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Céline Gounder, MD, ScM, FIDSA

5 Oct, 13 tweets, 2 min read

1/ POTUS says he's leaving Walter Reed and going back to the White House: washingtonpost.com/elections/2020…
Assuming he got sick Wed/Thurs, he's on day 5 or 6 of COVID. It's too early.

2/ On day 2 or 3 of COVID POTUS already had evidence of severe COVID with oxygen saturation under 94% on room air (& likely into upper 80s) & supplemental oxygen requirement.

3/ COVID patients often get worse at 7-10 days into illness (i.e. this Fri or Sat). I hope that doesn't happen. But he should be closely monitoring in a hospital NEAR AN INTENSIVE CARE UNIT until then.

4/ I have rounded on COVID patients at 8 or 9 AM who weren't on supplemental oxygen who rapidly worsens over a couple hours and ended up on a ventilator in the ICU by 10 or 11 AM.

5/ POTUS has a lot of risk factors for a worse course of COVID: elderly, male, obese, and heart disease. It is NOT SAFE for him to be so far away (even if a Marine One helicopter ride) from Walter Reed Hospital. If this were my patient, I would counsel against returning home.

6/ Unless POTUS is declared cognitively impaired and unable to make decisions for himself, he has the right to leave the hospital AGAINST MEDICAL ADVICE. That is his right.

7/ Are there reasons to be concerned about his capacity for decision making? Acute illness, hypoxemia (lower oxygen saturation levels) and steroids can impair cognitive function.

8/ He also just got started on dexamethasone (high dose steroids). This could have made his fever go away. Patients also feel really good on steroids. Aches and pains go away. They feel energetic. They can develop insomnia, mania, agitation and grandiosity.

9/ In the absence of transparency (not to mention at least honesty), it's really hard to know whether POTUS is safe to return home. Here's what we need to know:
- What have his fevers been and on what medications (aspirin, Tylenol, ibuprofen, steroids)?

10/
- What have his oxygen saturation levels been? on room air or on supplemental oxygen? At rest or with activity?
- When was his last negative COVID test? When was his last positive COVID test? (to better understand how far he is in the course of illness)

11/
- What do his lab tests show? white blood cells, neutrophils, platelets, liver/kidney/cardiac function tests, blood clotting tests, D-dimer, erythrocyte sedimentation rate, C-reactive protein

12/
- What do his radiology imaging tests show? lung x-ray, lung CT, ultrasound (was that of the heart? an echocardiogram?)
- Why was he started on monoclonal antibodies first?
- What prompted initiation of remdesivir? and then dexamethasone?

13/
- His health aside, he should remain in isolation until day 10 of illness. He could isolate in the White House, but that puts him too far from an ICU for his safety.

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More from @celinegounder

Céline Gounder, MD, ScM, FIDSA

@celinegounder

7 Oct

@CDCgov

1/ Late last month, Dr. Bill Foege—@CDCgov Director '77-83, central figure in smallpox eradication, former Task Force for Global Health & Carter Center leader, Senior Fellow at the @gatesfoundation, and a devout Christian—sent this plea to @CDCDirector Bob Redfield.

@CDCgov

2/ We are witnessing a "colossal failure of the public health response in this country." The result of "incompetence and illogic." The @CDCgov is the preeminent public health institution in the world. They should have been leading the response from the beginning.

3/ Basic tenets of public health:
- "Know the Truth." This White House is about obfuscation & confabulation.
- "a coherent FEDERAL plan," not a patchwork response: podcasts.apple.com/us/podcast/epi…
- We need cooperation & coalition, not division. The virus is winning by divide & conquer.

Read 8 tweets

Céline Gounder, MD, ScM, FIDSA

@celinegounder

5 Oct

@Elemental

1/ Great speaking with @Elemental's @smithdag today.
elemental.medium.com/everything-we-…
Some highlights:
- “If the fever came down on its own, that’s a very good sign prognostically. If the fever required medication to come down […] it wouldn’t necessarily mean he’s getting better..."

2/ Steroids like dexamethasone and medications like aspirin, Tylenol, and ibuprofen will reduce a fever.

3/ On Fri/Sat, Trump had an oxygen saturation below 94%. Dr. Conley said it didn't got down to the low 80s. So that would imply it dropped to the upper 80s.

Read 12 tweets

Céline Gounder, MD, ScM, FIDSA

@celinegounder

4 Oct

@CNN

1/ It's concerning that President Trump got so sick so quickly. Here's my take for @CNN: cnn.com/2020/10/04/opi…

2/ Today we learned that POTUS had a fever & an oxygen saturation level below 94% on Friday morning, prompting his transfer to Walter Reed. Reading between the lines of what Dr. Conley did & did not say, it's possible that the POTUS' oxygen levels dropped into the upper 80s.

3/ He again had a drop in his oxygen saturation level to 93% Sat AM. It is unclear whether he again was given supplemental oxygen at that time. He is now on at least 3 medications for severe COVID, including Regeneron's monoclonal antibody cocktail, remdesivir & dexamethasone.

Read 62 tweets

Céline Gounder, MD, ScM, FIDSA

@celinegounder

4 Oct

1/ What did we learn about the President's health today?
- He had a fever and oxygen saturation level under 94% on Friday, which prompted his transfer to Walter Reed Hospital.
- His oxygen saturation dropped Saturday AM. He was started on dexamethasone.

2/
- The President's kidney & liver function have remained normal.
- His cardiac function is normal or improving? Was it ever abnormal? We know he's had an ultrasound. Was this an ultrasound of the heart (echocardiogram)?

3/
- He received Regeneron's monoclonal antibody cocktail on Thursday.
- He was started on remdesivir on Friday and dexamethasone on Saturday.

Read 12 tweets

Céline Gounder, MD, ScM, FIDSA

@celinegounder

3 Oct

@meganranney

1/ Why do doctors like me & @meganranney ask how high the POTUS' fever has been, if his O2 levels have been low, whether he's required supplemental oxygen? It's the difference between moderate & severe COVID. This tells us a lot about prognosis & what treatments are indicated.

2/ If the president required supplemental oxygen, he has SEVERE COVID and should hand power over to VP Pence until he is clinically improved.

3/ POTUS was given remdesivir. *Assuming* evidence-/guideline-based use of remdesivir, this would also indicate that the president has SEVERE COVID (i.e. oxygen saturation less than or equal to 94% on room air, requiring supplemental oxygen/ventilator/ECMO).

Read 8 tweets

Céline Gounder, MD, ScM, FIDSA

@celinegounder

3 Oct

1/ What was POTUS' lowest oxygen saturation in the past week? Why was he transferred to Walter Reed. WE STILL DON'T KNOW. Given there still hasn't been a transfer of power to VP Pence, President Trump owes the American people an explanation.

2/ It now appears that the president required supplemental oxygen prior to arrival at Walter Reed. (We're having to read between the lines based on Qs answered and not answered).

3/ POTUS was given remdesivir. *Assuming* evidence-/guideline-based use of remdesivir, this would indicate that the president has SEVERE COVID (i.e. oxygen saturation less than or equal to 94% on room air, requiring supplemental oxygen/ventilator/ECMO).