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Doctors skeptical of Trump’s health despite discharge from hospital

Allowing President Donald Trump to leave Walter Reed National Military Medical Center and return home to the White House while he remains in a potentially dangerous period of the illness is risky, some medical experts said Monday.

Others suggested that the move seems reasonable, given that the White House is very well equipped for medical care, with constant physician attention and resources available.

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“Right now there’s nothing that’s being done that we can’t safely do at home,” Dr. Sean Conley, the president’s physician, told reporters at a briefing.

Some medical experts disagreed with Conley’s assessment.

“There is a lot of concern about safety,” said Dr. Kavita Patel, a primary care physician in Washington who is managing director in the Center for Health Policy at the Brookings Institution, on MSNBC Monday.

Conley said: “While he may not be entirely out of the woods yet, the team and I agree that all our evaluations and, most importantly, his clinical status support the president’s safe return home, where he will be surrounded by world-class medical care 24/7.”

Trump is receiving several medications, including the antiviral remdesivir and the steroid dexamethasone. Both are given intravenously, which can be done at the White House. He also received a single infusion of an experimental antibody treatment Friday, the White House said.

Trump’s oxygen levels dropped twice, prompting doctors to give him supplemental oxygen.

Experts say the first seven to 10 days of the illness are key.

“We know that patients with severe Covid have symptoms hit this little honeymoon period where their symptoms look better,” said Dr. Ken Lyn-Kew, a pulmonologist in the critical care department at National Jewish Health, a hospital in Denver. “Coming out of that honeymoon period, they either continue to get better or they have a decompensation.”

Given the timeline of Trump’s illness and the medications he is on, “most of us would not anticipate him being discharged in that setting,” Lyn-Kew said.

“When we look at the president, you know, how he looks on the outside is only one indicator of how well he’s doing,” he said. “There is some element of disconnect between how you look and feel and what’s going on inside you with this disease.”

One phenomenon Lyn-Kew noted is referred to as “happy hypoxic, where the patient does not feel as sick as their vital signs indicate.” When patients are hypoxic, their oxygen levels are low. “So for the purposes of a short video or a picture, the president can look just fine but still be doing poorly, and we wouldn’t know it.”

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Other factors that are not obvious from the outside include levels of inflammation and blood clotting.

Dr. Hugh Cassiere, director of critical care services for Sandra Atlas Bass Heart Hospital at North Shore University Hospital, part of Northwell Health, on Long Island, New York, agreed.

“The real question that we do not know is

Prospect of Trump’s early hospital discharge mystifies doctors

The talk of the president’s release from Walter Reed National Military Medical Center came as Conley and two other physicians treating Trump gave an upbeat but incomplete characterization of his condition. Outside doctors said they were mystified by what they said was an inconsistent portrayal of the president’s illness as relatively mild despite the aggressive mix of treatments he is getting.

The president’s medical team was at times cryptic: Asked whether CT scans showed any signs of pneumonia or lung damage, Conley replied, “Yeah, so we’re tracking all of that. There’s some expected findings, but nothing of any major clinical concern.” He declined to elaborate. At another point, Sean Dooley, a pulmonary critical care doctor, said the president’s “cardiac, liver and kidney function demonstrates continued normal findings, or improving findings.” He did not disclose which of those had been subpar.

“My impression is they are telling us everything that is of good news and limiting everything that is not perfect,” said Rochelle Walensky, chief of infectious diseases at Massachusetts General Hospital.

Robert Wachter, chairman of the University of California at San Francisco’s department of medicine, said any patient of his with Trump’s symptoms and treatment who wanted to be discharged from the hospital three days after their admission would need to sign out against doctors’ orders because it would be so ill-advised.

“For someone sick enough to have required remdesivir and dexamethasone, I can’t think of a situation in which a patient would be okay to leave on day three, even with the White House’s medical capacity,” Wachter said.

“Absolutely not,” William Schaffner, a professor of infectious diseases at Vanderbilt University’s medical school, said of the idea of sending Trump back to the White House on Monday.

“I will bet dollars to doughnuts it’s the president and his political aides who are talking about discharge, not his doctors,” Schaffner added.

Medical consensus has emerged that covid-19 patients are especially vulnerable for a period of a week to 10 days after their first symptoms. Some patients who seem relatively healthy suddenly deteriorate, either because of the virus itself or an excessive immune response that can cause damage to several organs, including the heart.

A multitude of possible cardiac complications have also been associated with covid-19, the most prominent of which involves a hardening of the walls of the heart that makes it difficult to pump blood and can lead to heart failure.

“People can be doing okay, but it can get a rocky very quickly,” said Amesh Adalja, a senior scholar at the Johns Hopkins University Center for Health Security and an infectious-disease specialist at the University of Pittsburgh.

Underscoring the concerns is the fact that President Trump may be the first patient — he is certainly among the first — to receive an unusual combination of three strong treatments, with a handful of supplements and an over-the-counter drug sprinkled in.

“He’s gotten kitchen-sink therapy,” said Walensky, of Massachusetts General. She noted that when dexamethasone was tested in clinical trials earlier

Offering Flu Vax at ED Discharge Boosts Uptake Rates

A Wisconsin pediatric emergency department (ED) implemented a screening protocol that significantly increased flu vaccination rates in a traditionally undervaccinated population, a researcher reported.

Compared with the 2018-2019 flu season, the proportion of children vaccinated increased from 9% to 20% in the 2019-2020 season after Children’s Wisconsin implemented an electronic health record (EHR) infrastructure that allowed nurses to screen, counsel, and refer all children presenting to the ED for flu shots at discharge, reported Shannon Baumer-Mouradian, MD, of the Medical College of Wisconsin in Milwaukee.

Of children vaccinated, about 75% had Medicaid, and half were racial and ethnic minority patients, who have been reported to have lower vaccination rates, Baumer-Mouradian said at the American Academy of Pediatrics (AAP) virtual meeting.

“Many of our children are uninsured or underinsured, and they do use the [ED] as their medical home,” Baumer-Mouradian told MedPage Today. “The ED breaks down barriers families have, whether it’s a lack of transportation to their primary care office or working weird hours and not being able to make it to appointments.”

Just 50% of children are vaccinated for influenza each year. In Wisconsin, vaccination rates are even lower at about 40%, Baumer-Mouradian said.

Health officials are warning of a “twindemic” this fall as the flu season approaches, but many Americans are hesitant to get a flu shot. In general, pediatric immunizations have plunged during the pandemic.

The AAP recommends all children receive a flu shot this year to reduce the chances of simultaneous influenza and COVID-19 outbreaks.

“If there was ever a winter to get a flu vaccine, it is this winter,” said Kenneth Hempstead, MD, of Kaiser Permanente in Roseville, California, who was not involved in the research.

After the program in this study improved immunizations only slightly in the 2018-2019 influenza season, Baumer-Mouradian and colleagues refined the protocol to also identify families who were more vaccine hesitant. In those settings, both a provider and a nurse counseled families in the 2019-2020 season.

“Identifying vaccine hesitancy meant not only did the nurse talk to the family about vaccines, but a trusted second-level provider also came in to spend time with families and encourage vaccines,” Baumer-Mouradian said during the virtual presentation. “I think that second step was an influential piece.”

Many families also reported that the wait time to get the flu shot in the ED was one of the main reasons they elected not to get it, so Baumer-Mouradian and colleagues started storing the vaccines in the ED refrigerators, she said.

The change resulted in a significantly reduced time to discharge for patients, from 20 minutes in the 2018-2019 season to 16 minutes last season. Also, the proportion of patients leaving prior to vaccination decreased from 30% to 10% between seasons, Baumer-Mouradian reported.

“Families didn’t want to wait around for the vaccine having already been in the [ED] for multiple hours in some cases,” Baumer-Mouradian said.

In total, 2,839 children were vaccinated at the hospital, which was a 2.3-fold increase from last year, the authors reported.