Editor’s Note: Kent Sepkowitz is a CNN medical analyst and a physician and infection control expert at Memorial Sloan Kettering Cancer Center in New York. The views expressed in this commentary are his own. View more opinion at CNN.
On Saturday, a team of doctors in crisp white coats updated the country on President Donald Trump’s medical condition as he battles Covid-19 at the Walter Reed National Military Medical Center.
While many news reports focused on the apparent discrepancy between the doctors’ timeline of events and those the White House had announced, I will focus on the vast amount of clinical information that the medical team did not clearly provide.
Unfortunately, though the doctors spoke many words, they gave very little information about Trump’s condition. The public must receive a more complete and useful medical report.
First, the doctors danced around the simplest question of all: whether the President is on, or has been on, oxygen support. Navy Cmdr. Dr. Sean Conley’s evasiveness suggests that the President, though “not on oxygen right now,” may have been on oxygen earlier while still at the White House. Indeed, a source told CNN the President received oxygen on Friday.
The amount of oxygen he is receiving is the single most important indicator of how he is doing. Right now, we are all breathing in air that is approximately 21% oxygen. Hospitalized patients with the thin pale green nasal tube can receive up to 40% oxygen comfortably, while more sophisticated contraptions allow patients to receive more than 75% oxygen.
The need for extra oxygen almost always reflects lungs that are not working properly due to pneumonia, blood clots, inflammation or other damage. And the more oxygen is required, the worse the lung damage likely is. I begin to worry when 40% oxygen is no longer sufficient – and become extremely concerned as it heads to 60% or 70%. At these levels, the need for mechanical ventilation on a respirator machine increases greatly.
The doctors also did not address whether he is receiving the potent anti-inflammation steroid, dexamethasone, which is known to both improve Covid-19 outcomes for critically ill patients, according to the UK’s national clinical trial, and make patients with lung inflammation from any cause feel better for a day or two. If he has received it, this might explain his apparent improvement from requiring oxygen to not needing support.
It’s notable that the last question posted to Trump’s medical team – one about whether the President had received steroids – went unanswered.
Dr. Conley did not mention any radiology tests (X-rays or CT scans) the president has received, saying only that they were conducting daily ultrasounds and daily lab work. The use of a sonogram in this setting, though not useless, is an odd choice given its limits in assessing lung function or inflammation. It is more typically used to measure heart function, detect evidence of blood clots or assess whether large amounts of fluid are accumulating around the lungs or heart.
When a reporter asked if there were any signs of damage, he declined to “go into specifics.” This may suggest that, like many patients with Covid-19, the President has an abnormal test result. Radiology results and lab tests are notoriously difficult to correlate with clinical conditions or prognoses so some hesitancy to be fully explicit is understandable. But the complete refusal to discuss the subject is quite disappointing.
There are two tests that are germane and should be presented as part of the daily briefing. First, the white blood cell count is comprised of four types of cells. One of them, the lymphocyte, is key to fighting viral infections. Many reports on Covid-19 have shown that a very low number of lymphocytes suggests trouble ahead.
A similarly useful set of tests are referred to as “inflammatory markers.” As our understanding of Covid-19 has progressed, we have come to realize that the virus is doing very little direct harm to tissue; rather the virus provokes intense inflammation in blood vessels, the heart, the brains, the kidneys and elsewhere, resulting in death and severe illness. Because elevated Inflammatory marker test results can predict a more severe outcome these results also should be provided.
Finally, we must know the President’s mental condition and how his mental acuity is being assessed. Covid-19 infection is known to cause a “brain fog” – some sort of cognitive clumsiness that can linger for weeks and months.
We should know whether he is being serially tested for this condition, which tests are being used and how decisions will be made regarding his acuity. National security considerations may preclude our knowing the actual results, but we deserve to understand the process of assessment.
Trump’s team of doctors today did a disservice to both the President and the public by giving a spotty report, filled with selective information about a serious medical illness. For most people on the team, this was their first time in the unforgiving glare of national scrutiny. Perhaps the moment was simply too large for them.
They must do better. And because the illness will continue to play out over days and potentially weeks, they will have several additional chances to improve the quality of their reports.
As we move forward during the President’s illness, we can only hope his doctors will remember that they are doctors and that – as with any patient or family interaction – only honest and direct communication is acceptable.