hi guys for those of you who don't know me my name is mike hansen i am a physician
who is board certified in internal medicine pulmonary disease and critical care medicine
now as a critical care doctor and as a long doctor i want to give my take on president donald
trump's covid 19 diagnosis and prognosis and how i think his doctors at walter reed medical center
will medically manage him we know that he tested positive in the early morning hours on friday so
that's today so basically last night going into today today is now october 2nd he was said to
have fatigue fever a hoarse voice and then later on in the day it came out that he's developed
cough and now just recently in the evening it's come out that he's had some shortness of breath
and i'm going to get back to that in a moment because the shortness of breath is the biggest
red flag in all of that so while at that white house initially the plan was he was going to be
staying at the white house in isolation and be medically managed there but then something came up
whether there was a shortness of breath or something else something prompted his medical
doctor at the white house to say you know what let's not stay here let's go to the hospital
while at the white house he did get zinc he got vitamin d he got melatonin he got pepcid
aka formodini excuse me famotidine and he also got this new polyclonal antibody treatment which
is a totally new therapy that we don't even know if it works or not um as there are no randomized
control trials that are even published about this it's an experimental therapy and i keep hearing
in the media promising but there's no such thing as promising until you actually have randomized
controlled trials that show that promise or at least some kind of evidence that shows that and
there's we don't have anything published that suggests that it's promising so i don't know
why some people are saying that in the media but in terms of what he did get he got the vitamin d
so with vitamin d there have been any randomized controlled trials for covid for vitamin d we know
that people with severe vitamin d deficiency do tend to have worse outcomes with covid but again
we don't know donald trump's vitamin d status anyway so who knows there's also some evidence
to suggest that melatonin might help but again no randomized control trial is showing this same
thing goes for famotadine or pepcid in the iv form there's some evidence to suggest that it
might help but again no randomized control trials in terms of this new polyclonal antibody that
it got it's really this is from regeneron the company regeneron so it's actually two
monoclonal antibodies that come together to bind to the coronavirus antigen and so in theory it's
going to block viruses or the coronavirus from entering the cells of the body but theories theory
and that hasn't been proven yet so that's what he got at the white house then later on we see him
walking to the helicopter which is significant in that time you know looking at that video he wasn't
in respiratory distress i can tell because looking at how fast he's breathing how deep he's breathing
is he using accessory muscles of breathing so 90 of our breathing is done by the diaphragm
the rest of the 10 is done by what we call the accessory muscles of breathing so that includes
sternocleidomastoids external intercostals and such so based on the fact that he's walking
without becoming short of breath or at least more short of breath and from what we could tell
he's not requiring he's not hypoxic to the point where he's requiring supplemental oxygen he's not
requiring supplemental oxygen so that of course is reassuring that at least tells me that this is
nothing more than moderate disease it's probably mild maybe moderate covet illness but nothing more
than that at least at this point the concern is that this can progress and it can progress very
quickly it can progress slowly and gradually or it can progress slowly and gradually and then
all of a sudden be a cliff where there's clinical deterioration now according to the press secretary
he'll be hospitalized for several days but that's of course assuming his disease does not progress
the decision to hospitalize someone with covid in general if you're not a president of the united
states of america is based on the breathing are they short of breath do they have hypoxia
meaning do they have lower oxygen levels so once it came out that he was short of breath then it
makes sense as to why he was hospitalized why they made that decision so initially
they said we're not going to hospitalize and then they change their mind later in the day
today so what is the advantage of being at the hospital so there's lots of advantages
there's actually some disadvantages too like you're at higher risk of getting hospital acquired
infections your higher risk of getting blood clots in the body this is before covid even so
let's talk about the advantages obviously there's more advantages and disadvantages when it comes to
being in the hospital for an illness so one of those things is you have more access to
everything including different types of doctors so he'll have access to a internal medicine doctor a
pulmonary critical care doctor a cardiologist an infectious disease doctor a kidney doctor if he
needs that there's also other advantages in terms of frequency of monitoring so he could have all
his vital signs measured more frequently and just has overall closer monitoring of him you have more
access to different treatments more access to you know whatever whether it's breathing treatments
whether that requires supplemental oxygen or a high flow nasal cannula or bipap mask or cpap
mask or even intubation all these things you have access to and they can be can be done quickly so
it seems that this is partly at least done out of an abundance of caution but also there is concern
when someone like him has shortness of breath so when i say someone like him i mean he's 74 years
old so he's older he's a male he's obese based on his bmi calculation of his heart and his weight
he may or may not have hypertension we know that in the past uh he's said to have cardiovascular
disease but they didn't say they just said it was a common form of cardiovascular disease not
a specific medical condition so whether that's chf or just atherosclerosis or coronary artery disease
we don't know but overall the numbers say that he's likely to come out of this okay most people
who get coronavirus don't require hospitalization but he did at least he is now there's severely
ill covid but then there's also critically ill covid where they require intensive care
unit and lots of times these are the groups of patients that require a mechanical ventilator
with a breathing tube or maybe they're in shock where they require pressure medications such as
levofed aka nor epinephrine that's something we give an icu to stimulate the blood pressure to go
higher when it's too low when people are in shock and then there's also the ards acute respiratory
distress syndrome right now i can tell you he's not an ards because his oxygen levels are too
good for that so he doesn't even meet criteria for that so when we're in when we see covid 19
patients in the icu there's a whole host of things that we're doing but he's not at that level right
now but if he were to quickly deteriorate with his clinical status he's right there in the hospital
where they can do things quickly and do icu level of care essentially right away if he were to have
clinical deterioration so getting back to his symptoms uh he's had fatigue someone said lethargy
he's had fever he's had cough he's supposedly shorter breath although he didn't look short of
breath while walking to the helicopter and walking out but again it's very subjective but he didn't
have any signs of respiratory distress he wasn't breathing fast he wasn't taking deep breaths no
accessory muscle use with his breathing um he does look very tired in his brief video from
the white house but you can't glean too much from that so with the feeling tired with the call for
the shortness of breath really it's the shortness of breath that is the most concerning and probably
what has prompted them to change his status from being in the white house to
hospitalization so besides symptoms what else i would want to know as a physician is i want to
know his vital signs what's his respiratory rate what's his heart rate his blood pressure what's
his oxygen saturation with the pulse oximeter i would want to do a physical exam of course what
do his lung sound like do they sound like there's fluid in those lungs or inflammation in the lungs
so listening for coarse breast sounds ronchi rows these are all different medical terms i would do
at the very least a chest x-ray but probably and i suspect they're going to be doing this because he
had shortness of breath i suspect they're going to do a ct skin of lungs a cat skin to lungs
but again it depends on his symptoms vital signs and physical exam i would do blood work that
includes things like cbc with differential i would do a cmp meaning a comprehensive metabolic panel
and this includes checking albumin levels i would also check blood clotting labs such as pt inr ptt
i'd also check a d dimer also other tests as well like a ck creatine kinase a crp ferritin and uh
troponin as well most likely along with an ekg so what are all these things that i just mentioned we
know that when we do a cbc a complete blood count with a differential we're looking for
something called the white blood cells and specifically within the white blood cells
a type of white blood cell called lymphocytes when the lymphocytes are low in covid 19
these are the patients that tend to have a worse prognosis and the same can be said for
patients with low albumin levels so that's what we're looking for or one of the things
we're looking for in the cmp the comprehensive metabolic panel we're also checking the dimer
levels so when these are very elevated to covid 19 patients they're more likely to have blood clots
uh i mentioned ekg i'd probably also do an echocardiogram again depending on the symptoms
uh that he's having this is you know based on what i know covid can have some cases where there's
what we call myocarditis inflammation of the heart muscle he's not describing typical symptoms of
myocarditis but then again these symptoms would be nonspecific so shortness of breath chest
pain maybe but because he's the president they're probably going to do extra testing than they would
for most people so that's why i would expect them to do a echocardiogram i'd also expect them to do
an ultrasound of the legs to look for blood clots in the legs
i would also expect them to do when they do the cat scan of the chest not just a regular cat scan
but a cat scan a ct angiogram so this is where we inject a dye a contrast dye into the vein
and then that gets into the blood vessels of the lungs and we can see if there's a blockage
in those blood vessels presumably that blockage is because of clot in the lungs that's what we're
looking for in the cat scan so when someone has covid 19 and they're short of breath to
the point where they're requiring hospitalization that is a big concern and i wouldn't be surprised
if president trump ends up getting a cta while in the hospital but we're still waiting on the
medical doctors to give us a report on what's going on right now this is all speculation so what
about treatment most patients with mild disease are not hospitalized but the president is not most
patients and that is why he's hospitalized despite only having mild illness maybe moderate illness
based on the information that i can glean so far so let's just say he has moderate illness
so in that case moderate illness to the point of being in the hospital then at this point he would
meet the criteria for warranting getting dexamethasone so dexamethasone is a
glucocorticoid which is a type of steroid and for covid 19 patients we give six milligrams
daily that can be either in the pill form or the iv form i would be shocked if he's
not getting decadron aka dexamethasone as we speak probably already did dexamethasone has been shown
to have improved mortality in hospitalized patients with moderate or severe disease
then there's rem desevere which might be somewhat helpful in hospitalized patients but both of these
drugs rem deserver and dexamethasone they might improve clinical outcomes but they're certainly by
no means a cure and then when it comes to convalus and plasma well he already had received antibodies
so giving him additional antibodies is unlikely to have any benefit even if he didn't receive those
antibodies convalescent plasma hasn't been proven to be beneficial in any randomized controlled
trials and i did actually make an entire video about convolution plasma for covid if you want
to learn more about that then there's the whole issue of anticoagulation meaning giving him a
blood thinner so blood thinners they're always given to hospitalized patients even before covid
unless there's a contraindication like if they have bleeding or or they're a very high risk of
having bleeding but covid does raise the risk of people developing blood clots especially those who
have cardiovascular risk factors like obesity like hypertension like high cholesterol this is because
covid the coronavirus latches on to those h2 receptors not just in the alveoli of the lungs but
also the ac2 receptors that line our capillaries the tiniest the tiniest blood vessels in our body
so the potential for blood clots is a big concern the other big concern is how extensive is his
covid pneumonia meaning how much inflammation is there in the lungs my guess is he's getting a cat
scan of lungs like i mentioned earlier probably a cta and on that we'll they'll be able to see how
much inflammation is actually within the lungs my guess is it probably can't be too bad at
this point because he's not requiring supplemental oxygen but there are known cases where people have
lots of inflammation in the lungs and initially their oxygen levels are just fine and it's not
to later on where the oxygen levels start to dip another potential treatment which is typically
reserved for critically ill patients which trump is not so critically ill patients sometimes get
tosalesimap this is an il-6 monoclonal antibody il-6 is a central player in the cytokine storm
that develops in covid patients who have severe disease when patients have very elevated
inflammatory markers like d-dimer like ferritin and elevated levels of il-6 these are associated
with critical and fatal covid 19 so i imagine these levels are going to be checked in president
trump and blocking the inflammatory pathway has been hypothesized to prevent disease progression
now several drugs that target this il-6 pathway have been evaluated in some randomized trials
for covid these include what i just mentioned the tosylizimab but also ceralymiumab and then there's
a more direct il-6 inhibitor called sultuximab so the results from these studies so far have had
shoddy results in one study of over 500 patients with severe covid treatment with tosylisimab
was associated with a decreased risk of invasive mechanical ventilation or death some observational
studies have not identified an associated clinical benefit though with tosylisimab
and use of the il6 pathway inhibitors may be associated with an increased risk of secondary
infections as it makes their immune system more vulnerable to other types of infections
now i've given all of these treatments to covid icu patients i've given convolution plasma rem
desevere i've given dexamethasone aka decadron and all these things including tosalyzin map as well
and all these things none of them gave a quick turnaround in the patient's recovery so do they
work or not based on my anecdotal experience it's hard to know because we're giving all these things
at once and the only way to really know for sure is by doing randomized controlled trials in terms
of randomized controlled trials there's still nothing that really shows much in the improvement
of covid 19 other than dexamethasone and possibly rem deserve but remember doesn't improve mortality
so the big question right now is his respiratory status so if he's feeling short of breath what i
want to know is how feel how short of breath does he feel and then also what is his pulse
oximetry is it in the is it 95 is it 94 is it 90 is it 85 this would tell me a lot presumably
he's a otherwise healthy guy than what i mentioned before and so his baseline pulse oximetry is
probably 100 or 99 some people have lower baseline levels of oxygen because they have certain medical
conditions such as copd emphysema pulmonary fibrosis pulmonary hypertension these are
different medical conditions that cause people to have chronically lower levels of oxygen levels so
lots of times these patients require supplemental oxygen because their baseline oxygen is around 88
or so but right now i would say president trump's respiratory status seeing him walking not
requiring supplemental oxygen not in respiratory distress i would describe his respiratory status
as stable but i am very concerned as to what happens next anything could happen in the next
hours it could happen the next days sometimes even weeks i've had patients in the icu where
they require supplemental oxygen for a long time and then they eventually slowly get better like
weeks to months later or i've had to go the other way where they slowly get worse or they all of a
sudden quickly clinically deteriorate it could go any number of ways and we just don't know
but the fact that over the last 24 hours he's progressing in the wrong direction
that is extremely concerning especially given his age that he's a male that he has a history
of high blood pressure high cholesterol and with him being obese so i am going to follow
this situation very closely and i will keep you posted so stay tuned and thanks for watching