Trump has COVID: A look at what we know
Let’s cut to the chase: it sounds like Trump is pretty sick.
The news coming out of the White House and their medical team seems to be both deliberately misleading as well as unintentionally obfuscating what’s going on with the President’s health.
Just like the administration’s response to the pandemic, their response to the President falling ill is marred by two big flaws: dishonesty and incompetence.
Some of their information suggests they are lying about when he got sick, how he was tested, and who was exposed. But some of the information that’s coming out suggests they’re in over their head and not up to the task in front of them.
We’ll get into some of that stuff later this week. But for today’s installment, I wanted to start by addressing what we know about how sick he is.
What we know about the President’s preexisting risk
Just based on age, Trump is in a high risk group for complications from COVID. According to data from Northwell Health during the first wave of the pandemic, about a third of patients in their 70s admitted to the hospital died from COVID.
But it’s misleading to just look at his demographics and think that we can extrapolate these numbers to tell us anything about the President’s likelihood of surviving. This is for a few reasons.
First, we’ve learned quite a bit about treating COVID since the first wave of the pandemic. We have medicines that seem to really work and we know when to administer them.
Second, the President gets admitted to the hospital with a different set of medical circumstances than the rest of us. He’s not being cared for by doctors and nurses who are spread thin. Look at the description of his team:
Three pulmonary critical care specialists, two infectious disease doctors, an anesthesiologist, an Army nurse, four Navy nurses, a clinical pharmacist and the director of the medical center's executive medicine program. That's in addition to the president's physician, Navy Cmdr. Sean Conley.
Third, even though he is an overweight 74 year old man, it doesn’t appear that he has many comorbid medical conditions such as diabetes, hypertension, or significant cardiovascular disease that would put him at significantly increased risk. I’m sure there will be disagreements about this point, which I’ll explain as a footnote below the text of this newsletter.
What have we learned about how sick he is?
The obvious caveat: there’s a huge amount of information that we don’t know.
We don’t know his vital signs (temperature, blood pressure, heart rate, respiratory rate, oxygen saturation). We don’t know what their trend has been, which is really important.
We don’t know the specifics of any of his blood tests. There’s a ton of information that doctors get from laboratory work that helps us prognosticate illness. There’s an alphabet soup of tests that are ordered on these patients: CBC, BMP, AST, ALT, CRP, ESR, LDH, Troponin, ferritin, among others.
Some of those tests are just noise rather than signal, but it’s information that we have in the hospital - I’m sure his doctors have it - and it helps us frame in our minds how sick someone is.
Alright, alright, enough with the caveats. What do we know?
We know that Trump had a high fever.
We know that he had low enough oxygen levels to require supplemental oxygen at various points.
We know that he had an abnormal chest CT scan.
We know which treatments he’s been receiving.
These things mean he’s pretty sick.
Patients don’t receive supplemental oxygen unless saturation levels drop below 90% (and often even a bit lower). And the time course of his illness - needing oxygen support on Friday after not being symptomatic on Tuesday - suggests progression.
The abnormal CT scan probably doesn’t inform all that much relative to the information we get from his oxygen status, work of breathing, and respiratory rate. We don’t have enough information about his fever curve (the trend of temperature over time) to draw many conclusions.
But the treatments that they’re giving him mean that his doctors think he’s sick. They’re worried enough to give him unproven medications.
And the timeline so far means that we don’t really know just how sick he will get.
Which COVID specific treatments is Trump getting?
He has received 3 specific treatments for COVID:
Remdesivir
Dexamethasone
A single 8g dose of two monoclonal antibodies from Regeneron
There’s a notable omission you may notice from that list: hydroxychloroquine.
Don’t look at what someone says, look at what they do. So I think you can extrapolate from this that no one really believes that hydroxychloroquine works in COVID, regardless of what public comments have been made, an idea which readers of this newsletter have known for months.
No word on whether anyone asked, “What the hell do you have to lose?”
As an aside, there was some debate that the difficulty drinking and walking captured in the video of the President at West Point were actually due to hydroxychloroquine toxicity.
Let’s get into these therapies. What do they all mean for his illness?
Let’s start with the first two on that list, remdesivir and dexamethasone.
Remdesivir is a medication that blocks viral replication. Since we the early manifestations of the disease are caused by direct effects of the virus, blocking viral replication early in the course of disease makes biological sense and has high quality clinical trial evidence supporting it.
Remdesivir isn’t a miracle drug, but it does seem to shorten recovery time in hospitalized patients by a few days.
Dexamethasone is the next drug that he’s being treated with. This is a corticosteroid (not to be confused with an anabolic steroid) that blocks an overactive immune system.
Dexamethasone is a game changing treatment for severe COVID.
It seems to have the best benefit in the sickest patients and the timing of administration can impact effectiveness.
Since a lot of the late manifestations - and most severe respiratory manifestations - of COVID appears to be caused by our own immune system working against us, dexamethasone is going to be effective during the later immune phase of the disease. Giving it too early may actually be counterproductive if it blocks your ability to fight off the initial phase of COVID, which is when symptoms are caused by direct viral effects.
Based on the timing that’s been released regarding his positive test, there’s been speculation that the dexamethasone was given too early and could do more harm than good. Based on the course of events, I think the decision to give it to him was based on his low oxygen levels and a CT scan that looked concerning.
Regardless of the specifics regarding why to give the dexamethasone, the fact that he was given it means that there’s reason to be concerned.
Which brings us to the last treatment he’s getting: the Regeneron antibodies.
Antibody treatments - more questions than answers
Trump has received treatments with two monoclonal antibodies from Regeneron. There’s super preliminary data on this treatment in patients who aren’t all that sick.
Since antibodies help the immune system clear the virus, giving them early on in disease course makes physiologic sense.
But this is an unproven treatment. And that makes it risky.
Getting this treatment is a questionable decision. We don’t actually know if it will make him better, make him worse, or not have any impact. The choice to use this treatment either means that his doctors were really worried about him, really worried about the perception that they were not “doing everything,” or don’t have a good understanding of the appropriate level of evidence to require before adopting an unproven therapy.
This is one of the issues with being a VIP - sometimes getting the “best” and “newest” treatment isn’t actually better. Sometimes it’s worse.
We simply don’t know.
But the report about the decision to give this treatment is a canary in a coal mine of incompetence. Take a look at the letter that they released:
The letter describes a “polyclonal antibody cocktail” that the President received. But the Regeneron medication is actually a cocktail of two monoclonal antibodies.
This is a minor inaccuracy, but it’s a mistake that simply shouldn’t be made in a formal letter released to the media about the medical treatment of the leader of the free world.
I read something like this in a letter that this physician knows will be scrutinized, and it really raises questions about competence.
In medicine, details really matter. And when doctors are getting this type of information incorrect, it’s alarming.
The bottom line: it’s too early to know what will happen, and we don’t really know anything
Trump could certainly be off supplemental oxygen moving forward and recover smoothly and quickly.
He could also have a prolonged hospitalization with permanent difficulty breathing. He could die. Or almost anything in between.
Based on the treatments that he’s been getting and the little information that we have, we should all be concerned that he’s really sick.
We don’t have enough information to prognosticate, and even if we did, it’s just too early in the course of his disease to know what’s going to happen.
More to come later this week on Trump and COVID.
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A little bonus footnote if you disagreed about my suggestion that Trump didn’t start out with any major comorbidities
There’s certainly an argument to be made here. The counterpoints in favor of him being sicker to start out:
The bullshit letter he dictated about his own health when he ran for President.
The video of him struggling to drink water and walk down a ramp at West Point earlier this year.
But the reason that I think I’m right about comorbidities is from looking at his medication list, which includes zinc, vitamin D, baby aspirin, melatonin, and famotidine, in addition to the COVID-specific medications.
He’s not on any blood pressure or blood sugar medications. While a sick patient with hypertension may have their blood pressure medications stopped, a diabetic patient in the hospital is very likely to be placed on insulin.
The sham doctor’s note released during his 2016 campaign mentioned that he takes a baby aspirin and a low dose of a statin. Now, you could argue that suggests he’s previously had either a heart attack or a stroke. But most people who had a cardiovascular event are prescribed a high potency statin, and I don’t suspect a subtle deception based on a nuanced understanding of the latest lipid guidelines.