For any physician — but especially for those of us who have diagnosed, treated and worked with patients with covid-19 — the course of President Trump’s medical care since he announced his diagnosis by tweet early Friday morning has been bizarre.
The medical obscurity began Friday, when we learned of the president’s diagnosis but got no information regarding prior tests and their results — important facts when trying to provide contact tracing and inform people if they might be at risk for a potentially deadly illness. Besides the positive test Thursday night, we then learned, Trump might have had symptoms earlier that day at a fundraiser in Bedminster, N.J., along with “low grade fevers and a cough” early Friday, which indicated that he had covid-19, the disease caused by the SARS-CoV-2 virus.
Behind the scenes, White House physicians, who can consult directly with any expert in the world they might want to reach, discussed potential treatments and opted for an experimental medication, an antibody cocktail made of artificial molecules that fight the spread of the virus in the body. Regeneron’s monoclonal antibody cocktail is not yet approved by the Food and Drug Administration; the treatment is not available to anyone outside of clinical trials. The drug was procured swiftly and directly from the company through the FDA’s compassionate use program, which is usually reserved for immediately life-threatening conditions or serious disease when no comparable or satisfactory alternative therapy options are available. That his doctors would risk using a drug that has not yet demonstrated its efficacy was a signal that either the president’s condition was much more serious than the White House was admitting or that his course of treatment was taking unusual turns.
Once Trump was admitted to Walter Reed National Military Medical Center on Friday night — ostensibly out of an abundance of caution — the president also received remdesivir, an expensive antiviral drug that’s in short supply for the nation’s 30,000 other hospitalized covid-19 patients, with an emergency use authorization (not full approval) from the FDA for patients who are critically ill with the disease.
His medical team never explained why they chose to start that treatment, either. On Saturday, White House physician Sean Conley assured the nation that Trump was not “presently on supplemental oxygen,” without answering questions about whether he ever had been; we later learned that the president had at least two episodes of lower oxygen saturation. Those incidents prompted the addition of a high-dose steroid, dexamethasone, which is also approved by the FDA under an emergency use authorization but is also reserved for patients with severe covid-19 who require supplemental oxygen. Dexamethasone also has a significant number of side effects, particularly for older patients, who can often experience delirium or psychoses as a direct result of the steroids.
As a doctor who’s treated covid-19, the decision to use those three major agents — an antibody cocktail, an antiviral drug and a high dose of steroids — indicated one thing clearly to me: Trump must have been getting sicker in the hospital. Each of the three major drugs used attack a different aspect of the disease; they attack the virus itself as well as the body’s response to the virus. But all the treatments have some potential harms, including damage to organs, and effects that might be more chronic and last beyond the covid-19 illness itself. Implicit in these decisions is the risk/benefit trade-off that occurs when assessing a patient and determining that the course of their illness merits treatments reserved for severely ill patients — a choice which is not taken lightly.
But the official medical team indicated otherwise. At one point, Conley stated, “He’s up and back to his old self predominantly” and “he met or exceeded all standard hospital discharge criteria,” even as the president was receiving medications reserved for hospital use only and at a point in his case where he still poses a high risk of relapsing or infecting others. In between the upbeat statements were incomplete answers that made it obvious that Trump might not have been as healthy as they indicated. Conley wouldn’t discuss Trump’s lab results or whether he had pneumonia. He wouldn’t discuss what his lungs looked like, citing health privacy laws, or how low his oxygen saturation level had dropped (though he was happy to note that it was 97 percent Monday morning). He wouldn’t say when Trump last tested negative for the coronavirus, or what his fever had been (though, again, he did note that Trump’s temperature Monday was 98.1 degrees Fahrenheit).
That is why many doctors who aren’t working on Trump’s case were stunned at the upbeat discharge from the hospital after a four-day stay — which puts the president squarely in the middle of the typical course of illness — of a patient who has clearly merited therapies for “severe covid-19 illness.” Yes, the president’s home has access to a makeshift operating room down the hall if necessary, but the White House is still materially different from a hospital. Typical length of stays for covid-19 patients who are treated the way Trump was can approach weeks, highlighting how tenuous the course of the disease can be even with the highest level of medical attention.
And after the president left Walter Reed and flew back to the White House, his appearance on the executive mansion’s balcony without his mask was atypical in so many regards: He is still actively infectious and could pose a material risk of infecting other people around him. Since it’s clear he had some sort of lung involvement from his disease, standing and walking without oxygen could prove more harmful in the long run than the symbolic show of strength was politically beneficial.
For Conley to invoke privacy laws as a reason to withhold important details — even as he happily rattled off every possible indicator that supported the claim that Trump was improving rapidly — only adds more reason for Americans to feel alarmed. In medicine, even when the data is concerning and the expected outcome for a patient is a bad one, transparency, candor and humility is paramount. Certainly, details which could compromise national security must be withheld, and the president’s care team are bound to respect that first. But the absence of details that informed the choice of treatments makes it impossible to assess whether they made the right decisions.
In the same time frame that Trump’s diagnosis, treatment and discharge unfolded, approximately 5 million coronavirus tests were performed nationwide. A number of those tests were done for reasons similar to the president’s case: They either had a known close contact with someone who was positive for the coronavirus or they had some of the symptoms typical of covid-19. A patient the exact same height, weight, age and gender as the president has a 50 percent chance of being hospitalized, a 10 percent chance of being admitted into the intensive care unit, and has 90 times the risk of dying when compared to a younger patient hospitalized with covid-19. Once patients are admitted to the hospital, it’s up to their physicians whether to try treatments that are not authorized by the FDA. But it’s more likely that they’d be used as part of a clinical trial to better understand the impact of a treatment than that they’d all be deployed in rapid succession for a patient who’s well enough to leave the hospital so soon.
The shocking revelation of the president’s diagnosis and his subsequent treatment and discharge have raised more questions than answers. Is he strong and invincible, as his words and actions attempt to show? Is he in need of experimental treatments reserved for severely ill patients, as his medical charts would indicate? Or are his doctors simply throwing everything at him to see what works? Five days into Trump’s illness, we don’t know.
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