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Sunday’s press conference on President Donald Trump’s status as a Covid-19 patient raised as many new questions as answers, leaving many medical experts concerned that the public still isn’t getting a complete or accurate picture of the commander in chief’s health.
At the briefing at Walter Reed National Military Medical Center, where the president is being treated, his doctors said Trump is “doing very well” and had improved so much he could be discharged as soon as Monday.
Yet the optimistic report on the president’s prognosis also came with an admission by his physician, Sean Conley, that Trump had needed supplemental oxygen on Friday and that his blood oxygen saturation had dropped to worrisome levels twice in the past three days. Conley said he’d withheld details about this at Saturday’s press briefing because he wanted to “reflect the upbeat attitude that the team, the president” has had about the course of Trump’s illness.
The president’s medical team also reported that Trump on Saturday started yet another drug to fight Covid-19: dexamethasone. The steroid has been shown in clinical trials to improve outcomes — but is only recommended for patients with severe or critical Covid-19. It’s also the third Covid-19 drug to be administered to the president, following an experimental monoclonal antibody treatment given Friday and an ongoing, five-day course of the antiviral remdesivir.
But dexamethasone can also have serious psychiatric side effects, and the decision to use it so early in the president’s infection sparked a new round of speculation about the severity of his illness.
Vox spoke to five infectious disease and intensive care doctors about the news to try to make sense of it. They said either Trump is sicker than the White House is saying or his doctors are overtreating their high-risk, 74-year-old VIP patient.
“I can tell you how I would approach the treatment of a patient or family member — it would be different,” said intensive care doctor Lakshman Swamy, who works with the Cambridge Health Alliance. “The challenge is that when you are a VIP patient, it doesn’t always mean you mean you get better care — it just means you get more care.”
One thing everyone agreed on: Trump’s health status today, whatever it is, doesn’t say anything about how he’ll be doing a week from now, given the unpredictability of this disease.
What we know about Trump’s health
If we go by the official reports from the White House, Trump has been improving and was doing just fine as of Sunday morning — but he had a bad Friday. That was when he experienced a fever and his oxygen levels dropped for the first time.
Conley said Trump’s “oxygen saturation transiently dipped below 94 percent. ... And after about a minute with only two liters, [it was] back over 95 percent.” After an hour, Trump was off the oxygen, Conley added. On Saturday, Trump’s blood oxygen saturation level again dropped to 93 percent for a short period — but Conley wouldn’t confirm whether the president required oxygen then, too.
Instead, since then, Trump’s health has improved so much, his doctors said, he may head back to the White House as soon as Monday. His doctors also said he hasn’t had a fever since Friday morning, his vitals are stable, and he’s no longer experiencing any shortness of breath.
Conley did not provide details about the results of the president’s chest CT scan, prompting Bob Wachter, chair of the Department of Medicine at the University of California San Francisco, to wonder if they’d found signs of pneumonia, other manifestations of Covid-19 lung involvement, or inflammation.
... But it seems far likelier that they found evidence of pneumonia or other manifestations of Covid lung involvement or inflammation, which is serious and raises the level of concern and risk. (4/8)
— Bob Wachter (@Bob_Wachter) October 4, 2020
Meanwhile, Trump has been given at least three new drugs — that are all still being tested — to treat Covid-19 and its symptoms.
Trump’s treatment protocol, explained
On Friday, Trump’s doctors say they started administering the intravenous antiviral remdesivir and a cocktail of experimental monoclonal antibodies — medicines that are supposed to stop the virus from replicating and progressing into cells.
We learned Sunday he also started taking dexamethasone, a steroid that reduces inflammation associated with Covid-19. (He had also been taking zinc, vitamin D, famotidine, melatonin, and daily aspirin — though it’s not clear whether those drugs are for Covid-19 specifically, since there’s no conclusive evidence to back their use against the novel coronavirus.)
Of the three Covid-19 drugs, dexamethasone has the strongest evidence behind it. “It’s the only drug to show improvement — overall improvement — in Covid-19,” said Joshua Barocas, an assistant professor of medicine at Boston University and infectious disease physician at Boston Medical Center.
Barocas referred to a study published in the New England Journal of Medicine. It showed randomly chosen patients who received dexamethasone experienced a reduced risk of death versus those who didn’t get the drug — but only when they were either intubated or receiving supplemental oxygen.
In patients who aren’t on oxygen, the risks associated with the drug’s use may outweigh the harms. Among the particularly worrisome side effects: confusion, delirium, mania, and a higher risk of other infections. The drug can even complicate a patient’s recovery by suppressing the immune system’s virus-fighting response. The Covid-19 treatment guidelines only call for dexamethasone in seriously ill patients.
“I wouldn’t be giving it to someone who is not on oxygen,” Swamy said.
Dexamethasone can cause frank mania, or more severe depressive states. Added to the risk of COVID related neuropsychiatric symptoms/severe delirium the press ought to be asking the medical team how they are formally monitoring his mental status @maggieNYT @jonathanvswan
— Paul Summergrad (@paulsummergrad) October 4, 2020
“It’s not a completely benign choice of medication,” Jen Manne-Goehler, an infectious disease doctor at Brigham and Women’s and Massachusetts General hospitals, added.
“It’s either overtreatment or he’s much more ill that [the White House] said,” said Clemens Wendtner, a professor of medicine in Munich, Germany, who treated the country’s first Covid-19 patients.
Trump is also on a five-day course of remdesivir, an antiviral developed by Gilead Sciences that’s supposed to stop the virus from replicating.
There is published evidence for the use of remdesivir — in hospitalized patients, it shortened their recovery time compared to the placebo group — but it’s not yet fully approved by the Food and Drug Administration and no one knows what happens when patients get the medication in conjunction with the others Trump is taking.
While we don’t know all the details here, I’ll say this— if you’re having dropping oxygen levels and being started on #dexamethasone, your discharge day shouldn’t be tomorrow. #covid19
— Dr. Abraar Karan (@AbraarKaran) October 4, 2020
As for the experimental cocktail of monoclonal antibodies: In theory, the treatment is supposed to work by neutralizing the coronavirus. But monoclonal antibodies for Covid-19 have not even been fully tested in humans. (We’ve only got published studies on hamsters and monkeys, and unpublished efficacy data from an ongoing human trial, according to Science magazine.)
“What’s confusing or surprising is [why] you would use something so early ... with no efficacy data out there,” said Manne-Goehler of the monoclonal antibodies. From a scientific standpoint, she reasoned, starting on the drug early might make sense if you’re trying to prevent the virus from entering cells. “But what’s odd is as a clinical doctor, I don’t jump to [prescribing] things I have little real-life efficacy data [on] in a person who is not super sick.”
Even if the experimental drug looks promising in early research, Swamy noted, “people said the same thing about hydroxychloroquine,” a drug now known to be ineffective for Covid-19. He added: “We don’t know enough about it.”
So one could read the use of unapproved drugs typically given in severe cases as a sign that Trump is sicker than the White House is acknowledging. Or maybe it’s just because the patient is the president, said Peter Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine.
“You know he’s got risk factors. He’s starting to get sick. Has had a fever and an oxygen requirement. The question is what do you do?” Hotez said. “If something were to happen to the president — whether he becomes incapacitated or worse — that’s a huge national security threat.”
All the doctors said it was difficult from the limited information being released from the White House to know what’s truly going on. What is clear: Trump’s doctors were veering far from the Covid-19 guidelines, with the multiple therapies — some unproven — being administered in combination.
The bottom line: It’s too soon to tell if Trump is on the road to recovery
Trump’s health status now — even if he’s discharged from Walter Reed medical center on Monday — tells us little about how he’ll fare over the next week.
Patients “can be doing fine, requiring a little bit of supplemental oxygen, and then very rapidly deteriorate to mechanical ventilation — that’s one of the scariest things about this virus,” Barocas said.
Manne-Goehler agreed: “What makes Covid scary is that who falls off a cliff, and who doesn’t, still can be difficult to predict.”
She recently cared for a patient who was similar to Trump in terms of age and underlying health risks, Manne-Goehler said. “He looked pretty bad, he got to the edge of the cliff and got better. But there are people who just blow through anything we try to do [for them] and do terribly. That script — even with what we understand about risk factors — is part of what scares the medical community.”
Trump’s doctors have also gone off script for his treatments, which makes applying what we know about how patients fare to the president even more challenging.
Overall, though, people with Covid-19 are generally doing better now than they did mere months ago because doctors have refined their approach to treating the disease. And while Trump has an elevated risk of complications and death — because of his age, gender, and underlying medical conditions — the odds of survival are in his favor.
But the public will have to wait until at least 10 days after his symptoms began for a clearer picture. That’s when patients, if they are doing well, are usually thought to be in the clear. If we assume the White House’s timeline is accurate, that brings us to October 10 or 11. Until then, Manne-Goehler said, the disease is “a roller coaster.”
