WASHINGTON — President Trump is set to leave Walter Reed Medical Center in Bethesda, Md., on Monday evening. But it’s unclear if Trump’s doctors were discharging their patient purely on medical grounds — or whether the president, anxious about the optics of a lengthy hospital stay and eager to resume his reelection campaign, simply demanded he be allowed to leave.
In a brief press conference Monday afternoon, Sean Conley said Trump was displaying few of the symptoms he’d experienced over the weekend, and that he generally met the medical criteria that would justify a hospital discharge.
Those medical criteria can vary — depending on the patient, on the progression of their disease, and the place they’re getting discharged to, infectious disease experts told STAT.
The experts were quick to note, however, that there is far too little public information for them to say whether the decision to discharge Trump is in keeping with normal medical practice. Conley, the White House physician, for example, declined to provide specifics regarding how high Trump’s fever reached, how low his oxygen levels dropped, or what his lung scans looked like. He also declined to provide the date of Trump’s most recent negative Covid-19 test.
There is also relatively little known about the kind of care Trump can receive at home at the White House. There is a small medical unit on the campus, including an exam room and office located close to the president’s personal residence. But its capabilities fall substantially short of the specialized care and state-of-the-art technology available at Walter Reed.
The infectious disease experts also noted that there are major risks for discharging any Covid-19 patient, anywhere, too early. While Trump may be nearing full health, it is also possible he could soon take a turn for the worse, as can happen for Covid-19 patients roughly a week after they start showing symptoms.
The treatments Trump has been getting suggest he may have a more severe case of Covid-19 than his doctors have indicated, said Taison Bell, a critical care and infectious disease physician at the University of Virginia. “The medical team is going to be monitoring him very closely the next few days and keep checking vital signs.”
Below, STAT lays out what we know — and what we can’t know — about Trump’s discharge.
How do doctors decide when a Covid-19 patient can leave the hospital?
Patients who have been sick enough to need hospitalization — about 20% of people who have Covid-19 symptoms — usually end up in a hospital bed because they experienced shortness of breath or had a fever so high it left them dehydrated and losing weight. Trump reportedly suffered a low-grade fever Friday, and Conley said he experienced minor dehydration upon arriving at Walter Reed. While his oxygen levels dropped, Conley said, Trump did not experience shortness of breath.
Doctors look for progress before allowing any hospitalized patient to leave the hospital.
“The kinds of criteria that we use in deciding to discharge someone would include things like their ability to eat and drink, to walk around without needing oxygen, and how their lab tests look,” said Helen Boucher, chief of geographic medicine and infectious diseases at Tufts Medical Center in Boston, who declined to discuss Trump’s case.
That doesn’t mean perfect scores on blood counts or measures of inflammatory biomarkers. Doctors want to see any abnormalities that were present trending in the right direction, she said. “People don’t have to be all better. They have to be on the road to being better.”
Does it matter where they are going when they are discharged — and when in the course of their infection?
Where patients are going is critical, whether it’s home or to a rehab facility. They need people to care for them and to keep a watchful eye over them so they can raise a red flag if something isn’t going right.
In the first week, people have what’s called the viral portion of the disease. A small proportion of people will get sicker in the second week — and those cases present more like an inflammatory syndrome, Boucher said. “We worry about that second phase. That happens around day 7 through 10. We’ll be monitoring anybody like that.”
Thomas File, president of the Infectious Diseases Society of America, said at the hospital where he practices, Summa Health in Akron, Ohio, only half of Covid-19 patients go home after five or six days, which is the median length of stay when ICU patients are excluded. Others go to extended care facilities to be monitored and cared for with more medical attention than at home.
What kind of treatment is available at the White House?
Trump isn’t going to be discharged into your standard suburban home. The White House residence itself has a small doctor’s office, and there’s also a sizable clinic next door. One official said that the entire enterprise, known as the White House Medical Unit, operates akin to an “urgent care clinic,” which can rapidly be scaled up into something resembling a top-tier hospital.
“Releasing him to the White House permits a much higher level of medical attention and intervention than any other person in the nation would ever receive. It’s not like releasing you or me to go home,” said Louis Caldera, who from January 2009 to May 2009 directed the White House Military Office, which includes the medic’s office.
Trump’s doctor said Monday, ahead of his discharge, that there was no care being provided to the president at Walter Reed that couldn’t be done at the White House’s medical unit, as of now.
Most likely, Trump would be seen in the White House physician’s personal office and exam room, which are on the ground floor of the White House, just steps from the president’s personal residence. The tiny office is tucked next to the ornate Map Room. It is connected by elevator to the residence, two floors above.
There are other, larger medical clinics on the White House campus, too. The White House also does not currently have anything resembling the trappings of the intensive care units used to care for the sickest of Covid-19 patients.
The largest clinic, according to photos, resembles an average internist’s office — though, uniquely, it has the White House seal emblazoned on certain walls. There are multiple exam rooms, which are outfitted with the standard vinyl leather exam chair. A 2009 photo shows an eye chart and a run-of-the-mill computer for accessing medical records.
“Literally when you walk in, it’s like a doctor’s office in that there’s a receptionist there,” said Caldera.
That clinic is located in an office building next door, and it’s normally available to anyone on the grounds. One White House physician, in her memoir, describes treating everyone from a tourist who fainted after not eating breakfast to an Army official who suffered a fatal brain hemorrhage. The office has been in the spotlight, too, for overzealously treating overworked White House staffers: Several news outlets reported in 2018 that the office would routinely hand out prescription drugs, like the sleeping pill Ambien, to White House staffers.
Do most people with Covid-19 leave the hospital while they still have symptoms?
Trump’s medical team said during Monday’s press conference that the president’s vital signs were normal and that he was walking around and feeling better. Bell, the UVA doctor, said he was encouraged that the team was releasing more information on the president’s clinical status. At UVA Hospital where he works, if patients are still in a period where they can be shedding the coronavirus and potentially infecting others, they are discharged with specific instructions on how to isolate to keep themselves and others safe.
In 2020 in America, most people leave the hospital still having symptoms, Boucher said. “We hope they’re better. So the criteria, say, for us to allow folks out of isolation after 10 days having Covid, they don’t say all your symptoms have to be gone. You have to be better. We make sure that someone has a spouse, a child, a sister or somebody, you know, it goes right with them or who can look after them.”
What do you do when people want to leave against medical advice?
During a public health emergency with a communicable infectious disease, it is appropriate in some cases to prevent people from leaving against medical advice if they don’t have a safe place to go, Boucher said. During Boston’s spring surge in Covid-19 cases, hospitals sent patients to a nearby empty convention center to keep them in isolation after discharge, whether their leaving was with or without their doctors’ blessing. The discharge plan for any Covid patient has to involve making sure the patient has a very clear understanding that the individual will be isolated for the duration, Boucher said.
“In the vast majority of those cases, we would do everything we could to ensure a safe discharge,” she said. That might include things like having a visiting nurse come to the home, oxygen in the home, and physical therapy. “I’d also try to talk them into staying.”
Are people using oxygen at home?
Trump has already been given supplemental oxygen at the White House, when he experienced a drop in his oxygen levels Friday before being flown to Walter Reed.
Generally speaking, it is not unreasonable to think that some people might require oxygen at home, perhaps when they slept at night for some period, Boucher said. In general, things are getting better and they would be requiring less oxygen if not no oxygen right before they left.
File of the Infectious Diseases Society said when patients arrive, supplemental oxygen is their biggest requirement. But they can be discharged when that need lessens, usually to another setting where they can be monitored. “We would like for them to be able to go home without oxygen supplementation,” he said.
Shortness of breath doesn’t have to be all the way resolved, Bell said, but it should have significantly improved.
Are there public health risks to discharging a Covid-19 patient too early?
Federal guidelines require people who have been symptomatic with Covid-19 to isolate themselves for 10 days after they start showing symptoms. Bell, the UVA doctor, worries about the people around the president, calculating that if he was symptomatic on Wednesday, he should isolate until Oct. 10.
“What really concerns me is, how is he going to behave once he gets back to the White House? He’s actually got to isolate and make sure that people are safe, especially if he’s in this infectious period still. Is he going to eschew a lot of these public health guidelines that they’ve shown a willingness to violate so many times consistently already, including yesterday?”
He was referring to Trump’s decision to take his motorcade out for a drive in Maryland, a decision that meant several Secret Service officers rode with him, in close proximity.