COMMENTARY

Trump Got Therapies You Wouldn't Get -- And You're Better Off

F. Perry Wilson, MD, MSCE

Disclosures

October 06, 2020

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This transcript has been edited for clarity.

Welcome to Impact Factor, your weekly dose of commentary on a new medical study. I'm Dr F. Perry Wilson from the Yale School of Medicine.

At the time of this recording, on October 5, the President of the United States is still hospitalized at Walter Reed Medical Center for COVID-19. According to press releases, he is doing relatively well despite some transient hypoxemia.

Despite that, according to his personal physician, he has received the following medications:

If you looked at this treatment regimen not knowing the patient, you'd assume that this was someone on the brink of death — ventilated. Last-ditch-effort time.

Of course, the president doesn't seem to be particularly sick. Let's face it: If you or I had COVID and were as sick as the president, there is no way we would be getting this kind of treatment. And here's the thing: We're probably better off.

Right now, the president might be the victim of a well-described medical phenomenon called the VIP syndrome.

When I was early in my training, a "very important person" was admitted to our hospital. I can't tell you this person's name, but trust me — a VIP.

So at some point during his care, he needed a chest tube pulled. The chief of cardiothoracic surgery came to do the honors. Before we went in, he turned to us and commented, "The last time I pulled a chest tube was 15 years ago."

See, the person you want to pull your chest tube is the third-year resident, the one who does it 10 times a day. But the VIP gets the chief of the whole department. Ironically, VIPs often get worse care.

First described by Walter Weintraub in 1964, VIP syndrome is nothing new. Our first president, in fact, may have been a victim.

Life of George Washington: The Christian, lithograph by Claude Regnier, after Junius Brutus Stearns, 1853. Gift of Mr and Mrs Robert B. Gibby, 1984 [WB-55/A1], Washington Library, Mount Vernon, Virginia. 

On December 13, 1799, George Washington at age 67 was struck with some type of bacterial epiglottitis. Over a 12-hour period, he was subjected to four blood-letting procedures — state-of-the-art medicine at the time — for a total of 80 oz of blood. That's 2.5 L of blood loss. He succumbed on December 14 shortly after gentlemanly thanking his doctors for their exceptional efforts.

To be fair, the VIP syndrome is really one of anecdotes. Few rigorous studies have tried to evaluate the phenomenon.

Nevertheless, case reports and case series appear across a variety of medical journals in psychiatry, in medicine. Even the vaunted New England Journal of Medicine touched on the aspects of emergency care for the VIP patient in 1988.

I don't envy the physicians taking care of the president. What are you supposed to do? We don't know the full details of his condition, but assuming that he was mildly ill, standard of care would basically be symptomatic relief. If he was hypoxemic, you could probably make an argument for steroids based on the RECOVERY trial. Remdesivir as well, provided that there was some evidence of lower respiratory involvement.

But the antibody cocktail? A drug that you can only get through compassionate use? That isn't standard of care.

We don't even have a phase 2 publication on this cocktail yet, much less a phase 3 trial. There's this published study in macaques that seems promising.

But whatever you think of the president, he is not a macaque.

What we know of the Regeneron cocktail right now comes from a press release that tells us of outcomes in just under 300 patients, showing that — at least among those with poor native antibody responses — viral load decreased faster with the cocktail. Okay.

But with that few people, do we really understand the risks? Monoclonal antibodies have a long history, but strange reactions can occur: allergy to the product, off-target effects. You know the drill.

Look, I'm not going to go hardcore egalitarian here. If we had a magic pill that cured COVID with no side effects but cost $10 million, sure — give it to the president even though the rest of us can't get it. The unfairness is not really what the VIP syndrome is about.

It's the risk the VIP faces getting medications — and combinations of medications — that we don't know enough about. Doctors know that standard care is the best care. That's why it's standard. The Hail Mary pass is for the fourth quarter when your team is about to lose; it's not your opener. But for VIPs, these essential truths get forgotten.

I can imagine what these docs are thinking, though.

What if the president worsened? What if the president died? Wouldn't you, as a physician, want to say that you did absolutely everything you could have possibly done?

This reveals a bias in medicine that often does more harm than good: the need to do something, or in this case, to do everything, even when the data don't yet support it. Because you don't want to be on the hook for a bad outcome.

But bad outcomes could happen because of this aggressive treatment. If the president has a rare reaction to the antibody cocktail — say he develops some autoimmune response — the physicians who treated him could be rightly criticized.

But you know what? I doubt they will be. Our bias is so strong in favor of treatment that if that rare event happened, we would brush it off as a risk that had been worth taking to save this particular life.

Of course, in the end, everyone deserves the best possible care. What's ironic is that because he is the president, Donald Trump may be receiving worse care than you or I would. Sometimes it's good to be a nobody.

F. Perry Wilson, MD, MSCE, is an associate professor of medicine and director of Yale's Program of Applied Translational Research. His science communication work can be found in the Huffington Post, on NPR, and here on Medscape. He tweets @methodsmanmd and hosts a repository of his communication work at www.methodsman.com.

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