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.


24 comments:

  1. I was waiting for you to do it! As always, absolutely thorough, informative and witty - you're the Heather Cox Richardson of Medical Science!

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    1. thanks! I'm an enormous HCR fan, don't think I hold a candle to her. And I wrote this piece so fast...

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  2. thanks Susan great review and I agree wholeheartedly. will forward to friends

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  3. Excellent and perceptive thoughts. Thank you! I noticed Silvio B. stayed in the hospital for I believe two weeks.

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    1. Berlusconi had pneumonia in both lungs - we have no idea about Trump's. I saw yesterday that Berlusconi is feeling so awful that he's begging his doctors to let him check into the hospital again - very sad. Next to Trump, Silvio is a saint and a statesman.

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  4. Excellent... I was about to search for your comments on the subject. Thank you.

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    1. Thanks. I was nervous posting something I had written so fast, but I guess it's not too bad.

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  5. Agree with your every word.

    This may shed light on the why of Regeneron as part of his treatment:

    https://www.cnn.com/2020/10/05/investing/trump-regeneron/index.html

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    1. Brava Melissa! I have to say that if I had covid I'd want an antibody cocktail too, on the evidence we have, but this explains why he went with one rather than the other.

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  6. Your lucid mind-medicine is always carefully researched, mixed, and titrated to our needs for: sanity, relevance, insight, logic and timeliness. Indeed, you help us make sense of the senseless...and that’s not easy. Thanks for shining the light in the tunnel and toward the end of it...hopefully!

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    1. Wow, thanks so much Sarah. I was pretty nervous about this one, having twisted my brain in order to get it out fast enough to be helpful.

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  7. Thanks for this incisive report. Let's pray that we will have a change in November, despite the suppression of voting places I am hearing about. Too bad that more Americans here don't vote, isn't it? Very important time.

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    1. I'm glad you liked it. The Republicans seem more and more desperate, as they should be. I'm encouraging everybody in swing states to vote in person. Only way to make 100% sure the vote will be counted.

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  8. Well written. I completely agree. In the UK we are on tenterhooks about the election. A Trump re-election would be just so despairing. He is the total showman. I also wonder what dose of Vitamin D he has taken? This small study adds to the evidence that it really does make a difference and may be the driver behind the seasonality of so many respiratory viruses. Thanks again.

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    1. I'm glad you liked the post, and I assure you that your tenterhooks are nothing compared to my tenterhooks! About vitamin D, all the studies I've seen are observational and are hopelessly confounded by preexisting state of health. Do you know of some I don't know about?

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    2. Hi Susan, I know what you mean. When I was diagnosed with MS I searched for the RCT's that would define the role of Vitamin D, as latitude, and blood levels seems to correlate so well with incidence and outcome. Alas there were none. My neuro, rightly enough said I would be waiting for ever for the right trial and the sensible thing to do it to be Vit D replete, needing 4-5000iu daily. Thats pretty standard advice now. So for me the biology makes sense, and now an admittedly small trial suggests considerable benefit and in the middle of a pandemic is seems wrong to simply wait till we advice people to supplement to counter our unnatural indoor life. After all, Vitamin D is the only reason our skins are pale. Have a look at
      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7456194/

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    3. Well, all things are possible. The results of that Spanish study certainly look positive - too positive, in my opinion. No study of any medication of any kind has found effects that miraculous on COVID-19 for any outcome (2% in the drug group, 50% in the placebo group). As an inborn skeptic, I have to be suspicious. I do see that a UK group is doing a large-scale prevention trial of vitamin D, but - strangely - it doesn't seem to have a placebo control. https://www.bbc.com/news/health-54526652

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  9. Thanks Susan. My own feeling it that we should just get on and take it. The trials will take us through the winter and deliver an answer too late to help right now. Expediency trumps etiquette. (That word will never be the same!) Its cheap and safe too. This letter to the BMJ is pretty packed with good evidence too.

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    1. Sure, it ain't gonna kill you, at least as long as you stick to 4000u a day. (what letter to the BMJ?)

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  10. Hummm...Im not sure if this reply box seems to allow for cut and pasted references. I'll have another go: https://www.bmj.com/content/371/bmj.m3872/rr-5
    I hope it's attached. Interesting if it's not as I use Blogger too.

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    1. Thanks for the reference, and more generally thanks for the chance for this interesting exchange of ideas. Unfortunately of the 4 references (12-14 and 85) claimed by this author to be "interventional," only one - the same small Spanish study you cited earlier - is a proper trial. But hell, you're probably right, given that the risks are small it may make sense to measure vitamin D levels in covid patients and top up those who are <20.

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  11. I agree and return my warm thanks. Ideas become honed each time they pass from mind to mind. You are very sharp and helpful. Interestingly, it seems if we're out in the sun enough we make about 15,000iu daily (max). People with MS are taking 5000iu daily pretty much through the year. It seems to me the indoor life is not what our light skins have adapted to. Indeed. Scandanavia, for instance, would have been impossible for humans to colonise if it were not for the tonnage of fish, until recently, they ate. I supplemented care home residents with 400iu daily, but levels were not so readily available then. Im sure they are universally low. Vitamin D is becoming a big story. I'll bet Trump was given 5000iu daily, or perhaps the faster acting Caldidiol once he was admitted.

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    1. 😀 A very quick googling of toxicity from sun exposure yielded this from the Mayo Clinic: "Vitamin D toxicity is usually caused by large doses of vitamin D supplements — not by diet or sun exposure. That's because your body regulates the amount of vitamin D produced by sun exposure, and even fortified foods don't contain large amounts of vitamin D." Anyway, I think we've wound up more or less on the same page.

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