Joe Summer
Footballguy
Ah, okay, that makes sense. Does Trump fit the CDC's guidelines for an "immunocompromised" person? If so, wouldn't that mean that he needs to have 2 negative tests, 24 hours apart?
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Trump/White House Covid positive thread (2 Viewers)
- Thread starter gianmarco
- Start date
gianmarco
Footballguy
Yeah, testing positive or negative now is a moot point. It has no bearing on his quarantine period. If anything, it's those earlier tests that do (first positive or last negative).
jm192
Footballguy
I think that's a political death sentence, but he's probably already on life-support.
You can't argue you're immune compromised while Pelosi is trying to invoke the 25th.
jm192
Footballguy
If we're being technical, it's 10 days or until discharge, whichever is shorter. That being said, despite all the press of "Dexamethasone being a powerful steroid," I think 10 days of Decadron is a pretty benign treatment. And I can see his physicians deciding to do the full 10 days "out of an abundance of caution."
But if they give him the full 10 day course, I wouldn't consider his disease any more severe because of it.
Anarchy99
Footballguy
What level of believability and accuracy do we expect from DJT's dog and pony show on Tucker Carlson tonight? He will be evaluated and assessed by Dr. Marc Siegel (a medical contributor to Fox and internal medicine specialist from NYU). He will provide his professional medical opinion on Trump's progress and overall health. What are the chances they find anything wrong with him? What is the likelihood they say he is in better shape than an Olympic track star?
gianmarco
Footballguy
Right. They are very likely overtreating him. Over the last couple days, it does seem like he's trending the right way, but we also know decadron is going to mask some symptoms so who knows, especially once he's tapered off.
But of course, he's planning a rally tomorrow in Florida. There's no timeline anyone can come up with where that fits any guidelines.
The Commish
Footballguy
growlers
Footballguy
I am going to try to clear up some misconceptions in the last few pages. I'm a doc who has taken care of hundreds of covid patients.
CDC guidelines for "immunocompromised" is more referring to people with AIDS, transplant recipients on anti-rejection drugs, etc. Not just for getting steroids.
A "regular" person in Trumps situation doesn't need to be retested at all after treatment for a proven test positive covid infection. Some people will shed noninfectious partial covid RNA for weeks that will return a positive test even after being treated so whether a patient can come out of quarantine is not dependent on testing negative, although that was used as a criteria in some early guidelines, it is not currently recommended. Some employers are still insisting on this, it doesn't follow the science.
Dexamethasone is not always given for 10 days - it is commonly given in a time frame of 5, 7, or 10 days. Clinical judgement, case by case basis.
I'm not 100% sure if there is a CDC specific stance on this, but my impression is that dexamethasone is not explicitly included as a "fever reducing medicine". If someone can produce official CDC guidelines that refute this, I wouldn't be shocked or anything, but my understanding is they are talking about ibuprofen and acetaminophen. He takes 81 mg aspirin routinely for CV prevention, this wouldn't "count" either IMO
My conclusion based on publicly released information is that he could leave quarantine 10 days after first symptoms appeared without any repeat testing. Now, with that said, I think it's insane for him to be doing a rally on day 11, but I'm just giving my strict interpretation of the guidelines. I would be allowed to go back to work on day 11 but of course I would be following strict PPE usage, etc and not spewing spit all across a stage and refusing to wear a mask like an idiot. I haven't knowingly had covid yet, but I would personally wait 14 days just as a margin of error - the guidelines are likely not to take into account some percentage of outliers that probably exist and I think i would be cautious to not infect other people in my line of work
jm192
Footballguy
Yeah, I think counting Decadron as a fever reducer is a bit of a stretch. But I also think even if you're taking it the full 10 days, you're usually outside the quarantine window by the time you've completed your 10 days.
Joe Summer
Footballguy
A question for the doctors or others who may know: is there a correlation between fever and infectiousness?
The CDC guidelines indicate that you can stop quarantining when your fever disappears. But if your fever goes away before 10-14 days, wouldn't you still be infectious?
The CDC guidelines indicate that you can stop quarantining when your fever disappears. But if your fever goes away before 10-14 days, wouldn't you still be infectious?
jm192
Footballguy
The studies show that most people with mild disease aren't infectous/contagious after ~10 days. You'll test positive, but won't have active virus to spread.
It's a multi-part thing. 10 days have to have passed, and fever subsided, etc.
lakerstan
Footballguy
A little humor from the world famous Spitting Image:
https://www.youtube.com/watch?v=D7S7sPIu0rc
may be NSFW based on your tolerance...
https://www.youtube.com/watch?v=D7S7sPIu0rc
may be NSFW based on your tolerance...
growlers
Footballguy
Complicated question that there are no 100% definitive answers for, just guidelines based on covid viral shedding studies and general virology experience with other disease.
There are some people that are asymptomatic that are infectious. I think the idea is that there is no way to look at an individual patient in front of you and determine if they are infectious. So based on prior studies, the infectious period was thought to be 14 days, then lowered to 10 a couple months ago based on new data. The fever caveat is that it is thought that people with fevers might be more infectious based on prior viral illness experience, so the need to be fever free for 72 hours was added to the 10 day guideline to pick up outliers.
growlers
Footballguy
Again, strictly speaking on the science, he doesn't need to be retested. If it's still positive it doesn't change the guidelines for isolation. Now politically, since 99% of the media and the public doesn't know this, it makes sense for him to have a negative test before he goes in public to prevent a backlash.
moleculo
Footballguy
gianmarco
Footballguy
I'd have to go back and check for sure, but I'm 99% sure that the 3 main classes/drugs considered antipyretics are acetaminophen, NSAIDs, and corticosteroids. In fact, I'm pretty sure steroids lower fever through more mechanisms of action and different pathways than Tylenol/NSAIDs. So, while it's not used primarily for that function like the other two, I would say it certainly counts as a fever reducer.
In the full context here, I agree it really doesn't matter but for the masking of symptoms to determine when he can leave quarantine. That 10 day recommendation is for mild illness and, at this point, I don't see how he can be considered mild.
I rather know how many days he's gotten decadron at this point over whether or not they do another Covid test on him. The latter is pointless. But if he's gotten 10 days of decadron (i.e. still on it), then we can't really say he's 10 days out from his symptoms AND 1 day fever-free without a fever reducer. He needs to be off it for at least a day to make that statement.
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I'm more worried for the "crowd". Who wants to show up to an event hosted by someone potentially contagious who was just at the epicenter of a super-spreader? Potentially patient zero of the super-spreader. He's normally off the wall anyway, but his thought processes sure don't seem to working even by his standard.
massraider
Footballguy
They're gonna put him up on the balcony again. Oof.
He had barely finished wheezing up the steps last time, and #Covita was trending. This cannot be good.
He had barely finished wheezing up the steps last time, and #Covita was trending. This cannot be good.
growlers
Footballguy
https://www.cdc.gov/coronavirus/2019-ncov/hcp/duration-isolation.html
I did a search of CDC for healthcare providers and some recent NEJM articles.
I mildly disagree on the fever reducer drug interpretation - I still take that to mean NSAIDS and acetaminophen. But I can't find any explicit instruction on this regarding steroids. Steroids are never used primarily as a "fever reducer", i would classify it more as a possible effect, so I am basing my opinion on interpretation of the CDC's language being used and assuming that language is purposeful. If they wanted to include steroids, I would think it would be clearly stated. I've definitely seen guidelines sent to me from the hospital, etc explicitly stating just NSAIDS and acetaminophen, but that may be simply that whatever doc is writing the memo is reading it the same way I am.
I strongly disagree about the severity of illness - CDC link above and everything I've seen in the last two months state mild or moderate illness is 10 days. Trump cant be categorized as severe -he would be moderate at most.
Yo Mama
Footballguy
Not only that, but it’s supposed to be about “law and order”. Going to have some serious Mussolini vibes.
gianmarco
Footballguy
Unless I'm missing something, everything I've seen and read states that hypoxia (sats < 94%) automatically defines disease severity as severe and requires hospitalization. I'm not seeing it on the CDC site as it doesn't look like they have specific criteria to define severity, but it is on UpToDate (can't link that here) and it's what I've seen from our guidelines. The fact he was at least in the mid 80s reading between the lines from the physician report who admitted he was in the high 80s (since 94% is a pretty soft cutoff), he was definitely hypoxemic. Thus, he should be categorized as severe.
As for steroids and fever reduction, here is a quick link. It talks about the pathway, but it specifically states:
Defervescence of fever by corticosteroids can mistakenly be interpreted as resolution of an infectious process
Again, I know it's not used as an antipyretic, but it certainly functions as one when given and I think absolutely should be considered as a fever reducer when given for Covid or anything else.
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jm192
Footballguy
We can argue about whether or not steroids are considered anti-pyretics. Again, I'll concede that it's considered a class of one.
But as a physician, it's not primarily used as an anti-pyretic. And I don't typically give consideration to "their fever will return once the steroids are stopped."
Also, it doesn't fit the course of the disease. If your breathing is improving, typically the fevers are coming down or gone.
I think the press has gone wild with talking about Decadron as this POWERFUL steroid that's going to make Trump crazy. It's pretty benign compared to a lot of things used in medicine.
jm192
Footballguy
But no one says "your fever is gone so your COVID is better."
The breathing improving is the bigger hallmark. If your disease course is such that you're breathing is improving, it stands to reason the entire disease is improving. I don't find people coming off of the ventilator suddenly spiking fevers when the Decadron comes off.
I've had patients in the Hospital 20+ days now and I've YET to see a fever when the Decadron falls off.
IF someone were to spike a fever after the Decadron stops, I would think they have a superimposed bacterial pneumonia.
gianmarco
Footballguy
I completely agree. And that's most likely the case. But we haven't really seen him since Covita. And he was still struggling with his respiratory effort at that point.
I'm sure the early intervention helped him out and he's probably fine. And he's likely ok at the 10 day point, especially since I'm pretty sure he's been sicker/had symptoms longer than they are telling us.
But given how he's going to be an exception due to getting these other treatments plus the early timing of his treatment plus with decadron potentially masking some symptoms, I would not be at all surprised if he worsens once they stop it. This is not your run of the mill Covid patient. And when discussing the guidelines and following them, he's going to be picked apart if he doesn't.
The frustrating part of all this is we are arguing about this stuff because we:
1) Don't truly know disease severity -- It should be classified as severe if hypoxemic, but they've never actually stated how that transpired and how long he was treated with oxygen, etc
2) How long he's been symptomatic or when he tested positive or when he tested negative
3) What he's been treated with and how long
Those are pretty basic things that I would think we are entitled to know about the POTUS. Instead we are left guessing how truly sick or not sick he is. And based on the amount of evasiveness we've seen, I think there are things that are worse than are being let on.
Anyway, we've gone over this enough and no point in going back and forth on minor details and clogging up the thread. My apologies and thanks for your thoughts on it.
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Terminalxylem
Footballguy
A test based strategy is used in some cases, but isn’t generally advocated. And Trump almost certainly qualifies for 20 days isolation based on his disease severity.
Terminalxylem
Footballguy
If one is strictly adhering to CDC guidance, Trump should be quarantined at least until completion of his Decadron course, and afebrile 24 hours. I realize clinicians haven’t been sticklers about it, but dexamethasone does have antipyretic properties, correct? And no, I don’t think the CDC explicitly enumerates all medications capable of lowering a fever.
And can you point to anywhere that states a range of 10-20 days isolation? My understanding is 10 or 20, depending on disease severity and level of immunocompromise.
But, you’re right, he’s gonna get multiple tests to try and end isolation earlier. It will be interesting to see what he does if persistently positive, though I’m sure the process will be so opaque we’ll never know.
ETA I see this has been beaten to death, and there is even disagreement amongst the healthcare providers. Suffice it to say, it’s hard for anyone to claim expertise with the rapidly changing knowledge base and public health guidance.
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Terminalxylem
Footballguy
As far as we know, Trump does not meet CDC criteria for immunocompromised wrt covid clearance.
Terminalxylem
Footballguy
Requiring supplemental oxygen for saturations less than 94% counts as severe disease. This mandates a 20 day isolation period.
The fever-reducing medications stipulation is vague, but effectively a moot point if he follows the 20 day guideline.
jm192
Footballguy
The CDC guidelines state something to the effect of "longer than 10 days and up to 20 days."
But yes, in practice, everyone discharged from the hospital is told 10 or 20 days. Then the health dept. steps in at discharge and tells them when they can actually come out.
I'm certain it's a different process for the POTUS--for better or worse.
The Z Machine
Footballguy
Does DC have public health police powers over the federal buildings? Maybe not, but they do have them on the streets of DC. He better be taking Marine 1 directly to an airport.
The Z Machine
Footballguy
Cuz nothing matters any more.
I would stay the heck away from the guy for at least another week. Also, I'd be surprised if he didn't some lingering effects on stamina, breathing, etc.
tri-man 47
Footballguy
Saturday night in Florida will already be Sunday in China, so 10 days.
Since this is all their fault, he's allowed to turn the tables and show them who's boss.His rapid discharge, dismissive attitude, and now plans for too-soon travel and appearances is an all-in move on his part. I feel anything he tries at this juncture is pointless, but quarantining in the WH for a couple of weeks certainly doesn't help him.
massraider
Footballguy
Stem cells yes.
Aborted fetus, no.
Read that somewhere, grain of salt and all that.
Aborted fetus, no.
Read that somewhere, grain of salt and all that.
gianmarco
Footballguy
Actually you have that backwards. It was developed using an immortalized fetal kidney cell from the 1970's that came from an aborted fetus.
The cells now from that line are not considered stem cells.
Either way, neither of those are considered ethical by the Republican party platform and something Trump is supposedly against. Until he needed it.
Terminalxylem
Footballguy
Aren’t many pro-life people against stem cell research? Embryonic stem cells are harvested from pre-implantation embryos, preventing further development.
ETA I see this doesn’t apply to Regeneron’s drug, but other ethical considerations do.
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growlers
Footballguy
I generally agree with almost all of your posts. But I wouldn’t automatically call sats <94% severe disease. I’ve discharged plenty of people 92-94% from the ER with no meds and no steroids, as long as a clear CXR (or sometimes depending on circumstances clear CT) The supposed story is he had a couple dips and only briefly was on oxygenTerminalxylem said:
I concede the CDC guidelines don’t explicitly lay out criteria but I totally disagree with your classification as anyone I’m discharging from the ER isn’t severe disease almost by definition and certainly by logic. I’ve had a bunch of people who were briefly low and discharged next morning, I would call that moderate which is how I’d classify trump
don’t get me wrong, I think trump is a reckless science denying Imbecile, but strictly speaking my interpretation of publicly known info on his condition coupled with CDC guideline is that he could be out there ten days after onset of symptoms with no repeat tests. Is that ideal medically or smart politically - no IMO - but if I can be cleared to treat patients in the ER at 10 days in his scenario I don’t see why he can’t be out there (going strictly by the guidelines)
Terminalxylem
Footballguy
While saturating briefly <94% is certainly underwhelming under most clinical circumstances, it is one of the criteria for severe covid. Moreover, only those with severe disease qualify for treatment with remdesivir and dexamethasone. The CDC references the NIH guidelines for both treatment and disease classification. Here is an excerpt from the latter addressing disease severity:
We know Trump required supplemental oxygen, but don’t know his nadir saturation, nor the duration of hypoxia. His doctor suggested somewhere in the mid- to high 80’s when he said something along the lines of “not in the low 80’s”, but I can’t find any specific number quoted lower than 93% - less than 94 regardless. So by the letter of the law, he had severe disease.
Of course there are caveats:
1. Trump clearly received treatment outside the standard of care.
2. Brief desaturation is very common, and of questionable clinical significance. It’s certainly possible the oximeter reading was a poor waveform/spurious. Alternatively, Trump may have sleep apnea, obesity hypoventillation or other undiagnosed cardiopulmonary condition with lower than average baseline saturations.
3. The information we have been given is limited and of questionable veracity. Particularly concerning are omissions regarding timing of testing, chest x-ray findings and the extent/duration of hypoxia.
Even given the above limitations, my impression is Trump has/had severe covid-19, and therefore should be subject to 20 days isolation after symptoms’ onset, provided he’s been afebrile 24 hours and other symptoms are improving. As @gianmarco pointed out, he’s planning a rally less than 10 days after symptom onset, so clearly he’s ignoring the guidelines.
for all the information here! Great discussion.Joe Summer
Footballguy
Terminalxylem
Footballguy
If he hasn’t fully recovered, perhaps. Might not be a great political move either.
More importantly, it may jeopardize the health of the people around him.
gianmarco
Footballguy
Pretty unlikely. Depends on his symptoms, but it's unlikely that he's going to do anything that's going to cause him to get any worse than he otherwise would.
But it certainly can pose a risk to anyone he is around. Add in hosting a large event, and it's incredibly reckless and irresponsible.
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The Z Machine
Footballguy
Staying away from the president for another week would seem prudent unless you've already recovered from COVID yourself.
growlers
Footballguy
Props to you, the NIH link convinced me. Good info in there and your post.
ironic thing regarding the "serious" discussion is that at the start of the pandemic it was like "oh, his O2 sat is only 88% despite oxygen?, I better intubate him before he crashes" to now it's "Oh, his O2 sat is 80% on high flow? He'll he fine for at least a couple days". My personal definition of "severe" has definitely evolved lol
On a side note, I've been giving 10 mg dexamethasone, interesting they put 6 mg dosing in the guidelines. 10 mg is our "standard" dose. We've been giving steroids to pretty much anyone sick enough to admit assuming they have infiltrates on CXR or CT. They are more conservative with them in their guidelines. I'm sure these details differ all over the country based on local practice, since in the end, these guidelines are opinions from panels, not based on rigorous blinded trials with multiple treatment arms of different dosage groups.
It's clear looking at those NIH guidelines that Trump didn't get treatment according to their guidelines. I don't have a big problem with it, it comes down to clinical judgement as always and we don't have all the data to judge for sure anyway.
I think it's definitely better to hold off on intubation - but I'll say it's way way more challenging to intubate someone with a sat of 76% on high flow - if you don't get the tube in 30 seconds they pretty much are gonna code. They just have no reserve. I've had at least 3 people I can recall that I've tubed in the ICU that I got the tube in immediately and they still died on the vent within a couple hours because they just couldn't be oxygenated regardless of settings.
KingPrawn
Footballguy
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