It's concerning that the President got so sick, so quickly. On Sunday we learned that the President had a fever and an oxygen saturation level below 94% on Friday morning, prompting his transfer to Walter Reed. Reading between the lines of what Dr. Conley did and did not say, it's possible that the President's oxygen levels dropped into the upper 80s. He received a low dose of supplemental oxygen with improvement in his oxygen saturation levels. He again had a drop in his oxygen saturation level to 93% Saturday morning. It is unclear whether he again was given supplemental oxygen at that time. He is now on at least three medications for severe Covid-19, including Regeneron's monoclonal antibody cocktail, remdesivir and dexamethasone.
We still have not been told how high the President's fevers have been. Infectious disease doctors, like me, will typically plot a patient's "fever curve" in relation to other vital signs (e.g. blood pressure, heart rate, oxygen saturation levels) and relevant labs (e.g. white blood cell counts) to better understand the trend in a patient's illness and what's helping and what's not.
The President had been without a fever since Friday, but we do not know what brought down his temperature. The President takes a daily aspirin, which could reduce a fever. Patients with heart disease and no history of heart attack or stroke should be prescribed a baby aspirin (81 mg), not full-dose aspirin (325 mg). If he's getting full-dose aspirin, that would imply he's likely had a heart attack or stroke. Either way, the President had breakthrough fevers on aspirin.
We haven't been told whether he's been given ibuprofen, Tylenol (acetaminophen), or other fever-reducing medications; this is important because normalization of his temperature without ibuprofen, acetaminophen, or other such medications would be a good prognostic sign.
The President's tests
Dr. Conley reported the President's kidney and liver function have remained normal. Dr. Sean Dooley, a pulmonologist also caring for the President, said that the President's kidney, liver and cardiac functions were normal or improving. It is unclear whether the President may have had abnormal cardiac testing. Neither provided specifics.
We have been told that the President had lung X-rays, a lung CT and an ultrasound, but not what kind of ultrasound. You can perform an ultrasound on almost any body part, but in this context, it's most likely that he underwent an ultrasound of the lungs, heart, kidneys or large veins. In addition to infection of the lungs, the SARS-CoV-2 virus may infect the heart, causing a heart attack or heart failure. Patients with Covid may also develop kidney failure or clots in blood vessels. We have not been provided with the results of any ultrasound, X-ray, CT, or other radiology scan.
The timing
On Saturday, Conley reported that the President had been sick for 72 hours. He then released a statement correcting himself and claiming that the President was on his third day of illness. The incubation period - the time from exposure and infection with the SARS-CoV-2 virus to symptom onset - may be as long as 14 days but is on average about four to five days. This would imply the President was most likely infected on September 25 or 26, which coincided with indoor and outdoor events to announce the President's nomination of Judge Amy Coney Barrett to the Supreme Court. As has been covered elsewhere, these events appear to have been super spreaders, with many in attendance since testing positive for Covid.
What treatment has the President received?
The Regeneron monoclonal antibody cocktail is so new that we have yet to fully characterize the side effects associated with it. The side effects of other monoclonal antibodies may include fevers, chills, weakness, headache, nausea, vomiting, diarrhea, low blood pressure, rash, life-threatening anaphylaxis, cytokine release syndrome (which may also be caused by Covid itself), toxicity to the heart, abnormal blood clotting, infections, autoimmune reactions and more. Furthermore, the Regeneron monoclonal antibody cocktail has not been tested in patients as old as the President. We do not know if the Regeneron monoclonal antibody cocktail has previously been given in combination with other drugs like remdesivir. In summary, we do not know if the Regeneron monoclonal antibody cocktail is safe or effective.
We have not been told whether the President is being treated with a blood thinner, which prevents blood clots, and if so, at what dose. Treatment with a blood thinner (e.g. low molecular weight heparin) is considered standard of care in hospitalized patients with Covid.
What's the President's prognosis?
Doctors think in terms of good and bad prognostic indicators. In the President's favor are his expedited access to testing and treatment. Early diagnosis and treatment of Covid likely predict a better outcome.
Many questions remain: When did the President first test positive for Covid? When did he develop symptoms? Who did he expose? Was the President given the Regeneron monoclonal antibody cocktail in hopes that the he wouldn't become symptomatic? That the diagnosis could be concealed? And how sick is he, really?
