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Tracing Trump’s Contacts
Treatment Implications
Timeline of Symptoms
The White House Physician
Use of Dexamethasone to Treat Trump Suggests Severe Covid-19, Experts Say
Many of the measures cited by his doctors are reserved for patients severely affected by the coronavirus.
President Trump arrived on Friday at Walter Reed National Military Medical Center in Bethesda, Md., for treatment of Covid-19.
Published Oct. 4, 2020Updated Oct. 5, 2020, 6:51 a.m. ET
President Trump’s doctors offered rosy assessments of his condition on Sunday, but the few medical details they disclosed — including his fluctuating oxygen levels and a decision to begin treatment with a steroid drug — suggested to many infectious disease experts that he is suffering a more severe case of Covid-19 than the physicians acknowledged.
In photos and videos released by the White House, there is hardly any sign that Mr. Trump is sick. But at a news conference at the Walter Reed National Military Medical Center in Bethesda, Md., Mr. Trump’s doctors said his oxygen levels had dropped to a level that can indicate that a patient’s lungs are compromised. The symptom is seen in many patients with severe Covid-19.
The president’s medical team also said that he had been prescribed dexamethasone on Saturday. The drug is a steroid used to head off an immune system overreaction that kills many Covid-19 patients.
The drug is reserved for those with severe illness, because it has not been shown to benefit those with milder forms of the disease and may even be risky.
Because of the incomplete picture offered by the president’s doctors, it was not clear whether they had given him dexamethasone too quickly, or whether the president was far sicker than has been publicly acknowledged, experts in infectious disease and emergency medicine said on Sunday.
“The dexamethasone is the most mystifying of the drugs we’re seeing him being given at this point,” said Dr. Thomas McGinn, physician-in-chief at Northwell Health, the largest health care provider in New York State. The drug is normally not used unless the patient’s condition seems to be deteriorating, he added.
“Suddenly, they’re throwing the kitchen sink at him,” Dr. McGinn said. “It raises the question: Is he sicker than we’re hearing, or are they being overly aggressive because he is the president, in a way that could be potentially harmful?”
Dr. Esther Choo, a professor of emergency medicine at Oregon Health & Science University in Portland, said of the doctors’ statements on Sunday: “This is no longer aspirationally positive. And it’s much more than just an ‘abundance of caution’ kind of thing.”
A Timeline of Trump’s Symptoms and Treatments
Oct. 4, 2020
Some experts raised an additional possibility: that the president is directing his own care, and demanding intense treatment despite risks he may not fully understand. The pattern even has a name: V.I.P. syndrome, which describes prominent figures who receive poor medical care because doctors are too zealous in treating them — or defer too readily to their instructions.
“You think you’re helping,” said Dr. Céline Gounder, a clinical assistant professor of medicine and infectious diseases at the N.Y.U. Grossman School of Medicine. “But this is really a data-free zone, and you just don’t know that.”
Still, based on the doctors’ account, Mr. Trump’s symptoms appear to have rapidly progressed since he announced early Friday morning that he had tested positive for the coronavirus.
Mr. Trump had a “high fever” on Friday, and there were two occasions when his blood oxygen levels dropped, his doctors said — on Friday and again on Saturday. The president’s oxygen saturation level was 93 percent at one point, his doctors said, below the 95 percent that is considered the lower limit of the normal range.
Many medical experts consider patients to have severe Covid-19 if their oxygen levels drop below 94 percent. The physicians said M Trump had received supplemental oxygen at the White House on Friday; they were not clear about whether it had been administered again on Saturday, or whether his blood oxygen levels had fallen below 90 at some point.
On Friday, Mr. Trump was given an infusion of an experimental antibody cocktail that is being tested in Covid-19 patients by the drugmaker Regeneron. Mr. Trump is also receiving a five-day course of remdesivir, another experimental drug that is used in hospitalized patients and has been granted emergency authorization by the Food and Drug Administration.
Regeneron’s antibody cocktail is being tested in patients early in the course of the infection, because the treatment fights the virus itself and may prevent it from spreading throughout the body.
Remdesivir is also an antiviral and is already commonly used with dexamethasone, which tamps down the body’s immune response and is given later in the illness, when some patients’ immune systems go into overdrive and attack their vital organs.
On Sunday, the doctors said that Mr. Trump was in good spirits and that he was walking on his own and not complaining of shortness of breath.
“If he continues to look and feel as well as he does today, our hope is to plan for a discharge as early as tomorrow to the White House, where he can continue his treatment,” one of his doctors, Dr. Brian Garibaldi, said at the briefing on Sunday.
But several medical experts said that the decision to prescribe dexamethasone to Mr. Trump did not align with that optimistic scenario.
A large study of dexamethasone in Britain found that the drug helped those who had been sick for more than a week, reducing deaths by one-third among patients on mechanical ventilators and by one-fifth among patients receiving supplemental oxygen by other means.
Guidelines from the World Health Organization recommend that the drug only be given to patients with “severe and critical Covid-19.” The National Institutes of Health has issued similar guidance, specifying that the drug is recommended only for people who require a mechanical ventilator to help them breathe, or who need supplemental oxygen.
“When I think about people needing dexamethasone, I think about people who are escalating their condition, who are heading closer to I.C.U. level than to home,” said Dr. Rochelle Walensky, chief of the division of infectious disease at Massachusetts General Hospital and a professor at Harvard Medical School.
Using multiple drugs at once could have an impact on their effectiveness, and it increases the risk of harmful drug interactions, said Dr. McGinn.
“You’re giving remdesivir, you’re giving dexamethasone, and you’re giving monoclonal antibodies,” he said, referring to the experimental treatment by Regeneron. “No one’s ever done that, not to mention famotidine and some zinc and a mix of cocktails, or whatever else he’s on.”
Uncertainty over the president’s condition stemmed at least in part from earlier mixed signals from the president’s physicians. On Sunday, the team acknowledged delivering an overly positive description of the president’s illness on Saturday.
“I didn’t want to give any information that might steer the course of illness in another direction, and in doing so, you know, it came off that we were trying to hide something, which wasn’t necessarily true,” Dr. Sean P. Conley, the White House physician, said to reporters on Sunday.
Dr. Rajesh Gandhi, an infectious diseases physician at Massachusetts General Hospital and a member of the panel that developed Covid-19 treatment guidelines for the N.I.H, said, “What would be very helpful to know is how much oxygen did the president need and for how long.”
The president’s physicians also have not described in detail the results of imaging scans of Mr. Trump’s lungs, or of blood tests indicating whether he is at risk for blood clots, a common complication in Covid-19 disease.
Mr. Trump is moderately obese, a condition that is usually accompanied by at least mild or moderate hypertension and mild to moderate diabetes, Dr. McGinn noted. The president’s high blood pressure is said to be under control, and he is not known to have Type 2 diabetes. Still, studies have identified the conditions as critical predictors of severe Covid-19 disease.
If Mr. Trump’s illness has significantly progressed, then dexamethasone and remdesivir are appropriate, several doctors said.
“He got the therapies that anybody going into any good hospital in the United States would receive today,” said Dr. Carlos del Rio, a professor of medicine at Emory University in Atlanta.
But the doctors also raised the possibility they might discharge the president as early as Monday, shortly after starting him on the steroid therapy, perplexing some experts.
“If you start somebody on steroids because their oxygen saturations are dropping, then that is the time to be vigilant and to be monitoring somebody more closely,” said Dr. Sam Parnia, an associate professor of critical care medicine at N.Y.U. Langone who has seen many Covid-19 patients.
“If there was a concern that certain things were not available at the White House when his oxygen was a little higher, it probably makes sense to be vigilant now,” Dr. Parnia said.
The fact that Mr. Trump is walking on his own, and that he delivered video statements in which he was able to complete sentences without gasping for breath, was seen as a positive sign by several experts.
Nevertheless, many sick Covid-19 patients appear to be doing well even when their lung function is poor, a condition doctors have nicknamed “happy hypoxia.”
“Of course, we like to see that he is feeling good, but it doesn’t put him in a category that’s essentially mild Covid,” Dr. Choo said.
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Steroids may also give a false impression of the patient’s state. The drugs are also known to affect mood, causing euphoria or a general happiness. Steroids can also disrupt sleep, leading to insomnia, irritability or depression.
In some cases they may cause psychiatric effects, leading to feelings of grandiosity and mania, or even delirium and psychosis.
“The thing about steroids is they can have psychiatric side effects at almost any dose,” said Dr. J. Michael Bostwick, a psychiatrist with the Mayo Clinic who authored a paper on the subject.
While steroids are used widely in medicine without much concern about psychotropic effects, “it is necessary to notice if the use of these drugs causes changes in mood or thinking or sleep,” Dr. Bostwick said.
During the first week of Covid-19, the course of disease is unpredictable, Dr. Parnia said. It is never clear whether the illness will progress or plateau. “It can go north, or it can go south,” he said.
Any patient who has experienced low oxygen levels, or hypoxemia, must be closely watched, said Dr. Michelle Prickett, a pulmonary and critical care specialist at Northwestern Memorial Hospital in Chicago.
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“It’s hard to feel confident early that things are going to turn around, especially in the presence of hypoxemia early on,” she sai
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Is Trump a political tool in the tragic world of plague. ?
As Trump’s condition makes headlines, America’s pandemic is getting worse
(CNN)The extraordinary attention generated by President Donald Trump’s fight with Covid-19 has obscured an alarming turn in a pandemic that is showing signs of accelerating as colder weather approaches, with 2,000 new America deaths recorded since he was diagnosed.
Cases of Covid-19 are rising in 22 states and are falling in only five, according to data collected by Johns Hopkins University, and the death toll in the United States is approaching 210,000. Yet there are few signs, despite the virus sweepin the White House and infecting Trump allies on Capitol Hill of any fresh White House appreciation of the danger or a plan to try to slow the spread of the disease.
The latest close Trump associate to return positive tests were White House press secretary Kayleigh McEnany along with two other press aides. There is little indication that the administration has undertaken a serious effort to contact and trace people who were at a Supreme Court nominating event nine days ago at the White House that appears to have infected multiple people. There are no official briefings warning Americans about what they need to do to mitigate the worsening situation. And the government experts who once were front and center are never seen alongside the President.
Trump did say he had learned a lot about Covid-19 during his stay in Walter Reed military hospital where he was taken on Friday, but the main focus of the President’s aides has been projecting him as strong 29 days ahead of an election in which he appears to be in considerable trouble. The President’s drive-by photo-op Sunday in front of supporters gathered with flags and banners outside Walter Reed reflected how he has consistently put his own personal and political goals ahead of a serious approach to the worst public health emergency in 100 years.
On Friday, when Trump went into the hospital, the United States recorded more than 54,000 new cases of the virus and 906 deaths. On Saturday, close to 50,000 new cases were reported along with 687 deaths. And on Sunday, there were 36,600 cases and 410 deaths according to Johns Hopkins figures collected by CNN. Tallies at the weekend are generally lower due to the difficulty of reporting.
Such numbers utterly contradict the message that Trump was giving hours before he was diagnosed with the disease himself, that the US was “turning the corner” and that “the end of the pandemic is in sight.”
The newly diagnosed patients will not have the state-of-the-art facilities, experimental treatments and dedicated hospital suites that are afforded to the President of the United States. Many patients in the pandemic have died alone in crowded hospitals cut off from loved ones.
The government’s top infectious disease specialist Dr. Anthony Fauci, who has been sidelined by the President said that the current baseline average of around 40,000 new cases a day heading into the fall and winter when people spent more time indoors was a danger sign.
“That’s no place to be when you are trying to get your arms around an epidemic,” Fauci said on CNN’s “New Day” on Monday.
Politics take priority over a serious virus response
Trump’s photo-op Sunday in front of supporters gathered with flags and banners outside Walter Reed National Military Medical Center risked exposing Secret Service agents riding in his armored SUV and amounted to a familiar flouting of government recommendations to stop the spread of the virus which has infected 7 million Americans. It was the latest flagrant sign of politics superseding Trump’s duties as a steward of the national well-being – with Election Day only 29 days away and voting in many states already underway.
It came amid lingering confusion about the President’s true state of health after a weekend in which the White House undertook strenuous efforts to minimize the seriousness of his case. But details about the cocktail of therapies that he is taking suggest that he is experiencing complications from the disease, even as his doctors said it was possible he could return to the White House Monday.
White House focuses on optics while America wonders about health of the President
The showman President’s motorcade photo-op followed a misleading and politicized White House performance that displayed all the failures that have made the US anti-Covid effort one of the worst in the world.
White House physician, Navy Cmdr. Dr. Sean Conley, admitted on Sunday to not telling the full truth about Trump’s condition the day before – including about two drops in his oxygen levels – to avoid overshadowing the “upbeat” official line on the President’s health.
Trump and his aides worked hard to show he was strong and getting better before he faces off with Democratic nominee Joe Biden, whose campaign said he again tested negative on Sunday. But the contradictions and misrepresentations from his medical team means that Americans can have no confidence that the White House is giving a complete picture of what’s going on. Conflicting messages and half-truths underscored the administration’s inability to properly manage the machinery of the state and to understand the importance of sending clear information about the President’s health and the continuity of power to Americans and potential adversaries abroad.
‘That should never have happened’: Inside Trump’s Walter Reed parade
The extraordinary attention that accompanies a presidential illness — in this case multiplied because the commander-in-chief is sick from a disease he has ignored, downplayed and said will soon go away — has obscured the alarming trajectory of the pandemic in recent days.
Including Friday, when Trump was dramatically flown to the hospital on Marine One, the US has recorded another 121,000 cases of Covid-19 and another 1,800 deaths. None of those new patients will get the dedicated round-the-clock medical care, experimental treatments, hospital suites and joy rides that are available to the President amid a national emergency in which many have died alone and patients are isolated from loved ones in crowded hospitals.
Trump says he ‘gets it’
White House’s inept ‘contact tracing’ effort leaves the work to others
In a video on Sunday, the President said that he had learned a lot of interesting things about Covid-19 that he planned to share with the country. It was not clear if he was finally appreciating the danger of the virus following his own infection. For months, the President has been briefed by the some of the best epidemiological experts in the world but did not treat the pandemic with the necessary seriousness. His video, posted on Twitter, did not include any admonition to Americans to take the disease more seriously after months of his flouting government health warnings and mocking those who observe them — including Biden.
“I learned it by really going to school. This is the real school. This isn’t the let’s read the book school and I get it. And I understand it,” Trump said.
The President’s subsequent jaunt outside the hospital in Bethesda, Maryland, clearly showed his education in Covid-19 does not include new respect for social distancing.
Such precautions were also ignored at a mostly mask-free event at the White House nine days ago at which Trump nominated Judge Amy Coney Barrett for the Supreme Court. At least eight people who attended the event, including the President, have been infected with Covid-19. Trump also ignored precautions at a fundraising event in New Jersey Thursday, where he went despite knowing his close aide Hope Hicks had been diagnosed with Covid-19.
His conduct raises the question of whether he endangered others while knowing he had been in close contact with someone who had tested positive for the virus. White House press secretary Kayleigh McEnany said Sunday that the President learned about his positive test when he returned from the trip. She did not say when he took the test. And given the obfuscation by the White House over the weekend, the truthfulness of any official statements at this point is in serious doubt.
Several Secret Service officers in the vehicle with Trump Sunday, who were wearing surgical masks and face shields, must presumably now quarantine after being in close contact with a patient with Covid-19, and risk becoming the latest casualties of Trump’s political ambitions.
Here’s who has tested positive and negative for Covid-19 in Trump’s circle
“Why leave? What is the purpose of this?” asked Dr. James Phillips, head of disaster medicine at George Washington University and an attending physician at Walter Reed.
“Certainly looking at the risks of transmission of Covid-19, what we know is being in enclosed spaces is dangerous,” Phillips said on “The Situation Room” on CNN. “Masks or no masks. Being inside a vehicle that is hermetically sealed circulates virus inside and potentially puts people at risk.”
The White House insisted that the car ride was cleared by the President’s medical team. But there is no medical protocol that suggests it is advisable for a patient with a serious, contagious illness to leave a hospital until they have recovered or are no longer contagious.
Trump’s illness robs him of campaign trail push
Trump’s desire to show that he is fit, compulsion to bask in the adoration of his supporters and desire to dictate news coverage is typical. But his latest behavior also may hint at how he feels about the political impact of his confinement a month before an election in which he is trailing Biden and that threatens to turn on his mismanagement of the pandemic. Trump, who has spent the last two presidential campaigns attacking the health of his rivals, Hillary Clinton and Biden, cannot afford to look weak at this critical moment.
Trump campaign adviser says rally protocols won’t change after President’s coronavirus diagnosis
With time running out to turn things around, the President was jolted by new polling data over the weekend. A NBC/Wall Street Journal survey taken following Trump’s boorish performance at last week’s first presidential debate showed Biden leading 53% to 39% among registered voters nationally. An ABC News/Ipsos poll, conducted after news about the President’s coronavirus diagnosis, found that 72% of voters believe the President didn’t take the threat of contracting coronavirus sufficiently seriously. A CBS News poll, meanwhile, found Biden with a 7-point lead among likely voters in the key swing state of Pennsylvania and even with Trump in Ohio — another Midwestern battleground that went to the President in 2016. These surveys were largely completed by the time the President’s coronavirus diagnosis became known.
View Trump and Biden head-to-head polling
It remains unclear how the President’s sickness changes the final weeks of the campaign. He is unable to fly around the country and fire up his loyal base voters. The fate of the last two presidential debates — following the upcoming vice presidential clash on Wednesday between Mike Pence and California Sen. Kamala Harris — remains in doubt. And Trump’s infection now makes it almost impossible for the President to deflect from the one issue that reflects the presidency in its worst light: the pandemic.
Oxygen concerns
White House physician sows confusion with briefings
Earlier on Sunday, Trump’s doctors revealed that the President had suffered several alarming drops in oxygen levels. Conley again delivered a briefing that raised more questions than it answered about Trump’s condition. He said that he didn’t mention drops in Trump’s oxygen levels Saturday because he didn’t want “to give any information that might steer the course of illness in another direction.”
He acknowledged that his evasive answers “came off that we were trying to hide something” but said that “wasn’t necessarily true,” adding that the President is “doing really well” and is responding to treatment.
The episodes prompted doctors to start treating Trump with the steroid drug dexamethasone, which has been shown to help patients with Covid-19. It is typically given to patients on supplemental oxygen or ventilation.
Conley also hinted at more unrevealed details when he refused to say what was revealed by X-rays or CT scans of Trump’s lungs.
“There’s some expected findings, but nothing of any major clinical concern,” he said.
All patients have expectations of privacy. But Trump shoulders a public trust given his position. It is not just crucial for voters to have some understanding of his condition. The health of the President is a crucial national security issue and commanders-in-chief have a higher duty to disclosure than regular citizens.
The approach taken by the President’s doctors suggests to many experts that the White House has been downplaying the seriousness of his condition as he fights a disease in which a patient can quickly deteriorate during the course of the infection over a period of days.
“His physicians are treating him very aggressively. And based on what we know so far, the President is ill,” said Dr. Patrice Harris, a past president of the American Medical Association, told CNN’s Wolf Blitzer.
“We know that during the course of the illness, a patient can feel just fine and suddenly take a turn for the worse. So really for the President’s own health and safety, this visit outside of the hospital was quite risky today.”
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