The President’s disease course can teach us a LOT about risk, treatment, VIP medicine, and more.

Here’s our show on super spreader events.

Here’s Doc Vader on VIP medicine.

Here’s our show on understanding COVID risk.

Here’s the Paul Offit show I referenced on vaccines/antibodies.

Transcript below!

Hey everyone, it’s Sunday, October 4th. This is Dr. Z, welcome to the ZDoggMD show. All right, there’s been some things in the news. Donald Trump has COVID-19. This is really an amazing development, completely predictable actually if you watch back, you know the retrospectoscope is always 20/20 hindsight, right? If you look back and see where the exposure patterns and all that were, particularly the SCOTUS ceremony, going out on the campaign trail, all of that stuff. So what I wanna do today, though, is in this live show, we’re goin’ live to Facebook, we’ll put it up on the replay on YouTube and of course supporters who subscribe on both YouTube and Facebook will get their own version after this where we have a more in-depth discussion, taking your comments and all of that, but I’ll still take some comments at the end of this so stay tuned.

I wanna get into kind of a lot of the nuance of what Donald Trump’s COVID-19 diagnosis means, what we can learn from it, how he’s being treated, what it means for VIP medicine for the therapeutics, and for the general understanding of risk of this disease. And how we respond to it depends on our risk. So when it was announced that he tested positive along with Melania and Hope Hicks and then the circle started to widen, it immediately made me think of a show we just did about how COVID-19 is felt to spread. And in a way it spreads in this over-dispersed way, that’s a fancy way of saying it clusters in super-spreader events. There are certain individuals who are more likely to spread this disease than others, so 10 or 20$ of the population of people who get infected cause 80% maybe of the actual spread of infection. So it’s not a linear thing. Like if you get infected, you might infect nobody or infect one person, but if you’re unlucky and you’re one of those super-spreaders, you just emit a lot of virus and then you combine that with enclosed indoor locations, poor ventilation, lack of distancing, lack of masks, all of that, you have a recipe for a lot of people getting sick from a single super-spreader event.

And looking back through what happened, undoubtedly at some point in that chain when they backward contact trace, they’ll isolate, okay, this was a venue where things really started to go out of hand or there’s a single super-spreader that’s going from venue to venue and it’s the common cause of other infections. The second thing I thought was woo, well, they just had a debate and Biden was on the same stage along with Chris Wallace and they’re in this triangle basically shouting at each other for two hours. Well, we know that high amounts of emission can occur during loud talking, singing, shouting in enclosed spaces with poor ventilation. Now presumably they had good ventilation, people weren’t wearing masks obviously. But you do worry because the formula for this is time of exposure, so the longer you’re exposed to the infected individual. Those other factors like projecting a voice. Are they a super-spreader? How’s the ventilation? You know these kinds of things and the susceptibility of other people.

So just because Joe Biden tests negative does not mean he’s not gonna be infected from that venue or something else, right? Which then gets me back to more things we can learn from the infection process. And I wanna get this out of the way, this is very important. The people who are out there wishing harm on the president on social media publicly, that kind of thing, that’s a really bad thing to do. Just as a human being it’s a bad thing to do. It doesn’t matter what you feel about the president, I’m trying to be completely apolitical on this, right, as a moderate. It doesn’t matter how you feel about the president, wishing bodily harm or death on another human being, it doesn’t matter who they are, is just not good karma for you. It’s not widening your circle of compassion.

It doesn’t matter. We can hope that good comes of this no matter what and that good doesn’t mean that you have to wish harm on another human being, right, due to some retribution or justice or whatever you think it is. So getting that out of the way, going back to sort of transmission chain, it was really interesting reading about in the Supreme Court nomination ceremony the way they were handling that. So what presumably happened is people would show up for the ceremony, they were wearing masks, and then they would get a rapid antigen test. I believe it’s Abbott’s antigen test where they swab the nares, the nasal passages there, not going very deep, but it’s not a PCR test, it’s an antigen test, okay. What that means is it’s less sensitive and less specific than a PCR test. So you’re gonna catch less cases, so you may have false negatives where someone’s actually infected, but they don’t test positive. And you may have false positives, as well, where somebody’s negative, but they do test positive. Now in this case, they were using this rapid thing, it turns around very rapidly, in you know, 15 minutes or whatever, and they were using it to say, okay, now you guys are negative? Take off your masks, chill out, everybody’s cool, right?

Well, what did I just say about false negatives, bad sensitivity and false positives? That’s the wrong test for this purpose because people could be infected, but early in the course where they’re not yet testing antigen positive. The test could’ve failed to detect an actual teeming amount of virus. There’s a whole series of things that could’ve gone wrong, so then to give everybody a carte blanche to not distance, not wear masks, hug each other, shake hands, and that’s what was happening at this thing. And this is the thing, you know I’ve talked about Scott Atlas, Dr. Scott Atlas on the show with Jay Bhattacharya about how he’s really been kind of crucified by Stanford folks and all of that, but you know he was at this thing mingling around, shaking hands, and that sort of thing. And I feel like as a doctor, you really ought to be advising well okay, this isn’t the best way to lower risk. There may be a better way to do this, right? So again, it’s about risk.

You have a bunch of old people there, many with co-morbidities. You have the guy from Notre Dame, the president, you have the president and his wife. You have a bunch of old senators wandering around. This is not a low-risk group. If this were a bunch of college kids you could make the argument, okay well, okay if we miss a few they get a little infected, their risk of dying is relatively low. Their risk of spreading it is not zero, but hey you could make some arguments about risk and who we want out in the world taking those risks and who we don’t. I’ll tell you who I don’t want out in the world taking risks, our politicians and leaders upon whom our national security depends. So that was a complete cluster F of how to actually manage risk. And again, the left will say it’s indicative of the right’s ability to understand science, risk, and how they’re downplaying this, right? And the right will say, well, we did these things. So again, forget about the politics. I mean oh, we tested and we did this and. Forget about all this stuff.

This is what happened, all right, so this is how we have to think about risk. Like again, I don’t mind if it’s college kids doing that in terms of risk. I do mind if it’s a 74-year-old president. Now let’s talk about the 74-year-old president. What are his risk factors now that he’s positive? And he had symptoms, so he wasn’t just an asymptomatic carrier. And again, I don’t wanna get into did he go out and campaign and do things like this knowing he was positive or knowing that he could’ve been positive. At this point, it doesn’t matter. We can do the retrospective look at that later. What I care about is okay, so what are his risk factors? He’s 74, so he’s older than 65, puts him in a high-risk category. Just so you know, 80% of the 207,000 deaths in the United States have been individuals 65 and older. 80% of the deaths are individuals 65 and older. Okay, so he’s in a high risk group.

What else makes him high risk? He’s male, that’s another high risk factor. He’s obese, that’s another high risk factor. By the way, I see people donating to me by PayPal here, I’ll read those at the end of the show. Thank you for supporting independent content and not making it so advertiser-driven, trying to transcend and make social media better. Thank you for supporting stuff you care about. What’s a third risk factor for him? Well, there’s some talk that he has some low-grade hypertension. We know his diet isn’t great, but that’s speculation. And again, I’m not his doctor, so I’m not gonna speculate on that, but this is basically what we think are his risk factors. Well, now what happened?

Well, what we understand from what his doctors are saying at Walter Reed, which is an incredible establishment. I am sure he has the best care, which we’re gonna talk about VIP care. Is that, at some point, his blood oxygen level did dip into the 93 range. That’s concerning. That is a concerning sign. It was concerning enough that they wanted to bring him into the hospital. Okay, well that raises his risk factor. Just if you look at all the statistics, if you end up in the hospital, your blood oxygen dropped and you have those risk factors, your overall mortality according to data that was posted by Eric Topol on Twitter, is roughly 32%. So about a third of those patients statistically will die. Well, should we be gripping our nails and very concerned for Donald Trump? Well, we should be, right? But let me elaborate on this. So what ends up happening? Well, he gets a few different interventions. He’s getting the usual homeopathic stuff, zinc, vitamin D, famotidine, which is an acid blocker that they’re studying, stomach acid blocker they’re studying for COVID, again we don’t have great data yet.

And he’s taking a baby aspirin or an aspirin daily and again, with his age and risk factors, he might be doing that anyways depending on the data and what other stuff he has going on that we’re not privy to, right? But COVID-19 is known to disregulate blood clotting and so that’s not an unreasonable intervention in that setting. So you have that, but what else did he get? He got Regeneron’s monoclonal antibody cocktail. What is a monoclonal antibody and what does it do?

So let me see if I can explain this simply. You’ve heard of convalescent plasma. Convalescent plasma is a fraction of the blood that’s removed from patients who’ve recovered from COVID-19. Presumably it contains antibodies that the patient has made against the corona SARS coronavirus 2. And by infusing it into a patient with active coronavirus disease, you presume that those antibodies will bind to the virus and help your immune response to contain the viral replication. Now what’s the downside of convalescent plasma? It has a mix of all kinds of stuff. So it has antibodies that don’t necessarily neutralize the virus, but they may bind to the virus and in some cases, that can actually enhance viral uptake. I’m not saying that’s what happens with SARS-CoV-2, but it does happen with things like Dengue. It’s so-called antibody mediated enhancement.

So when you don’t bind to the right part of the virus, you can actually cause the virus to be recognized and pulled into the very cells it’s trying to infect. Now again, we don’t know that that occurs with SARS-CoV-2, but it’s certainly a risk and the data on convalescent plasma is still pretty soft. We’re waiting on really good prospective randomized control trials to see. And it’s not without risk because because of the other components you can have allergic reactions and that sort of thing, kind of similar to a transfusion reaction, right? But what did the president get? The president got monoclonal antibodies. These are designed to bind to the actual business end of the virus, the spike protein on the capsule of the virus that’s responsible for binding to human cells and bringing it into the cell. Those are neutralizing antibodies and what that means, and I’d encourage you to watch the interview I did with Paul Offit where we went through this, there’s a couple on my website,

What that means is that the virus is actually knocked out by antibodies binding to it, by the immune response that’s triggered by that and so on. And they neutralize the virus. Now there’s a couple different antibodies there so that different variants, I won’t use the technical terms of the virus that might escape the initial antibodies might have less chance of that with multiple binging antibodies. Now what’s the status of this drug, right? It’s very expensive, it’s very hard to make, it’s very hard to scale up and only 10 people including the president have gotten it outside of the current ongoing randomized control trials in humans under compassionate use. The president is one of them. So he got something very, very special that’s not part of a trial that he got very early on, I think Friday, when he was not well enough and they actually had to take him by helicopter to Walter Reed. By the way, very concerning. Anyone who tells you that’s not concerning, and oh there’s just an abundance of caution. Something was going on with the president that concerned the doctors enough that they wanted to take these actions and that’s fine. You wanna do that.

Now let’s talk about this for a second. People get very upset, particularly on the left about the care that the president’s getting relative to the other six million Americans that have been, more than that, that have been infected with SARS-CoV-2 now, especially the predominance of individuals who are dying of this disease are minorities and low-socioeconomic status individuals, are essential workers, are front line people and Hispanic, African American patients, Pacific Islander patients, and we’ve talked about why that may be, because they’re crowded in poorly-ventilated spaces, they’re essential workers that are having to be exposed, they tend to have more chronic disease, diabetes, obesity, hypertension, lung disease. And so for all those reasons are they the people that are gonna get this very expensive, esoteric, early treatment? No, they’re not.

And that’s because we live in America. We live actually in a world that’s resource-constrained where you cannot give everybody the gold standard of care. And if you think that hasn’t been happening already in the United States for decades, you are smoking crack on another planet. I worked at Stanford for 10 years as a hospitalist. You don’t think that when the VIP patient came in they got the red Stanford blanket and got a level of treatment that was in ether sphere well above what the average patient got? They did, with a twist. They actually got worse care in many ways because people were afraid to do the routine stuff that actually saves lives because they didn’t wanna bother the patient. People were anxious and nervous about making mistakes. Imagine what it’s like right now to be the president’s doctors. No pressure, fam, right? The dude has to go in front of the press, he says three days and 72 hours and it’s an international incident. Does the wrong thing it’s gonna be looked at in history as like oh my gosh, what happened, right? So VIP medicine is not without its challenges. I tell VIP patients, don’t be a VIP patient. And we should be treating everyone the same ideally, but we don’t.

Now in this case, the president is getting extraordinary care. He got the monoclonal antibodies, he got remdesivir, which at this point is like, that’s a very small treatment effect, usually in very sick patients. So is it gonna do a lot? I’m gonna roll the dice and say no, but as part of a bigger approach maybe it’ll help a little bit. It’s another big pharma thing where it’s like it does this much so pharma’s gonna charge a billion dollars for it and it doesn’t do crap, whereas maybe preventing the disease in the first place might be the most cost-effective thing you can do. So do I begrudge his team for giving him this amazing level of VIP care?

Okay, sit down for a second ’cause I’m gonna rant. He’s the president of the United States. You don’t think we ought to be treating him at the highest possible level since his death would be a national security crisis and could lead to chaos the likes of which you can’t even predict? So if you’re saying that he shouldn’t have gotten that or that everybody should get that, you’re living in a world that doesn’t exist. Think clearly and rationally and practically and after the fact, you can argue for justice and equity and try to expand our circles of compassion. But right now, this is an existential threat to our leadership, so yes. And I’m glad he’s getting the best possible care that American medicine can give him. And we oughta be learning from that care. So he got the monoclonal antibodies, he got remdesivir. What else? He got supplemental oxygen. Well, that’s more of an indicator of how sick he is or was. Now here’s the thing, if you watch and this is something that really irks me. People love to read Donald Trump’s words filtered through the press and not actually watch or listen to what he’s saying. They are diametrically different experiences. Now some will say it’s because Trump is a sociopath and he’s very persuasive and watching him speak you’re being manipulated. And some will say, well, it’s because the press takes his quotes out of context and spins ’em certain ways and he’s a talker, not a writer and whatever. I don’t care what the answer is, watch the videos that Trump made both leaving the White House and the most recent video he did. I’ve watched those videos. He does not look his usual self, okay.

Any medical professional can get a vibe from patients and watching Trump as he’s progressing, watching what’s happening, he is scared, you can tell. He’s not his usual blustery self. He’s using a lot of the words like we, we’re very proud of what we’ve done and you know, he is seeing his own mortality having this illness and getting a experience of what it’s like to have COVID-19. If you talk to people who’ve had it, it sucks. So let that sink in, just get a gestalt for your patient just watching that through telemedicine, looking at what you’re being filtered, right, it’s being filtered. But watch what’s happening there, he was not doing well, all right. But the sense I get watching the video now is he’s a little better.

So could it be, was it the monoclonal antibodies? Was it the remdesivir? Was it the oxygen? Was it the TLC? Was it the break from the usual stress of what he’s doing? Who knows? Could we be wrong and could he get worse again? Absolutely, because that’s the course of COVID in people who get worse. They get a little better, you actually think oh, things are good, and then they decompensate, end up in the ICU getting high-flow oxygen, getting intubated, right. Now what’s the other intervention that they undertook on President Trump that we should really know about? One of the only interventions that’s been randomized control trial data’d to show that it actually works in patients who are either getting supplemental oxygen or are on a ventilator and that is dexamethasone, a steroid.

What do steroids do like dexamethasone? Very high potency, specific steroid. They tamp down the immune system. Now this is where it got really tricky with his care and again, I’m weekend quarterbacking on this. I’m not there, I don’t know what his vitals are. I don’t know what’s been going on, how long the course has been, right. But typically the recovery trial out of the UK showed that dexamethasone does not help patients who are early in their course, who aren’t getting oxygen, and who aren’t that sick. In fact, C. Michael Gibson on Twitter, who’s a cardiologist I respect, reported that there was a trend towards worse outcomes in those patients when you give them steroids early, why? Because in the early phase of infection the virus is replicating and you need your immune response to be maximized, in theory, in order to control the viral replication. In the second phase, if you fail to do that, that’s when the immune response suddenly goes in patients who are gonna get sick and the immune response becomes the problem.

Whether it’s this Bradykinin storm they’re talking about now, cytokine storm, the huge amount of fluid and goo and hyaluronic membranes and stuff that form in the lungs. All of that is an immune response. And so dexamethasone given during the very severe phase of illness showed pretty good outcomes on mortality and outcomes. Well, so he got dexamethasone. Did his doctors make a mistake? Did they give it too early? Well, it turns out now it’s clear he was on supplemental oxygen. So they used their judgment based on that and said let’s give him dex. There you go. Is that a good sign, a bad sign, what’s going on? Hard to know ’cause it’s still quite early, but again, he is getting the gold standard of care.

Notice what they’re not mentioning, hydroxychloroquine, Ivermectin, these other drugs that everyone was rumbling about, that were so politicized. No one’s talking about him getting those right now, right? These are the drugs that have been studied so far or in studies right now. So that’s where he is now in his treatment. If you eyeball him on the last video, he’s tired. You know what struck me a little bit is that his mentation, let me explain that word for people who aren’t doctors and nurses and healthcare people. Mentation is a fancy way of saying how’s he thinking? How’s his cognition?

When he did the last video he did, he’s looking at the camera, it’s not clear that he’s looking at cue cards or anything like that, which is not something that he loves to do anyways, and you can tell that he’s going down a path and he’s talking and he’s saying, well, you know this is the thing, they wanted me to stay in the White House, that’s not who I am, leaders don’t do that. I came here, I wanted to be involved, this and that. Melania is doing well, by the way, she sends her regards, this and that. I wanna thank the doctors, I wanna thank the world leaders who said this, who’ve been doing this. These doctors are great. You know I wasn’t feeling so good, now I’m feeling better. So actually his mentation was quite clear. He appears to be thinking, you know, consistently and clearly and it wasn’t your typical kind of rambling thing, it was pretty clear.

So that’s good sign from a standpoint of how much oxygen is the brain getting, what’s his blood pressure like. You can learn a lot just from interacting with the patient even virtually for a very short period of time. Again, could it all be cherry-picked and the minute he’s done with that he just crumps? Sure. We’re not there, right? Just like you can’t psychiatrically diagnose the president from a distance, you have to be with him. And I hate it when people do that.

So bottom line is we’re in a position now where the next few days will tell us what’s gonna happen, right? We’ve seen the effect of VIP medicine, we’ve seen the effect of being lax with the science of risk on COVID-19, which we’ve talked about on the show. We underestimate risk in the elders and we overestimate it in the young and so our response is completely backwards. We quarantine the young at home and then we let the old go to parties.

So we really need to think about what we’re doing and what we can learn from this. It’s an election year, people are gonna be a-holes about it, I get it, don’t do it. So you know we’re in a position where you’ve got the president in the hospital, it’s pretty unprecedented. I mean I remember when Reagan got shot, it was a big deal. Regardless of politics, people pulled together and I’m seeing less of that here. We’re so polarized by social media, we’re so manipulated by algorithms and by the media that we won’t come together and say, you know what? We’ll hold him accountable when he gets out for doing the right thing for COVID based on risk and based on a big picture that he has access to that also remember not all of us have access to. Doctors see a narrow window of very sick people in the hospital, economists see the window of this calamity of poverty and hunger and unemployment that’s gonna harm us.

Teachers see kids not getting looked after and education in the way that they’re used to and getting abused at home and no one to monitor that, no escape route. So all this we’ve talked about. So I think what we need to do today, it’s Sunday, this is my Sunday sermon. Let’s widen our circles of compassion. Let’s have some love and understanding and channel it through us in the face of human suffering no matter who it is, no matter what your politics are, no matter what your sense of justice and inequity is, let’s do that. And I suspect if we look inwards and channel that kind of love, the world will start to change in a way that shouting on Twitter and screaming at each other and polarizing and generating this hateful, negative energy will never accomplish.

So that’s my call to action. I’m trying myself to do that. Now my second call to action is this. I’ve talked a lot about how I think social media is really hurting us. After a lot of discussion with the moderators of the group, we have a group of 52,000 people called the ZPac TribeTalk group that during an election year it’s gotten harder and harder and harder to see the value of that group. The moderators are exhausted trying to stop people from fighting each other, trying to stop people from attacking each other, trying to stop political posts, trying to have it live up to the potential and the hope of social media, which is a gathering place to exchange ideas, support, and love. And we decided, we made a very difficult decision to shut it down until people either start to wake up a little or the election’s over or we never start it up again. Because I’ve decided “premum non nocere” do no harm and I feel like that group is doing harm right now.

And it’s hard to do because it’s 52,000 people and some people are so lovely there, doctors and nurses and patients all together exchanging ideas. And we have to shut it down because we’re so polarized that we cannot show love in the face of suffering to each other.

Now my hope is there are other ways to do this. We have the Supporter group, these are subscribers. They’re paying 4.99 a month, why? Because they actually care about this stuff. It immediately weeds out people that just want to express anger or hatred or negativity or want some secondary gain of getting attention. These are people that care. My Supporters, and there’s 7,400 of them right now, it is the most beautiful experience to be with them on live shows where we have discussions and the discussion group we have called Supporter Tribe is closed, it’s curated by me, and it’s a beautiful, beautiful place. So maybe that’s where we can learn how to do it better and then I can open back up to the public, but if that’s a place you wanna be and you wanna support content like this that’s independent without a ton of sponsors and all this other stuff where I have to look over my back, did I say the wrong thing and piss off the monoclonal antibody maker, Regeneron? Or maybe I should’ve been more careful about what I said, I never, ever censor myself like that. And with Supporters, you get all the F bombs, too. So that’s my pitch, guys. I think we can make things much, much better. I love you. Please do me a favor whether you support us or not, share the show, have the discussions in a civil way. I’m actually really deeply rooting for the president and for his team to get him well again so then we can yell at him for doing the right thing about COVID, all right guys. I love you and we are out. Peace.

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