hey guys welcome back to another medical update when it comes to president trump's diagnosis of
covid 19. as a pulmonary and critical care doctor i'm watching dr sean conley who is president
trump's physician give a press conference along with the rest of his medical team which includes
three pulmonary critical care doctors two infectious disease doctors an anesthesiologist
as well as a clinical pharmacist nurses it's obvious that dr conley is choosing
to withhold certain medical details so in this video i'm going to take what he's saying with
the information that's being given to us and do my best to read between the lines so that people
can have a real understanding of what is going on here with president trump and i'm going to try to
classify the severity of this covid 19 illness because it's not an easy thing to do at the end
of this video i'm going to talk about what this means for president trump's health moving forward
so let's go ahead and take a look at to what was being said during the press conference
so he starts out by saying that president trump continues to improve as with any course of illness
there are frequent ups and downs especially when being monitored closely this is very true
now i work in the intensive care unit a lot and there's going to be fluctuations of everything
pulse oximetry blood pressure heart rate these things fluctuate so it is true now i'm not saying
president trump is in the icu he's not he's far from it but the point being is with more frequent
monitoring there are going to be fluctuations he then goes on to say that president trump has these
transient dips in his oxygenation and therefore they started dexamethasone and i'm going to come
back to that in a bit he says that thursday night when he was first diagnosed the oxygen saturation
was in the high 90s then late friday morning the oxygen transiently dipped below 94 percent
and that's when he recommended supplemental oxygen he says trump didn't want it but he did
end up giving two liters of supplemental oxygen so very minimal and that was on for about an hour
and then his oxygen saturations did climb and he no longer needed the oxygen supplementation dr
conley convened with the rest of the medical team that day and decided they should bring president
trump into walter reed medical center and that's how they came to that conclusion then dr
dooley steps to the microphone and says that he continues to improve he doesn't have any fever
his vital signs are stable he's not requiring supplemental oxygen he's ambulating meaning he's
walking around he also says that his cardiac liver and kidney function are normal or improving that's
interesting to me because yesterday they said his liver and kidney is normal so why did he add
or improving today you know one possibility coming out of that would be perhaps president trump has
elevated troponin levels elevated troponin levels are relatively frequent in hospitalized patients
no matter what reason they are in the hospital for so with elevated troponin levels depending on how
high they are that could be reflective of someone having a heart attack a myocardial infarction
but we don't know how high this troponin levels were if they were elevated this is all speculation
and if you did have a heart attack they would know based on not only the troponin level but
in conjunction with an ekg echocardiogram so that's not what's going on here it's possible
he has a very slight elevated component level that's now downward trending but again we
don't know for sure if they gave us the testing results there wouldn't have to be the speculation
so then dr garibaldi who's also a pulmonary critical care doctor steps to the microphone
and tells us that he's completed his second dose of rem deserve yesterday
and is not having any side effects related to that so the concern with
rem deserver is it can impair liver and or kidney function and so far he's not had any side effects
from that rem vis-a-vis when it comes to liver kidneys he also says that they're planning on
discharging president trump as early as tomorrow so then reporters start asking questions
and the answers that we get from dr conley says that yesterday he had another episode of oxygen
desaturation where it went down to 93 percent they watched it and then the oxygen saturation
went higher after that he's unsure if they gave more supplemental oxygen yesterday
and he says if they did it was very minimal he specifically asked if the x-ray in the cat scan
shows anything any signs of pneumonia or long involvement and then he says there are some
expected findings but nothing of clinical concern so if his chest x-ray was normal if his cat's skin
was normal if his lung ultrasound was normal you would say it's normal or it's unremarkable
the fact that he says it's expected findings well the way that i interpret that is someone has
covid 19 especially with pulmonary or respiratory symptoms like cough shortness of breath or with
lower oxygen levels that to me means there's going to be an infiltrate on the lung imaging study so
there's going to be evidence of viral pneumonia this ground glass opacity that we would see
and that would be the expected finding so when he says there are expected findings that tells me
that's what's on that cat scan that's what's on that chest x-ray that's what's on that
lung ultrasound so he has covid-19 pneumonia there's viral pneumonia
based on my interpretation of what's being told to us now i want to talk about covid 19 disease
severity as of right now there are no strict definitions of classification of disease severity
what constitutes mild versus moderate versus severe illness versus critical illness
is very much a gray area now generally speaking someone who has symptoms but is
not short of breath and does not have low oxygen levels this would be considered mild covid 19.
moderate illness is characterized by shortness of breath and or low oxygen levels with evidence
of viral pneumonia seen on a chest x-ray or cat scan of the lungs or even ultrasound of the lungs
severe illness is characterized by someone who's having trouble breathing and consistently requires
extra oxygen and or ventilatory support then there's critical illness which is when patients
have either ards and or hypotension to the point where they're requiring very high levels of oxygen
and or ventilatory support so this can include things like high flow nasal cannula or mechanical
ventilation either non-invasive mechanical ventilation or invasive mechanical ventilation
non-invasive ventilation means things like bi-level or bipap that's where we give a mask
and we strap it to the head and it's right on that face there and there's no leakage or there
should be no leakage and with that you're blowing two different pressures so one for inhalation
one for exhalation so when someone takes a breath in there's a higher pressure
and then when they breathe out there's a lower pressure that's called bi-level ventilation that's
non-invasive ventilation invasive ventilation is when someone has a breathing tube in so it
goes down the throat and that's hooked up to a breathing machine a ventilator so these are
things that would be categorized as critically ill covid 19 illness but again defining the severity
of illness is hard to do because there's no strict definitions and this also makes it tricky in terms
of what medication to give for example these studies show dexamethasone which is a type of
steroid specifically a type of glucocorticoid this reduces mortality in moderate and severe disease
but not in mild disease but again what defines mild versus moderate versus severe it's still
very much a gray area so for doctors to try and convey medical updates to patients and families
and in this case to the public it's hard to give crystal clear answers the rationale behind giving
dexamethasone is that it can suppress inflammation within the body so the hope is that it'll suppress
the inflammation that takes place within the lungs for covid 19 we give dexamethasone in either iv
or pill form it's six milligrams once a day and we give it for a total duration of 10 days one of
the side effects that always occurs with steroids is that patients blood sugar levels become higher
so hyperglycemia and that is why we sometimes have to counteract that by giving someone insulin
now the concern when you give someone insulin is that you can drop the blood sugar too low to the
point of causing hypoglycemia and that and that in itself causes a whole other set of problems so
we have to counteract the hypoglycemia by giving someone sugar and it's this kind of game of back
and forth typically when we give dexamethasone we do check blood sugar levels by doing finger sticks
and that's usually done every four or six hours when someone's in the hospital getting steroids
now in this press conference they mentioned nothing about this but if his blood sugars
were out of whack they would not be talking about doing discharge planning so my presumption is that
his blood sugars are doing okay if the doctors wanted to be credible they would provide results
of diagnostic tests that's the best way that they can be transparent bottom line this would include
giving results of his lung imaging whether that's chest x-ray cat scan long ultrasound
this would include giving results of his blood work such as his cbc his complete blood count
what did his white blood cell count show there's different types of white blood cells
and we know that with lymphocytes which is a type of white blood cell
those are lower and more severe disease of cover 19. other diagnostic testing i want to know the
results of are his d-dimer levels typically when d-dimer levels are high with covid 19 there's a
much higher chance of someone having a blood clot also how high are his ferodine levels the more
higher the level ferritin the more inflammation there is within the body the other thing is
albumin levels the lower the albumin levels are the poorer the prognosis tends to be and
like i mentioned the same thing when it comes to lymphocyte count did you have an ultrasound of the
legs looking for a clot in the legs did he have a ct angio a cat scan of the lungs with an angiogram
looking for blood clots in the lungs did he have that done did he have an echocardiogram was his
echocardiogram normal that's an ultrasound of the heart presumably it is normal but stepping back
and looking at this from a bird's eye view where does trump lie on the spectrum of covid 19 illness
right now his oxygen saturation is 98 he's not requiring supplemental oxygen
what would progression of his illness look like if he were to have clinical deterioration
well typically this entails stepping up his oxygen therapy so he could be put on two liters nasal
cannula maybe three four or five if that's still not enough oxygen maybe an oxygen face mask or
something called high flow nasal cannula these devices provide a lot more oxygen than a nasal
cannula if these are still not enough that's when you start talking about mechanical ventilation
either non-invasive mechanical ventilation meaning like a bipap mask or with invasive mechanical
ventilation with a breathing tube and being on a ventilator your breathing machine and lots of
times patients who require a breathing tube and a ventilator these are the patients who also often
require blood pressure support with vasopressors so things like levofed which is norepinephrine
or vasopressin these are medications we gave iv to stimulate the blood pressure
which can happen in someone who's in shock or has ards so that would be the sickest of the sick it's
the ones who are mechanically ventilated requiring 100 oxygen and sometimes even that is not enough
and that's why some patients end up getting ecmo ecmo or extra corporeal membranous oxygenation
that's essentially where we take blood out of the body we pump it out of the body pump it back in
and when we do that we are putting oxygen into that blood and extracting carbon dioxide from
that blood but that is a very risky procedure and that's only done in the most extreme circumstances
and sometimes despite us doing all these things patients still end up dying that
is just the reality of this disease so with the bird's eye view president trump is nowhere near
that end of the spectrum he's much closer to the opposite end of the spectrum he's not requiring
supplemental oxygen in other words he's breathing in the same air that i'm breathing in which is 21
oxygen that's room air my action saturation right now is 100 his is 98 and we're both breathing the
same amount of oxygen so his respiratory status is very stable right now but the
important thing to keep in mind is that patients with covid 19 can look like they're doing fine
they can have improvement in their symptoms they can have improvement with their oxygenation
and within hours clinically deteriorate to the point of requiring mechanical ventilation
especially when the inflammatory phase of the illness becomes very prominent meaning
the cytokine storm that can develop typically that's done or that happens around day 7 to day 10
of the illness so obviously they're going to keep a close eye on him still throughout these
upcoming days and probably upcoming weeks as well and we'll have to see what happens
so i'm gonna end this video on that note thanks for watching and i'm gonna continue to watch
this closely and make another video on it so if you haven't already make sure you subscribe and