we don personal protective equipment when we triage patients in the surge tent, evaluate a patient in the Emergency Department, or see inpatients with COVID-19 and a foot and/or condition that requires our attention. When all geared up, I actually feel rather safe in the presence of COVID-19 patients; however, it's after evaluating and treating such patients, when I transition back to the non-COVID environment, that I always fear “bringing the virus with me,” even as I strictly adhere to the transition protocol. That risk is always there, and it wears on us. Personally, since the pandemic was declared, I have only had to spend just a few hours at a time geared up and working with COVID-19 patients; and, my hat goes off to the nurses, other doctors, and staff members that clean the rooms and transport our patients, those individuals that work all day long in the hostile COVID-19 environment. The physical and mental stress is great and we have seen some of our colleagues get sick with the virus, and even die. So, now we are thinking about easing up the social distancing requirements, and trying to get our daily activities, practices, and our economies back to normal…the way it was before the widespread outbreak of COVID-19. I can only hope that we do this in a scientifically sound and reasonable fashion, and that our strong desire to return to the way it used to be does not give the virus the upper hand once again. I also hope that what we return to is actually a new normal, one wherein we once again emphasize the importance of public health and preparation for the next pandemic.