Tuesday, October 6, 2020

Stethoscope Extra: A Few Quick Thoughts on Presidential COVID

Donald Trump has COVID-19. No surprise – he disdains masks and those who wear them, and doesn’t even pretend to keep his distance including in closed spaces with other people. People in his West  Wing behave as though the pandemic didn’t exist, using frequent testing as a manly substitute for all that other wussy stuff. Since the rapid tests they use miss about 50% of COVID-19 cases, it was inevitable that the disease would penetrate the White House walls sooner or later.

Everything you are being told about his illness is spin. No surprise there either – the man is a pathological liar who recruits liars to his inner circle, and who happens to be obsessed with seeming fit, systematically hiding potentially negative information about his health.

 

Where he got it

Hope Hicks was sick enough on Wednesday, September 30th.that she was given a separate room on Air Force 1. That day Trump’s aides thought their boss seemed under the weather, before a COVID-19 rapid test was positive Thursday. Impossible to say whether Hicks gave it to him, he gave it to her, or – more likely – they both got it from a third person.

The third party was likely to have been one of the guests at a real party, the super-spreader Barrett nomination celebration on Saturday September 26th, 4 days before Hicks and Trump fell ill (a classic incubation period). At least 7 other attendees are known to have tested positive. Coney Barrett herself is not responsible for the White House outbreak, because she already had COVID-19 months ago. Though the announcement of the nomination was made outdoors, where it’s harder to transmit disease, it turns out there was also an indoor reception inside the White House afterwards. No masks, no physical distancing:



The White House attempted to keep Hicks’s illness secret. and probably would have tried to do the same with Trump’s if he hadn’t gotten too sick. We only found out because someone leaked the swab tests to Bloomberg news. 

The people around Trump are dropping serially into the COVID-19 chasm, from Melania to Hicks to Kellyanne Conway to personal assistant Nick Luna, campaign manager Bill Stepien, chair of the Republican National Committee Ronna McDaniel, advisor Chris Christie, and press secretary Kayleigh McEnany. Not to speak of Senators Mike Lee and Thom Tillis, whose diagnoses may disrupt Republicans’ rush to fill RBG’s Supreme Court seat as well as Tillis’s own re-election campaign. Some other staff and guests have tested negative, but even the best PCR tests for COVID-19 – and we don’t know whether that’s what they’re using – have a real-life false negative rate between 3% and 37%.

 

Whom he’s exposed

If you have been exposed to someone with COVID-19, you immediately go into quarantine for 2 weeks on the chance you too might have the disease. Not our President, who knew Wednesday at the latest that his close advisor Hicks was ill. 

The most infectious period for is from two days before a patient develops symptoms through the first day they feel ill. Aides and journalists thought Trump seemed unwell on Wednesday, but let’s say charitably that he became ill only on Thursday when his test came out positive, so Tuesday Wednesday Thursday were the worst days for disease transmission. 

Tuesday, of course, was the “debate” where Trump spent 98 minutes yelling and spitting at Joe Biden from a 10-foot distance. Fortunately Biden is fairly unlikely to have been infected, because he was almost certainly beyond the reach of droplets, and because aerosols are relatively unlikely to be active at that distance. So far he seems well and has tested negative, but only time will tell.

On Wednesday, the journalists and Air Force personnel on the Presidential plane unwittingly shared their space not only with an unmasked and infectious President but with an unmasked Hope Hicks who was already thought to have COVID-19. Trump also hung out at close quarters with reporters at the White House and held a rally in Minnesota, where he schmoozed unmasked with local Republican heavies and attended a fundraiser inside a private home.

On Thursday, already feeling unwell and fully aware of Hicks’s diagnosis, Trump went to a $250,000 a head fund-raiser in New Jersey and knowingly exposed dozens of his own donors.

On Sunday he insisted on exposing his Secret Service protectors by leaving the hospital for a photo-op jaunt deemed “Insanity” by Dr. James Phillips, a physician in the very hospital where Trump was being treated. This showed utter disregard for the health and the lives of his companions in the hermetically sealed vehicle.

Monday evening Trump wore a face mask on his way home from Walter Reed, but he removed it as soon as he crossed the threshold. This may have been because he was having such a hard time breathing through it, and he may have replaced it as soon as he caught his breath, to protect the hundreds of staffers inside the White House. I wouldn’t bet on it.

 

How are exposed people being protected?

They’re not. A Centers for Disease Control team is standing by to do contact tracing, but the White House hasn’t called them in, and has declared it has no plans even to track down, test, or quarantine the attendees at the Barrett and Bedminster events.

None of the journalists who rode on the Presidential airplane on Wednesday were told, at the time or afterward, that they were being exposed. They only found out from the media.

All the people in Trump’s inner circle should be in quarantine, from Ivanka to Jared to Mark Meadows to Trump’s debate prepper Rudy Giuliani (whose bad cough means he’s likely infected, whatever the swabs say). Instead, they’re out in the world, with Mike Pence insisting he’s heading to Utah for the vice-presidential debate this Wednesday. 

Did Pence really have no contact with any of those infected people within the last two weeks? Didn’t sit in a room close to the President or the campaign manager or the rest? Hard to believe, and if he did have contact he should be in quarantine. If necessary, he and Kamala Harris can hold their debate virtually.

 

The medication non-scandal

Much is being made of Trump’s supposedly receiving unique and untested cocktails of medications that could be doing heavens knows what kind of harm. There’s plenty of mystery and scandal in the story of his illness, but in my opinion his therapy does not fall into either category. 

Remdesivir, given daily for 5 days, is an antiviral which may shorten the course of COVID-19 patients though it’s never been shown to save lives or prevent deterioration to ventilator dependency. The earlier any antiviral drug is given – e.g. acyclovir for shingles or Tamiflu for influenza – the better it works, so the only reason ordinary folk aren’t starting courses of remdesivir the moment they test positive for COVID-19 is that it requires intravenous infusion. It made sense to give this as early as possible.

Monoclonal antibody medications are similar to convalescent plasma therapy in that they give you somebody else’s antibodies, but they the fancy antibody cocktails are concocted to be particularly high-dose. They, too, are believed to work better in neutralizing the coronavirus if they are given soon after a person is infected. Later, the amount of virus  in the body can become so great that it overcomes the neutralizing capacity of those external antibodies. And still later, the patient produces enough of his or her own antibodies that the ones being infused don’t add anything. I am somewhat surprised that the White House medical team chose to administer the Regeneron antibody cocktail, which judging from the company’s own statement has had somewhat less impressive results than the similar produced made by Eli Lilly, which reportedly reduced by 72% the need for hospitalization among COVID-19 patients receiving a dose early. 

Oxygen: COVID-19 patients need it only if they have pneumonia, a condition where infected fluid deep in the tiny air spaces of the lungs prevents sufficient oxygen from getting into the blood. The fact that oxygen was administered to Trump on Friday means he definitely had developed COVID-19 pneumonia early on, though his doctors have scrupulously avoided using the word.

We also know that Trump has relatively severe pneumonia, because he is being given the steroid, dexamethasone. This drug is never given to patients with mild or moderate COVID-19, because it does not help and may even made things worse. Note that all steroids hep you up, and they can make even the stablest person act off the wall. So dexamethasone side effects may have contributed to Trump’s poor judgement in making a foolhardy political theater field trip outside the hospital on Sunday. (I’m being generous…)

None of the doctors have mentioned blood thinners, but he almost certainly is receiving them, because that’s fairly standard treatment for anyone with COVID-19 who is ill enough to be hospitalized and therefore considered at high risk for blood clots.

The rest of the medications he’s getting are all fluff, from famotidine to zinc to melatonin to vitamin D, but there’s no reason to expect any of it will give him side effects or make him worse. Fortunately nobody seems to have offered him hydroxychloroquine, oleandrin, or Clorox.

The only scandal about the President’s treatment is that he was discharged from Walter Reed last night. Medically speaking this is total madness. First of all, he was not well enough  to leave the hospital – visibly short of breath after the minor effort of climbing the White House stairs; ordinarily, he would have had to sign out of the hospital against medical advice. Secondly, COVID-19 is notorious for taking a turn for the worse a week or so after the patient first develops symptoms, so the next few days are precisely when his health is most vulnerable. He will of course have better care inside the White House than anybody else could in their own home, including x-rays, blood tests, and intravenous medication, but that kind of turn for the worse can be sudden and disastrous in an elderly, hypertensive, obese patient, and is a reason in itself to keep such  a patient in  a hospital setting. I’m not entirely amazed by Trump’s preferring the appearance of health over its reality, but I’m shocked that his doctors went along with him.

 

The osteopath non-scandal

Dr. Conley, the White House physician, is a graduate of an osteopathic school of medicine, and has a D.O. (Doctor of Osteopathy) rather than an M.D. after his name. Some commentators, including Rachel Maddow, have considered it a scandal that the President is being cared for by “an osteopath” rather than “a doctor.” It is not a scandal – for many decades the curricula in American osteopathy schools has been nearly identical to what is taught in regular (“allopathic”) medical schools, with the osteopathy part deemphasized to the point that many D.O.’s don’t do any manipulation at all. A D.O. is considered equivalent to an M.D. for purposes of medical licensure or entering specialty training.

In this the United States is very different from most of Europe, where osteopaths get their first training as physical therapists and where they all practice manipulation therapy.

 

Politics…

I’m no pundit, but my take on the political implications for Trump is that they are devastating. The whole basis of his campaign – ignore the pandemic, promise a rapid return to economic boom, exploit racism and right-wing conspiracy theories to the max – has exploded, and when all that’s on the news is COVID COVID COVID it’s Joe Biden who benefits. Trumpian loyalists will never abandon him, but to the voters who are still on the fence this stark demonstration of the failure of the Trumpian approach to COVID-19 is unquestionably likely to push them in the direction of the candidate who has respected science and advocated measures to protect himself, anyone around him, and  the American people.

If he’s sick, then they planted it when they tested him. – a Trump supporter

 

When I first heard, I did wonder if he made it up to get out of the next debate or win sympathy – a Biden supporter

Not to speak of the fact that the candidate, his campaign manager, and many of his top surrogates are all in isolation with COVID-19, and others may need to quarantine.

I’m sure you’re all aware by now that if Pence and  Trump were to be incapacitated at the same time, the  presidency would pass down the line of succession to . . . Nancy Pelosi.