Clinical Care of COVID-19 Patients in a Front-line ICU

Robert A. Raschke MD

Tyler J. Glenn MD

Kim I. Josen MD

HonorHealth Scottsdale Osborn Medical Center

Scottsdale, AZ USA

These are some clinical observations made after over the past 10 months, working in a busy COVID-19 ICU unit in Scottsdale, AZ. The opinions expressed here are those of the private practice authors.

Overview of triage and rounding on large numbers of COVID-19 patients in the ICU service. Our approach to bedside care of our ICU service has required abbreviation for the sake of efficiency in the face of more than a doubling of our census. Our approach to rounding is opinion-based. We’ve been forced to evolve our triage and rounding systems in order to survive.

Our hospital uses the Abbott ID-Now® rapid point-of -are test for screening all COVID-19-asymptomatic patients admitted to our hospital, but due to its low sensitivity in hospitalized patients (1). We do not trust it to rule-out COVID-19 in patients with pneumonia being admitted to the ICU and also order an in-house PCR for such patients prior to, or upon ICU admission. We are cautious about transferring COVID-19 patients out of the ICU on bilevel positive airway pressure (BiPAP) or high-flow nasal cannula since many such patients have deteriorated and bounced-back to the unit within the subsequent week.

We try to see as many of our COVID-19 ICU patients (who are practically all our patients) sequentially, without interruption if possible, leaving our masks and gowns on continuously and moving quickly from room to room, changing only gloves between patients unless a bacterial pathogen that requires contact isolation has been identified. Little/no helpful information can be gleaned by entering the room of patient who is proned in a rotoprone bed. Such patients may only be supined for brief periods, sometimes in the middle of night shift; and discussion with the nurses regarding their physical exam findings during supine positioning is high yield. Auscultation of COVID-19 patients using isolation stethoscopes is seldom of value. Palpation of the neck/trunk for crepitus, neurological examination (especially in patients emerging from heavy sedation and/or supined after prolonged proning), and assessment of fluid status are high yield. We keep track of how many days the patient has received mechanical ventilation, the cumulative fluid balance (which sometimes gets very positive), and signs and lab values possibly related to complications of COVID-19 discussed below. The duration of antibiotics and sedation medications needs constant monitoring to avoid overuse. We do not routinely follow serial INR, ferritin, CRP, or D-dimer, since these do not affect patient management. We sometimes use BNP and procalcitonin to trigger further cardiac or infectious disease evaluations respectively. We do not treat isolated elevated procalcitonin with antibiotics, nor do we treat isolated d-dimer with therapeutic dose anticoagulation.

We have been conservative in our treatment of COVID-19, relying primarily on dexamethasone and usual evidence-based critical care practice. Over the course of the outbreak, our conservative approach has been validated; various hyped but off-label therapies (hydroxychloroquine, antirheumatic therapies, universal therapeutic anticoagulation) have failed to show benefit and possibly caused harm when subjected to evidence-based scrutiny (2,3). Benefits of remdesivir in patients with advanced respiratory failure seem unclear/minimal (4). Most of our patients present to the ICU in the second or third week of illness, already having developed IgG antibodies and therefore unlikely to benefit from convalescent serum or monoclonal antibodies.

Clinical course and management of respiratory failure. Many patients remain awake and able to tolerate spontaneous ventilation with non-invasive ventilation and/or high-flow nasal canula oxygen delivering high FiO2, for as long as two weeks before they either recover or require endotracheal intubation. Before the current outbreak, it was unusual to manage severely hypoxemic patients without intubation and mechanical ventilation. For COVID-19, it seems to be the norm, with intubation delayed until the last possible moment, as it is unclear that mechanical ventilation with its attendant complications (immobility, sedation, invasive support apparatus) offer any definite benefit. Once intubated, many patients seem to transition abruptly to refractory hypoxemia and hypercarbia, which previously would have made them candidates for Extracorporeal membrane oxygenation (ECMO) transfer. In one recent case, we requested ECMO evaluation for a patient prior to intubation, anticipating that he would deteriorate badly immediately thereafter. The consultant requested intubation before ECMO evaluation, and indeed, once intubated, the patient immediately became too unstable for uncannulated transfer. In general, the numbers of patients fulfilling historical criteria for ECMO consideration have greatly overwhelmed ECMO capacity.

We have tried several approaches to invasive mechanical ventilation, but each has drawbacks. Our primary mode of ventilation, pressure-regulated volume control, has sometimes resulted in high plateau and driving pressures as respiratory system compliance worsens. We’ve used pressure control ventilation in some patients to limit driving pressure, but this has led to unrecognized worsening of respiratory acidosis in some. We have managed several episodes of cardiac arrest due to uncontrolled combined respiratory and metabolic acidosis in COVID-19 patients being treated with permissive hypercapnia ventilation who subsequently developed acute renal failure. We are now trying airway pressure-release ventilation (APRV) as an optional approach in which we try to avoid proning and heavily sedating the patient, but aim for Richmond Agitation-Sedation Scale (RASS) of -1 to -2 and allow maintenance of spontaneous respiratory efforts by the patient during “T high”. It is not clear whether any of these approaches results in better clinical outcomes.

Our use of prone positioning has increased dramatically. Self-proning of awake patients receiving non-invasive mechanical ventilation or high-flow nasal canula oxygen has allowed some to survive episodes of severe oxygen desaturation and avoid intubation. We have extensively utilized proning in mechanically ventilated patients with PaO2/FiO2 <150. Several of our patients experienced cardiopulmonary arrest when briefly supined resulting in several fatalities. Consequently, we have learned to placed US-guided internal jugular central venous catheters and chest tubes in patients in proned and semi-proned positions. We have noted that at some point, prone positioning needs to be abandoned if the patient is ever going to recover, even if their PaO2/FiO2 ratio falls upon supine positioning. In such patients, supine positioning allows reduction of heavy sedation and resumption/improvement of spontaneous breathing efforts that may allow ventilator weaning to slowly proceed.

Complications of COVID-19 in the ICU. We have seen more barotrauma than previously described, some occurring during non-invasive ventilation prior to endotracheal intubation (5). Point of care chest ultrasonography has been instrumental in several cases in which anterior pneumothoraces were not clearly apparent on chest radiography, except perhaps as a deep sulcus sign, and also to rapidly rule-out pneumothorax as a cause of acute cardiopulmonary decompensation.

Hypotension requiring intravenous vasopressors is common (6). In many cases, it seems due to sepsis and sedation with propofol and/or dexmedetomidine. We have occasionally seen acute or chronic cardiomyopathy, but not as often as noted early in the pandemic (7). We have repeatedly diagnosed relative adrenal insufficiency later in the hospital course –after dexamethasone has been discontinued. Such patients commonly received etomidate during intubation which could possibly be contributory.

Bacterial co-infections are uncommon at presentation, consistent with published meta-analysis (8), and we do not routinely give antibiotics to all patients with COVID-19 pneumonia up front. Later in the course of mechanical ventilation, many patients experience recurrent fever, leukocytosis, elevated procalcitonin and/or worsening pulmonary status prompting endotracheal secretion and blood cultures and empirical antibiotics. We have commonly isolated a wide variety of potential bacterial pathogens from the respiratory secretions of such patients including methicillin-sensitive Staphylococcus aureus (MRSA), methicillin-resistant Staphylococcus aureus (MRSA), gram negative rods, some multi-drug resistant. We recently isolated carbapenem-resistant Enterobacter. It is uncertain whether these represent true cases of secondary pneumonia.

Coagulopathy related to COVID-19 is complex and increased risk of thrombosis and bleeding seem apparent (9). We administer enhanced prophylactic-dose anticoagulation to all our patients (typically 40mg enoxaparin every 12 hours in patients without morbid obesity or renal failure), but do not treat elevated d-dimers with therapeutic anticoagulation in the absence of documented venous thromboembolism (4). A minority of our patients have had documented venous thromboemboli prior to ICU admission and a few have had acute myocardial infarctions and strokes. We try to get CT angiography of the chest and doppler ultrasound of the lower extremities on all patients requiring mechanical ventilation. Bedside ultrasonography demonstrating acute right heart failure has been helpful in a few cases in which pulmonary emboli were suspected but the patient too unstable for CT angio or VQ scan. Three of our patients experienced CNS hemorrhages, two of which were fatal. Gastrointestinal bleeding is not uncommon.

Acute renal failure is common and complicates permissive hypercarbia, sometimes necessitating high dose bicarbonate infusions (6). Circuit thrombosis during dialysis is common, perhaps a manifestation of COVID-19 coagulopathy, and sometime necessitating therapeutic anticoagulation.

End of life issues. It is our impression that the mortality in intubated patients is higher this winter than it was previously in the pandemic. This might be because patients are receiving more aggressive therapy earlier in the course of illness, and often are only intubated after failing a prolonged course of non-invasive mechanical ventilation. Perhaps this selects treatment-unresponsive patients for intubation. Prognostication seems very difficult. We treated an 89-year patient with severe comorbidities who rapidly recovered after a 4-day course of mechanical ventilation and a 28-year-old previously healthy man who died despite receiving veno-venous ECMO. We have not found clinical scoring systems such as

Sequential Organ Failure Assessment (SOFA) to be helpful in prognosis, since many patients have isolated severe single organ dysfunction at the time of ICU admission, and therefore have similar SOFA scores – mostly comprised of points given for severe respiratory failure. Old-fashioned bedside common sense and family discussion still seem the best approach to determining code status. It is logistically difficult/impossible to safely administer CPR to some patients who are proned, especially those that are morbidly obese. We have told families that we are instituting limited code status (no CPR, no ACLS) in such situations, subsequently discussing resumption of full code status if/when the patient recovers enough to tolerate resumption of supine positioning.

Psychosocial issues. Incredible emotional injury is being experienced by patients’ families. Several of our patients come from families in which two or three primary relatives have already died from COVID-19. We called one patient’s wife to inform her that her husband had narrowly survived a prolonged arrest secondary to pneumothorax, interrupting her during her son’s funeral, who had died from COVID-19 pneumonia the previous week. Eventually, that family suffered the death of three primary relatives from COVID-19 over the course of three weeks.

We have tried to use cellular technology to help mitigate restricted family visitation, but it seems a poor substitute. Our nurses have had some patients make cell phone video messages to their loved ones before intubation – sometimes the last memory their families will ever have of them. We have held our cellphones by the ears of COVID-19 patients as they are dying so that their loved ones can say goodbye. It was heart-wrenching to hear a husband of 42 years sobbing uncontrollably over the phone, telling his dying wife that he loved her, and how much he’s going to miss her as we prepared to remove her endotracheal tube to let her die.

The nurses, respiratory techs and physicians have shown incredible bravery and self-sacrifice and outward morale is good. But all are suffering severe vicarious injuries the full effect of which may not be apparent for years to come. Much of the human connection previously so important to ICU practice has been lost – few of the patients can interact, and the families are generally not allowed to visit. We simply don’t have the time anymore to call them as often as we would like, and it’s unusual to call them with good news. We should plan for a future increase in PTSD and burn-out among healthcare providers.

We are grateful to have received my COVID-19 vaccination, and I was sincerely astounded by the organizational excellence of the vaccination event implemented by HonorHealth here in Phoenix. They did a very good job that will serve our entire vaccine-willing population in the coming months.

References

1. Basu A, Zinger T, Inglima K, Woo KM, Atie O, Yurasits L, See B, Aguero-Rosenfeld ME. Performance of Abbott ID Now COVID-19 Rapid Nucleic Acid Amplification Test Using Nasopharyngeal Swabs Transported in Viral Transport Media and Dry Nasal Swabs in a New York City Academic Institution. J Clin Microbiol. 2020 Jul 23;58(8):e01136-20. [CrossRef] [PubMed]
2. WHO Solidarity Trial Consortium, Pan H, Peto R, Henao-Restrepo AM, et al. Repurposed Antiviral Drugs for Covid-19 - Interim WHO Solidarity Trial Results. N Engl J Med. 2020 Dec 2:NEJMoa2023184. [CrossRef] [PubMed]
3. Salama C, Han J, Yau L, et al. Tocilizumab in Patients Hospitalized with COVID-19 Pneumonia. N Engl J Med. 2020 Dec 17. [CrossRef] [PubMed]
4. American Society of Hematology. COVID-19 Resources: COVID-19 and VTE/Anticoagulation: Frequently asked questions. Version 5.1 (last updated December 24, 2020). Available at: https://www.hematology.org/covid-19/covid-19-and-vte-anticoagulation (accessed 1/3/21).
5. Botta M, Tsonas AM, Pillay J, et al., PRoVENT-COVID Collaborative Group. Ventilation management and clinical outcomes in invasively ventilated patients with COVID-19 (PRoVENT-COVID): a national, multicentre, observational cohort study. Lancet Respir Med. 2020 Oct 23:S2213-2600(20)30459-8. [CrossRef] [PubMed]
6. Cummings MJ, Baldwin MR, Abrams D, et al. Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in New York City: a prospective cohort study. Lancet. 2020 Jun 6;395(10239):1763-1770. [CrossRef] [PubMed]
7. Arentz M, Yim E, Klaff L, Lokhandwala S, Riedo FX, Chong M, Lee M. Characteristics and Outcomes of 21 Critically Ill Patients With COVID-19 in Washington State. JAMA. 2020 Apr 28;323(16):1612-1614. [CrossRef] [PubMed]
8. Langford BJ, So M, Raybardhan S, Leung V, Westwood D, MacFadden DR, Soucy JR, Daneman N. Bacterial co-infection and secondary infection in patients with COVID-19: a living rapid review and meta-analysis. Clin Microbiol Infect. 2020 Dec;26(12):1622-1629. [CrossRef] [PubMed]
9. Helms J, Tacquard C, Severac F, et al., CRICS TRIGGERSEP Group (Clinical Research in Intensive Care and Sepsis Trial Group for Global Evaluation and Research in Sepsis). High risk of thrombosis in patients with severe SARS-CoV-2 infection: a multicenter prospective cohort study. Intensive Care Med. 2020 Jun;46(6):1089-1098. [CrossRef] [PubMed]
10. Hayek SS, Brenner SK, Azam TU, et al. In-hospital cardiac arrest in critically ill patients with covid-19: multicenter cohort study. BMJ. 2020 Sep 30;371:m3513. [CrossRef] [PubMed]

Cite as: Raschke RA, Glenn TJ, Josen KI. Clinical Care of COVID-19 Patients in a Front-line ICU. Southwest J Pulm Crit Care. 2021;22(1):11-15. doi: https://doi.org/10.13175/swjpcc070-20 PDF

Why My Experience as a Patient Led Me to Join Osler’s Alliance

There are a number of books and articles written by doctors that relate their own experience as patients. Count this as another although I promise it will not be nearly as entertaining as “The House of God”. Over a month ago I became short of breath and a chest x-ray revealed left lower lobe consolidation. Despite lack of fever, it seemed that an infectious process was most likely, and when multiple tests for COVID-19 were negative, it was felt by my pulmonary physician to be most likely coccidioidomycosis despite a negative cocci serology. After beginning on empirical therapy with fluconazole for nearly a month, I am feeling better.

Most of us know that there is considerable laboratory to laboratory variation in serologic tests for Valley Fever (1). However, when my initial cocci serology was negative, efforts to send it a good reference lab such as Pappagianis’ Lab at UC Davis became nearly impossible. After making an appointment at Sonora Quest and waiting a week for an appointment to get my blood drawn, it was apparently sent to Davis, but when payment was not assured, it was not run. I would have been paid for it out of pocket but there seemed no way to communicate this.

Similarly, it took 3 visits to a commercial outpatient radiology practice, Simon Med, to get a routine chest x-ray. I can understand the need for appointments for CT scans. However, routine x-rays were so backed up that I waited several hours to get a chest x-ray performed although I did get an electronic copy. Fortunately, I am able to read my own chest x-ray and did not need to wait for a radiologist’s report which arrived on a Tuesday after the chest x-ray was taken late on a Friday.

Honestly, I had no idea that our patients were receiving such poor care. Delays of this magnitude go beyond what I view as acceptable. Overall, I think my doctors are great but I have concerns about an overall decline in patient care. It should not take a week to get routine labs drawn. Sick people should not be making multiple trips to get a simple chest x-ray. This may be another symptom of the hyperfinancializaton of medicine where patient care is sacrificed for profit. The hospital labs and x-ray departments of years ago were run by physicians and mostly concerned with patient care and not losing money. Today with businessmen controlling nearly all aspects of healthcare patient care is less important than maximizing profits.

I worry that our businessmen/managers are buying medical practices and directly supervising healthcare professionals. Healthcare is a business to them, no different than selling hamburgers at McDonalds. Their goals of increasing income and reducing expenses to maximize profits while hiding behind the façade of a non-profit organization is quite apparent. However, what is equally clear is that there is a lack of medical knowledge in these medical managers and decisions can be “penny wise but dollar foolish”. Look at the decision to not pay for a more reliable cocci serology which costs $80. They have spent more than this on fluconazole. Bad medicine is usually costly.  

The COVID-19 pandemic has brought to light many of the inadequacies of business interests dominating medicine (2). Hospitals are overflowing and inadequate personnel with inadequate personal protective equipment are available to care for them. Those remaining providers are expected to just “pick up the slack”.

Although I have long lamented (some say whined) about the businessmen’s mismanagement of medicine, what could we do? Business interests seemed to control the hospitals, the insurance companies, Centers for Medicare and Medicaid Services (CMS), and the licensing boards. We were being squeezed and trainees just beginning practice were in no position either financially or professionally to confront business interests which could end their career.

I appear to not be the only one who feels way. Last year, Eric Topol MD, founder and director of the Scripps Research Translational Institute and editor-in-chief of Medscape, wrote a piece published in The New Yorker, "Why Doctors Should Organize” (3). In it, he explained his view that the nation's nearly 900,000 practicing doctors needed to organize to bring back the doctor-patient relationship that existed before the business part of medicine took over its soul. Physician organizations such as the American Medical Association (AMA) represents only about 17% of US physicians, and have done little for medicine as a profession. The next largest, the American College of Physicians, represents internal-medicine specialists. Most of the smaller societies (e.g., ATS, American College of Chest Physicians) represent a subspecialty and have correspondingly fewer members each. The AMA once represented three-fourths of American doctors; the growth of subspecialty societies may have contributed to its diminishment. In any case, there is no single organization that unifies all doctors. The profession is balkanized into different specialties each hostilely eyeing the other specialty organizations.

Therefore, Topol has led the formation of Osler's Alliance (now Medicine Forward) (4). This organization, named for William Osler, hopes to draw together the nation's doctors, who come from different backgrounds, specialties, and political leanings but agree that the way they interact with patients is not what they envisioned when they decided to devote their lives to medicine.

"Such an organization wouldn't be a trade guild protecting the interests of doctors," Topol wrote. "It would be a doctors' organization devoted to patients (5)."Another organizer of Osler's Alliance, Esther Choo, MD, MPH, an emergency physician and professor at Oregon Health & Science University in Portland, described physicians' widespread daily feeling that "this can't be the way it's supposed to be," but also a lack of empowerment to make changes (5). That's where the numbers come in, she said. A massive group of physicians standing up against practices could force change.

The first step, Choo said, is to break down the fundamental mission into "bite-sized advocacy (5)." That might entail advocating for answers to why increased documentation demands are necessary and how, specifically, they help the patient rather than dutifully complying with directives for more charting.

The leaders emphasize that membership in the group is not about money, which is why it's only $5 a year. Signing up builds support and allows access to chat streams and information in a broad network. "When you start seeing advertisements for health systems that say, 'We give the gift of time to patients and clinicians,' " answered Topol, "then we'll know we're turning the right corner (5)."

If you are a physician or other provider, you might consider joining Osler’s Alliance. What have you and your patients got to lose? Staying the present course would seem to lead to nowhere.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Galgiani JN, Knox K, Rundbaken C, Siever J. Common mistakes in managing pulmonary coccidioidomycosis. Southwest J Pulm Crit Care. 2015;10(5):238-49. doi: http://dx.doi.org/10.13175/swjpcc054-15
2. Dorsett M. Point of no return: COVID-19 and the U.S. healthcare system: An emergency physician's perspective. Sci Adv. 2020 Jun 26;6(26):eabc5354. [CrossRef] [PubMed]
3. Topol E. Why Doctors Should Organize. The New Yorker. August 5, 2019. Available at: https://www.newyorker.com/culture/annals-of-inquiry/why-doctors-should-organize (accessed 11/30/20).
4. Osler’s Alliance website. Available at: https://oslersalliance.mn.co/about (accessed 11-30-20).
5. Frellick M. Medical Leaders Launch Grassroots Doctors' Alliance. Medscape. November 25, 2020. Available at https://www.medscape.com/viewarticle/941623 (accessed 12/30/20).

Cite as: Robbins RA. Why My Experience as a Patient Led Me to Join Osler’s Alliance. Southwest J Pulm Crit Care. 2020;21(6):138-40. doi: https://doi.org/10.13175/swjpcc066-20 PDF

Correct Scoring of Hypopneas in Obstructive Sleep Apnea Reduces Cardiovascular Morbidity

James M. Parish, MD¹

David Baratz, MD²

¹Mayo Clinic Arizona; Phoenix, AZ USA

²Pulmonary Associates, Phoenix, AZ USA

Obstructive Sleep Apnea (OSA) is a life-altering disease with a prevalence of 10% in men and 9% in women (1). In some groups (severe obesity, BMI > 40 kg/m2) the prevalence may be as high as 40% (2). One of the most controversial areas in the field of sleep medicine for many years has been the definition of the syndrome. Investigators who first identified OSA created the apnea index (AI), the number of apnea events per hour. An apnea was defined as a complete cessation of airflow for at least 10 seconds. When continuous positive airway pressure (CPAP) treatment for OSA was first introduced, a definition that third-party payors, such as the Center for Medicare and Medicaid Services (CMS), could use to determine which patients qualified for treatment was needed. The definition at that time was 30 apnea events during a 6-hour recording, which corresponded to an AI of 5 events per hour. As further information developed about the syndrome of OSA, the presence of the hypopnea was recognized. A hypopnea was an event that was not a complete cessation of airflow, but rather was a reduction in airflow associated with either a reduction of oxygen saturation and/or an arousal from sleep. Hypopneas were found to have the same clinical significance as apneas. However, controversy surrounded the exact definition of hypopnea. What percentage reduction in airflow? What degree of desaturation, 3%, 4%, other? (3) And what was the exact definition of arousal? Additionally, at this time, CMS would not recognize the use of hypopneas in the definition of OSA for the purpose of qualifying patients for the use of CPAP and a result, many patients with predominantly hypopneas did not meet the qualifications for CPAP.

Subsequently, an agreement between the sleep community and CMS was reached utilizing the definition of hypopnea of a reduction of airflow to 30% of baseline and a 4% oxygen desaturation (4). This definition was based on findings from the Sleep Heart Health Study demonstrating significant cardiovascular effects in patients with obstructive sleep apnea/hypopnea syndrome utilizing this definition. The association of hypopnea with arousal was left out of this definition at this time because there was poor reproducibility in scoring. While the benefit of this agreement was the inclusion of hypopneas which allowed more patients to qualify for PAP therapy, there was a large group of individuals with hypopneas with 3% desaturation and/or an arousal who did not meet the criteria for therapy.

In 2012 the American Academy of Sleep Medicine (AASM) recommended that the hypopnea definition include any decrease in airflow by at least 30% from the baseline with an oxygen desaturation of at least 3% or an arousal from sleep (5,6). This definition often forced many sleep laboratories to score studies twice, once using the 3% rule and the other using the 4% rule. The 3%-4% controversy has continued for many years.

Since then CMS and other payors has not adopted the recommendation of the AASM primarily because of lack of evidence that a 3% decrease is associated with cardiovascular disease and relied on a more restrictive definition of OSA fewer patients with OSA (as defined by the AASM) have been able to obtain life changing therapy such as CPAP. In the view of many, this has increased the risk of developing cardiovascular disease.

In this issue of SWJPCC an article by Quan et al., “The Association Between Obstructive Sleep Apnea Defined by 3 Percent Oxygen Desaturation or Arousal Definition and Self-Reported Cardiovascular Disease in the Sleep Heart Health Study” demonstrates that employing a definition of hypopnea utilizing a 3% reduction in the oxygen desaturation results in an equivalent incidence of cardiovascular disease (CVD) or coronary heart disease (CHD) as the more restrictive 4% definition (7). The shows that in patients followed in the Sleep Heart Health Study (SHHS) that 6307 participants developed CVD/CHD at equal rates based on odds ratios and 95% confidence intervals.  The SHHS was a prospective multicenter cohort study designed to investigate the relationship between OSA and CVD (8).  6441 subjects 40 years and older were recruited in 1995 to undergo polysomnography, having demographic information taken and then self-report if they were ever told by a doctor that they had angina, heart attack, heart failure, stroke or undergone coronary bypass surgery or coronary angioplasty. CHD or CVD was defined as a positive response to one or more of these conditions or procedures. In addition, the presence of hypertension, diabetes, depression, insomnia and hypersomnia in these subjects was assessed.

In this current analysis of the SHHS 3326 participants were found not to have OSA by the 4% CMS rule. Using the 3% AASM definition of hypopnea, 2247 of the 3326 participants were found to have OSA. Participants that were not diagnosed by the 4% rule had OSA ranging in the mild to severe categories. This study suggests that the regulatory requirement by the CMS of using a 4% decrease in oxygen desaturation denies a substantial number of patients the opportunity for treatment of their OSA and may worsen cardiovascular disease or coronary heart disease.

This paper is the first to assess the association of the 3% criteria in the risk of developing CVD/CHD in patients with OSA. The importance of this paper cannot be underestimated.  There are no other studies that have been done or are being done that investigate the risk between OSA or cardiovascular disease using polysomnographic measurements. By utilizing the 3% rule in clinical practice a much larger number of patients would meet the diagnostic criteria of OSA and be eligible to receive treatment.

Treatment of OSA with CPAP has been shown to reduce the severity of CVD, CHD, diabetes, motor vehicle accidents. It also improves daytime alertness, concentration, emotional stability, reduces snoring, and reduces medical expenses (9-11).

The current study provides the necessary information to help resolve the ongoing controversy. The studies data is very robust, using the well-known Sleep Heart Health study. A limitation of the study is that it relies on self-reported history of cardiovascular disease, which is subject to recall bias, but the data is otherwise very strong and robust. Also, some of the correlations are less statistically significant when adjusted for other co-variates.

This study provides proof that a large number of patients with symptomatic and dangerous OSA have been undertreated. It calls for a change in the policy by the CMS and all other payors to provide therapy for patients with OSA based on the American Academy of Sleep Medicine criteria using a 3% reduction in oxygen saturation to score hypopneas.

References

1. Peppard PE, Young T, Barnet JH, Palta M, Hagen EW, Hla KM. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol. 2013 May 1;177(9):1006-14. [CrossRef] [PubMed]
2. Rajala R, Partinen M, Sane T, Pelkonen R, Huikuri K, Seppäläinen AM. Obstructive sleep apnoea syndrome in morbidly obese patients. J Intern Med. 1991 Aug;230(2):125-9. [CrossRef] [PubMed]
3. Redline S, Sanders M. Hypopnea, a floating metric: implications for prevalence, morbidity estimates, and case finding. Sleep. 1997 Dec;20(12):1209-17. [CrossRef] [PubMed]
4. Meoli AL, Casey KR, Clark RW, Coleman JA Jr, Fayle RW, Troell RJ, Iber C; Clinical Practice Review Committee. Hypopnea in sleep-disordered breathing in adults. Sleep. 2001 Jun 15;24(4):469-70. [PubMed]
5. Anonymous. CPAP for Obstructive Sleep Apnea Updated 2020. https://www.cms.gov/Medicare/Coverage/Coverage-with-Evidence-Development/CPAP. 
6. Berry RB, Budhiraja R, Gottlieb DJ, Gozal D, Iber C, Kapur VK, Marcus CL, Mehra R, Parthasarathy S, Quan SF, Redline S, Strohl KP, Davidson Ward SL, Tangredi MM; American Academy of Sleep Medicine. Rules for scoring respiratory events in sleep: update of the 2007 AASM Manual for the Scoring of Sleep and Associated Events. Deliberations of the Sleep Apnea Definitions Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med. 2012 Oct 15;8(5):597-619. [CrossRef] PMID: [PubMed]
7. Quan SF, Budhiraja R, Javaheri S, Parthasarathy S, Berry RB. The Association Between Obstructive Sleep Apnea Defined by 3 Percent Oxygen Desaturation or Arousal Definition and Self-Reported Cardiovascular Disease in the Sleep Heart Health Study. Southwest J Pulm Crit Care. 2020;21(4):86-103. [PubMed]
8. Quan SF, Howard BV, Iber C, Kiley JP, Nieto FJ, O'Connor GT, Rapoport DM, Redline S, Robbins J, Samet JM, Wahl PW. The Sleep Heart Health Study: design, rationale, and methods. Sleep. 1997 Dec;20(12):1077-85. [PubMed]
9. Javaheri S, Barbe F, Campos-Rodriguez F, Dempsey JA, Khayat R, Javaheri S, Malhotra A, Martinez-Garcia MA, Mehra R, Pack AI, Polotsky VY, Redline S, Somers VK. Sleep Apnea: Types, Mechanisms, and Clinical Cardiovascular Consequences. J Am Coll Cardiol. 2017 Feb 21;69(7):841-858. [CrossRef] [PubMed]
10. McEvoy RD, Antic NA, Heeley E, Luo Y, Ou Q, Zhang X, Mediano O, Chen R, Drager LF, Liu Z, Chen G, Du B, McArdle N, Mukherjee S, Tripathi M, Billot L, Li Q, Lorenzi-Filho G, Barbe F, Redline S, Wang J, Arima H, Neal B, White DP, Grunstein RR, Zhong N, Anderson CS; SAVE Investigators and Coordinators. CPAP for Prevention of Cardiovascular Events in Obstructive Sleep Apnea. N Engl J Med. 2016 Sep 8;375(10):919-31. [CrossRef] [PubMed].
11. Anonymous. CPAP – Benefits and Health Risk Prevention. AASM. Sleep Education. 2015, Aug. 10. Available at: http://sleepeducation.org/essentials-in-sleep/cpap/benefits (accessed 10/18/20).

Cite as: Parish JM, Baratz D. Correct Scoring of Hypopneas in Obstructive Sleep Apnea Reduces Cardiovascular Morbidity. Southwest J Pulm Crit Care. 2020;21(4):104-7. doi: https://doi.org/10.13175/swjpcc059-20 PDF

Trump’s COVID-19 Case Exposes Inequalities in the Healthcare System

Early Friday morning (October 2, 2020) President Trump announced through Twitter that he had tested positive for COVID-19 (aka SARS-CoV-2). Later Friday afternoon he was whisked away by helicopter for a 10-minute ride to Walter Reed National Military Medical Center (WRNMMC, formerly Bethesda Naval Medical Center) which is across the street from the National Institutes of Health campus in Bethesda. There he received REGN-COV2, a combination of two monoclonal antibodies (REGN10933 and REGN10987) directed against the spike protein of the COVID-19 virus. In addition, he received a dose of remdesivir (an antiviral drug) as well as zinc, vitamin D, famotidine (Pepcid®), melatonin and aspirin. As of Saturday morning, Trump has done well by all accounts.

All the therapies administered to Trump are unproven but have some evidence supporting their use against COVID-19. The Trump administration issued an emergency use authorization for remdesivir earlier this year after the drug showed moderate effectiveness in improving outcomes for patients who were hospitalized with the coronavirus (1). REGN-COV2 is now in Phase 3 clinical trials, is still experimental and has not received emergency use approval from the FDA. However, it had sufficient evidence for President Trump to receive the drug in response to a compassionate use request to the manufacturer (2). There is also some evidence that the other ancillary therapies might be useful therapies against COVID-19 (3-7).

What these therapies have in common is that the available scientific evidence of their efficacy was funded, at least in part, by the US government, most prominently the FDA’s Coronavirus Treatment Acceleration Program (CTAP) (8). The US government has spent several billion dollars on COVID-19 therapies including $450 million on REGN-COV2 and at least $75 million for remdesivir (9,10). The success of the program is remarkable in light of the disbanding of the National Security Council pandemic unit which had predicted the disaster we are now enduring (11). The ingenuity of the scientific community is truly amazing when motivated by billions of dollars. Those Americans who actually pay taxes should be proud of their government officials for making such successful investments on their behalf.

President Trump’s care is in contrast to my own or the general public. I recently became ill with increasing shortness of breath, orthopnea and a nonproductive cough but no fever. Because I have a history of diastolic dysfunction, I had assumed this was heart failure. As a physician who has many friends in the medical community, I am privileged to be able to call my cardiologist who saw me later that day. The general public might well have had to accept his next available appointment which was over 3 months or go to an emergency room. After 2 days, and 5 trips to a free-standing radiology center and 2 trips to a laboratory testing site, it became clear that I had left lower pneumonia by chest-x-ray and a normal brain naturetic peptide. Later that day I went to a free-standing clinic and had a rapid COVID-19 test which was negative. Because my presentation was atypical for bacterial pneumonia, I called my pulmonary physician who also saw me later that day. He ordered a coccioidomycosis serology and a COVID-19 test by PCR. The former because of the high possibility of Valley Fever which can cause up to a third of community-acquired pneumonias in Arizona and the latter because of the poor sensitivity of the rapid COVID-19 antibody test (12,13). However, I was not able to schedule the collection of the nasal swab or blood for 10 days at a free-standing laboratory. This seems excessively long and my pulmonologist decided against empirical treatment for Valley Fever because of a potential drug interaction with one of my heart medications (dofetilide).

President Trump often brags that the US has the greatest healthcare system in the world and for him it is. Although he repeatedly touted ineffective therapies for COVID-19 such as hydroxychloroquine, bleach and light and belittled those who wore masks, when he got sick only scientifically based therapy was used despite the expense (14). The general public probably does not have President Trump’s or my access to physicians. Donald Trump, the White House staff, and some professional athletes are getting daily COVID-19 tests but the rest of us taxpayers are forced to wait 10 days to get a nasal swab and a blood sample drawn.

USA Today is now reporting that President Trump had earned capital gains from Regeneron Pharmaceuticals and Gilead Sciences, the manufacturers of REGN-COV2 and remdesivir (15). According to a 2017 financial disclosure form filed with the U.S. Office of Government Ethics in June 2017, Trump had a capital gain of $50,001 to $100,000 for Regeneron Pharmaceuticals and $100,001 to $1 million for Gilead. Trump’s subsequent disclosure forms, including his 2020 form signed July 31, did not list Regeneron or Gilead. Ostensibly, he, other family members and close associates sold their stocks to avoid any apparent conflict of interest.

Based on previous experience, I remain skeptical that therapies developed and distributed by our tax monies will really be free. Will the clever businessmen who run drug companies take money from the US government for product development and then bill a hefty sum for their product? Will the rush to develop a vaccine before the November elections put expediency over safety? Some vaccines rushed to market such as the polio vaccine of 1955 or the swine flu vaccine of 1976 resulted in serious side effects in some recipients (16). As Trump is so fond of saying, “We will have to wait and see”.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. FDA. COVID-19 Update: FDA Broadens Emergency Use Authorization for Veklury (remdesivir) to Include All Hospitalized Patients for Treatment of COVID-19. August 28, 2020. Available at: https://www.fda.gov/news-events/press-announcements/covid-19-update-fda-broadens-emergency-use-authorization-veklury-remdesivir-include-all-hospitalized#:~:text=Today%2C%20as%20part%20of%20its,laboratory%2Dconfirmed%20COVID%2D19%2C (accessed 10/3/20).
2. Farr C, Stankiewicz K. Here’s everything we know about the unapproved antibody drug Trump took to combat coronavirus. CNBC. October 2, 2020. Available at: https://www.cnbc.com/2020/10/02/what-we-know-about-regeneron-antibody-drug-trump-took-to-combat-coronavirus.html (accessed 10/3/20).
3. Arentz S, Yang G, Goldenberg J, et al. Clinical significance summary: Preliminary results of a rapid review of zinc for the prevention and treatment of SARS-CoV-2 and other acute viral respiratory infections [published online ahead of print, 2020 Aug 1]. Adv Integr Med. 2020;10.1016/j.aimed.2020.07.009. [CrossRef] [PubMed]
4. Entrenas Castillo M, Entrenas Costa LM, Vaquero Barrios JM, Alcalá Díaz JF, López Miranda J, Bouillon R, Quesada Gomez JM. "Effect of calcifediol treatment and best available therapy versus best available therapy on intensive care unit admission and mortality among patients hospitalized for COVID-19: A pilot randomized clinical study". J Steroid Biochem Mol Biol. 2020 Oct;203:105751. [CrossRef] [PubMed]
5. Freedberg DE, Conigliaro J, Wang TC, Tracey KJ, Callahan MV, Abrams JA; Famotidine Research Group. Famotidine Use Is Associated With Improved Clinical Outcomes in Hospitalized COVID-19 Patients: A Propensity Score Matched Retrospective Cohort Study. Gastroenterology. 2020 Sep;159(3):1129-1131.e3. [CrossRef] [PubMed]
6. Zhang R, Wang X, Ni L, et al. COVID-19: Melatonin as a potential adjuvant treatment. Life Sci. 2020;250:117583. [CrossRef] [PubMed]
7. Mohamed-Hussein AAR, Aly KME, Ibrahim MAA. Should aspirin be used for prophylaxis of COVID-19-induced coagulopathy? Med Hypotheses. 2020 Jun 8;144:109975. [CrossRef] [PubMed]
8. FDA. Coronavirus Treatment Acceleration Program (CTAP). Available at: https://www.fda.gov/drugs/coronavirus-covid-19-drugs/coronavirus-treatment-acceleration-program-ctap (accessed 10/3/20).
9. Loftus P, Walker J.  U.S. Commits $2 Billion for Covid-19 Vaccine, Drug Supplies. Wall Street Journal. July 7, 2020. Available at: https://www.wsj.com/articles/u-s-commits-2-billion-for-covid-19-vaccine-drug-supplies-11594132175 (accessed 10/3/20).
10. Public Citizen. The Public Already Has Paid for Remdesivir. Available at: https://www.citizen.org/news/the-public-already-has-paid-for-remdesivir/ (accessed 10/3/20).
11. Riechmann D. Trump disbanded NSC pandemic unit that experts had praised. AP News. March 14, 2020. Available at: https://apnews.com/article/ce014d94b64e98b7203b873e56f80e9a (accessed 10/3/20).
12. Valdivia L, Nix D, Wright M, Lindberg E, Fagan T, Lieberman D, et al. Coccidioidomycosis as a common cause of community-acquired pneumonia. Emerg Infect Dis. 2006;12(6):958-62. [CrossRef] [Pubmed]
13. Guglielmi G. Fast coronavirus tests: what they can and can't do. Nature. 2020 Sep;585(7826):496-498. [CrossRef] [PubMed]
14. Robbins RA. Lack of natural scientific ability. Southwest J Pulm Crit Care. 2020;21(1):15-22. [CrossRef]
15. Tyko K. Trump COVID-19 treatment: President had stakes in Regeneron and Gilead, makers of antibody cocktail, Remdesivir. USA Today. October 3, 2020. Available at: https://www.usatoday.com/story/money/2020/10/03/trump-walter-reed-treatment-president-regeneron-gilead-remdesivir/3610111001/ (accessed 10/3/20).
16. Trogen B, Oshinsky D, Caplan A. Adverse Consequences of Rushing a SARS-CoV-2 Vaccine: Implications for Public Trust. JAMA. 2020 Jun 23;323(24):2460-2461. [CrossRef] [PubMed]

Cite as: Robbins RA. Trump’s COVID-19 Case Exposes Inequalities in the Healthcare System. Southwest J Pulm Crit Care. 2020;21(4):82-5. doi: https://doi.org/10.13175/swjpcc055-20 PDF 

Lack of Natural Scientific Ability

Back in March President Trump suggested he would have thrived in another profession, medical expert (1). Despite no training or experience, Trump boasted “I like this stuff. I really get it”. Citing a “great, super-genius uncle” who taught at MIT, Trump professed that it must run in the family genes. Trump went on to say “People are really surprised I understand this stuff … Maybe I have a natural ability.”

This was followed by a series of White House briefings where Trump and members of his White House Coronavirus Task Force spoke on the COVID-19 pandemic. Trump tried to dominate these conferences and repeatedly lied about the coronavirus pandemic and the country’s preparation for this once-in-a-generation crisis. Below is a partial list of 35 of the biggest lies about the COVID-19 pandemic he’s told as the nation endures a public-health and economic calamity are in Table 1 (2). 

Table 1. Partial list of Trump lies regarding the COVID-19 pandemic (2).

Date	Trump claim	Truth
2/7/20	The coronavirus would weaken “when we get into April, in the warmer weather—that has a very negative effect on that, and that type of a virus.”	Respiratory viruses can be seasonal, but the COVID-19 can be transmitted in ALL AREAS, including areas with hot and humid weather and is clearly not diminishing.
2/27/20	The outbreak would be temporary: “It’s going to disappear. One day it’s like a miracle—it will disappear.”	Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, warned days later that he was concerned that “as the next week or two or three go by, we’re going to see a lot more community-related cases.”
Multiple times	The claim: If the economic shutdown continues, deaths by suicide “definitely would be in far greater numbers than the numbers that we’re talking about” for COVID-19 deaths.	The number of people who died by suicide in the US in 2017 was roughly 47,000, nowhere near the COVID-19 deaths now at about 147,000 (3).
Multiple times	“Coronavirus numbers are looking MUCH better, going down almost everywhere,” and cases are “coming way down.”	Most states now have rising COVID-19 cases, hospitalizations and deaths (3).
7/2/20	The pandemic is “getting under control.”	Most states now have rising COVID-19 cases, hospitalizations and deaths (3). It is not under control.
7/4/20	“99%” of COVID-19 cases are “totally harmless.”	The evidence shows that the virus “can make you seriously ill” even if it doesn’t kill you
7/6/20	“We now have the lowest Fatality (Mortality) Rate in the World.”	The U.S. has neither the lowest mortality rate nor the lowest case-fatality rate (3).
3/4/20	“The Obama administration made a decision on [laboratory] testing that turned out to be very detrimental to what we’re doing.”	The Trump White House rolled back Food and Drug Administration regulations that limited the kind of laboratory tests states could run and how they could conduct them.
3/13/20	The Obama White House’s response to the H1N1 pandemic was “a full scale disaster, with thousands dying, and nothing meaningful done to fix the testing problem, until now.”	Barack Obama declared a public-health emergency two weeks after the first U.S. cases of H1N1 were reported, in California. Trump declared a national emergency more than seven weeks after the first domestic COVID-19 case was reported, in Washington State. While testing is a problem now, it wasn’t back in 2009. The challenge then was vaccine development: Production was delayed and the vaccine wasn’t distributed until the outbreak was already waning.
Multiple times	The Trump White House “inherited” a “broken,” “bad,” and “obsolete” test for the coronavirus.	The novel coronavirus did not exist in humans during the Obama administration.
Multiple times	The Obama administration left Trump “bare” and “empty” shelves of medical supplies in the national strategic stockpile.	The stockpile’s former director said in 2019, before the coronavirus pandemic, that it was well-equipped. The outbreak has since eaten away at its reserves.
5/10/20	Trump attacked “Joe Biden’s handling of the H1N1 Swine Flu.”	Biden was not responsible for the federal government’s response to the H1N1 outbreak.
3/6/20 & 5/11/20	“Anybody that needs a test, gets a test. We—they’re there. They have the tests. And the tests are beautiful” and “If somebody wants to be tested right now, they’ll be able to be tested.”	Trump made these two claims two months apart, but the truth is still the same: The U.S. does not have enough testing.
3/24 & 3/25/20	The United States has outpaced South Korea’s COVID-19 testing: “We’re going up proportionally very rapidly,” Trump said during a Fox News town hall.	When the president made this claim, testing in the U.S. was severely lagging behind that in South Korea. As of March 25, South Korea had conducted about five times as many tests as a proportion of its population relative to the United States.
5/11/20	America has “developed a testing capacity unmatched and unrivaled anywhere in the world, and it’s not even close.”	The United States is still not testing enough people and is lagging behind the testing and tracing capabilities that other countries have developed.
Multiple times	“Cases are going up in the U.S. because we are testing far more than any other country.”	COVID-19 cases are not rising because of “our big-number testing.” Outside the Northeast, the share of tests conducted that come back positive is increasing, with the sharpest spike happening in southern states. In some states, such as Arizona and Florida, the number of new cases being reported is outpacing any increase in the states’ testing ability. And as states set new daily case records and report increasing hospitalizations, all signs point to a worsening crisis.
3/11/20	The United States would suspend “all travel from Europe, except the United Kingdom, for the next 30 days.”	The travel restriction would not apply to U.S. citizens, legal permanent residents, or their families returning from Europe.
3/12/20	All U.S. citizens arriving from Europe would be subject to medical screening, COVID-19 testing, and quarantine if necessary. “If an American is coming back or anybody is coming back, we’re testing,” Trump said. “We have a tremendous testing setup where people coming in have to be tested … We’re not putting them on planes if it shows positive, but if they do come here, we’re quarantining.”	Testing was already severely limited in the United States at the time Trump made this claim. It was not true that all Americans returning to the country are being tested, nor that anyone is being forced to quarantine.
3/31/20	“We stopped all of Europe” with a travel ban. “We started with certain parts of Italy, and then all of Italy. Then we saw Spain. Then I said, ‘Stop Europe; let’s stop Europe. We have to stop them from coming here.’”	The travel ban applied to the Schengen Area, as well as the United Kingdom and Ireland, and not all of Europe as he claimed.
Multiple times	“Everybody thought I was wrong” about implementing restrictions on travelers from China, and “most people felt they should not close it down—that we shouldn’t close down to China.”	The travel ban was the “uniform” recommendation of the Department of Health and Human Services.
Multiple times	travel restrictions on China were a “ban” that closed up the “entire” United States and “kept China out.”	Nearly 40,000 people traveled from China to the United States from February 2, when Trump’s travel restrictions went into effect, to April 4.
3/17/20	I’ve always known this is a real—this is a pandemic. I felt it was a pandemic long before it was called a pandemic … I’ve always viewed it as very serious.”	Trump has repeatedly downplayed the significance of COVID-19 as outbreaks began stateside. From calling criticism of his handling of the virus a “hoax,” to comparing the coronavirus to a common flu, to worrying about letting sick Americans off cruise ships because they would increase the number of confirmed cases, Trump has used his public statements to send mixed messages and sow doubt about the outbreak’s seriousness.
3/26/20	This kind of pandemic “was something nobody thought could happen … Nobody would have ever thought a thing like this could have happened.”	Experts both inside and outside the federal government sounded the alarm many times in the past decade about the potential for a devastating global pandemic.
3/2/20	Pharmaceutical companies are going “to have vaccines, I think, relatively soon.”	The president’s own experts told him during a White House meeting with pharmaceutical leaders earlier that same day that a vaccine could take a year to 18 months to develop.
3/19/20	Trump said the FDA had approved the antimalarial drug chloroquine to treat COVID-19. “Normally the FDA would take a long time to approve something like that, and it’s—it was approved very, very quickly and it’s now approved by prescription,” he said.	FDA Commissioner Stephen Hahn quickly clarified that the drug still had to be tested in a clinical setting.
3/23/20	Trump suggested in a briefing on April 23 that his medical experts should research the use of powerful light and injected disinfectants to treat COVID-19.	Trump walked this statement back the next day, saying he was being “sarcastic”.
5/8/20	The coronavirus is “going to go away without a vaccine … and we’re not going to see it again, hopefully, after a period of time.”	Tony Fauci has said that until there is “a scientifically sound, safe, and effective vaccine” the pandemic will not be over.
Multiple times	Taking hydroxychloroquine to treat COVID-19 is safe. “You’re not going to get sick or die,” Trump said on one occasion. “It doesn’t hurt people,” he commented on another.	Trump’s own FDA has warned against taking the antimalarial drug with or without the antibiotic azithromycin, which Trump has also promoted.
5/9/20	“One bad” study from the Department of Veterans Affairs that found no benefit among veterans who took hydroxychloroquine to treat COVID-19 was run by “people that aren’t big Trump fans.” The study “was a Trump-enemy statement.”	There’s no evidence that the study was a political plot orchestrated by Trump opponents, and it reached similar conclusions as other observational reports. The VA study was led by independent researchers from the University of Virginia and the University of South Carolina with a grant from the National Institutes of Health.
3/20/20	Trump twice said during a task-force briefing that he had invoked the Defense Production Act (DPA), a Korean War–era law that enables the federal government to order private industry to produce certain items and materials for national use. He also said the federal government was already using its authority under the law: “We have a lot of people working very hard to do ventilators and various other things.”	Federal Emergency Management Agency Administrator Peter Gaynor told CNN on March 22 that the president has not actually used the DPA to order private companies to produce anything. Shortly after that, Trump backtracked, saying that he had not compelled private companies to take action. Then, on March 24, Gaynor told CNN that FEMA plans to use the DPA to allocate 60,000 test kits. Trump tweeted afterward that the DPA would not be used.
3/21/20	Automobile companies that have volunteered to manufacture medical equipment, such as ventilators, are “making them right now.”	Ford and General Motors, which Trump mentioned at a task-force briefing the same day, announced earlier in March that they had halted all factory production in North America and were likely months away from beginning production of ventilators.
3/24/20	Governor Andrew Cuomo of New York passed on an opportunity to purchase 16,000 ventilators at a low cost in 2015, Trump said during the Fox News town hall.	Trump seems to have gleaned this claim from a Gateway Pundit article. There is no evidence that Cuomo was offered the ventilators or turned any offer down.
3/29/20	Trump “didn’t say” that governors do not need all the medical equipment they are requesting from the federal government. And he “didn’t say” that governors should be more appreciative of the help.	Trump told Fox News’ Sean Hannity on Thursday, March 26, that “a lot of equipment’s being asked for that I don’t think they’ll need,” referring to requests from the governors of Michigan, New York, and Washington. He also said, during a Friday, March 27, task-force briefing, that he wanted state leaders “to be appreciative … We’ve done a great job.”
3/29 and 3/30/20	Hospitals are reporting an artificially inflated need for masks and equipment, items that might be “going out the back door,” Trump said on two separate days. He also said he was not talking about hoarding: “I think maybe it’s worse than hoarding.”	There is no evidence to show that hospitals are maliciously hoarding or inflating their need for masks and personal protective equipment when reporting shortages in supplies.
4/14/20	Asked about his past praise of China and its transparency, Trump said that he hadn’t “talk[ed] about China’s transparency.”	Trump lauded the country in tweets he sent in late January and early February. In one, he highlighted the Chinese government’s “transparency” about the coronavirus outbreak.
3/29/20	WHO ignored “credible reports” of the coronavirus’s spread in Wuhan, the Chinese city that first reported the new virus, including those published in The Lancet medical journal in December.	The Lancet said it did not publish such reports in December. Its first reports on the virus’s spread in Wuhan were published on January 24.

Trump eventually stopped the news briefings in face of their declining popularity and public trust and being outshone by Tony Fauci MD, director of National Institute of Allergy and Infectious Disease. Fauci is best known as an expert virologist for his handling of the Acquired Immunodeficiency Disease Syndrome (AIDS). He has faithfully served his patients, the American people, through six presidential administrations, providing sound, science‐based guidance. However, he has been wrong. Two examples are not recommending masks early in the COVID-19 pandemic and stating that few COVID-19 patients were asymptomatic (4). However, both were based on the best available scientific evidence of the time which turned out to be wrong. In neither instance was Fauci’s honesty questioned and, in both instances, Fauci self-corrected those errors.

The strained relationship between the White House and Fauci has been apparent for months. Trump was visibly annoyed when Fauci spoke at news briefings (5). In April Trump retweeted a call to fire Fauci during early criticism of Trump’s mishandling of the COVID-19 pandemic (6). He has attempted to silence Fauci’s inconvenient scientific voice from testifying before Congress and giving TV interviews (7). More recently, he has tried an old tactic of having aides and underlings attack opponents and then evaluating how it plays with the public. If it goes well Trump repeats it, but if it does not, he says the aide was acting on his own. The White House let their top economic advisor, Peter Navarro, attack Fauci in an USA Today op-ed (8). Last Sunday, White House scientific advisor Brett Girori MD tried to undermine Fauci last Sunday on Meet the Press saying Fauci only looks at the COVID-19 pandemic from “a very narrow public health point of view”; doesn’t “have the whole national interest in mind’; and repeated the White House opposition to Fauci’s call for states experiencing COVID-19 surges to pause their reopening processes (9).

The attacks against Fauci were apparently unsuccessful. Referring to the White House attacks, Fauci remained calm saying, “I cannot figure out in my wildest dreams why they would want to do that” (10). New polling from Quinnipiac University found that 65% of voters trust the information Fauci is providing about the coronavirus while only 30% trust the information provided by Trump (11). In the face of the polls favorable to Fauci, the White House is now distancing itself from Navarro saying he went rogue failing to obtain proper clearance for his op-ed (12).

In a closely related event, the Trump Administration has mandated that hospitals sidestep the Centers for Disease Control and Prevention and send critical information about COVID-19 hospitalizations and equipment to a different federal database (13). From the start of the pandemic, the CDC has collected data on COVID-19 hospitalizations, availability of intensive care beds and personal protective equipment. The change sparked concerns that the administration was hobbling the ability of the nation's public health agency to gather and analyze crucial data in the midst of a pandemic. It further allows data to be manipulated, altered or spun for political purposes. The decision raises serious questions about the credibility, transparency, and availability of data needed by public health officials, researchers, and physician leaders to advance science-based and data-driven decision-making. The White House has lied enough to show they cannot be trusted with data needed for responses to the COVID-19 pandemic such as reopening.

The scientific data is what it is. It has no philosophy, no politics, and is often not what we want it to be. During this pandemic which is the most catastrophic public health disaster since the “Spanish Flu” of 1918, we need scientific leadership to ensure that the data is driving our responses and not being driven by a political agenda. Leaders like Tony Fauci are needed for this pandemic. Others who attempt to undermine Fauci for their own nefarious political purposes will hopefully be ignored by the public. Nonscientific wags who claim scientific abilities they do not have do not really get it. They will likely lead us towards a cataclysmic catastrophe that could be diminished with sensible decisions made on the basis of science rather than politics.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Nakamura D. ‘Maybe I have a natural ability’: Trump plays medical expert on coronavirus by second-guessing the professionals. Washington Post. March 6, 2020. Available at:  https://www.washingtonpost.com/politics/maybe-i-have-a-natural-ability-trump-plays-medical-expert-on-coronavirus-by-second-guessing-the-professionals/2020/03/06/3ee0574c-5ffb-11ea-9055-5fa12981bbbf_story.html (accessed 7/17/20).
2. Paz C. All the president’s lies about the coronavirus. The Atlantic. July 13, 2020. https://www.theatlantic.com/politics/archive/2020/07/trumps-lies-about-coronavirus/608647/ (accessed 7/17/20).
3. Coronavirus Resource Center. Johns Hopkins University. Available at: https://coronavirus.jhu.edu/ (accessed 7/17/20).
4. Panetta G. Fauci says he doesn't regret telling Americans not to wear masks at the beginning of the pandemic. Business Insider. Jul 16, 2020. Available at: https://www.businessinsider.com/fauci-doesnt-regret-advising-against-masks-early-in-pandemic-2020-7 (accessed 7/17/20).
5. Lahut J. Trump is reportedly getting frustrated with Dr. Fauci's 'blunt approach' during White House press conferences. Business Insider. Mar 23, 2020. Available at: https://www.businessinsider.com/trump-reportedly-growing-frustrated-with-dr-faucis-blunt-approach-2020-3 (accessed 7/17/20).
6. Brewster J. Trump retweets call to fire Fauci after he criticized U.S. response to virus. April 13, 2020. Available at: https://www.forbes.com/sites/jackbrewster/2020/04/13/trump-retweets-call-to-fire-fauci-after-he-criticized-us-response-to-virus/#47860ca451d6 (accessed 7/17/20).
7. Pramuk J. White House blocks Fauci from testifying at House coronavirus hearing. CNBC. May 1, 2020. Available at: https://www.cnbc.com/2020/05/01/anthony-fauci-blocked-from-testifying-at-house-coronavirus-hearing.html (accessed 7/17/20).
8. Navarro P. Anthony Fauci has been wrong about everything I have interacted with him on. USA Today. July 14, 2020. Available at: https://www.usatoday.com/story/opinion/todaysdebate/2020/07/14/anthony-fauci-wrong-with-me-peter-navarro-editorials-debates/5439374002/ (accessed 7/17/20).
9. Meet the Press. July 12, 2020. https://www.nbcnews.com/meet-the-press/video/adm-brett-grior-dr-fauci-is-not-100-percent-right-about-covid-19-response-87536197610 (accessed 7/17/20).
10. Nicholas P, Yong E. 1.        Fauci: ‘Bizarre’ White House Behavior Only Hurts the President. July 15, 2020. Available at: https://www.theatlantic.com/politics/archive/2020/07/trump-fauci-coronavirus-pandemic-oppo/614224/ (accessed 7/17/20).
11. Stelter B. New poll reaffirms that most Americans don't trust the President, but they do trust Dr. Fauci. CNN Business. July 16, 2020. Available at: https://www.cnn.com/2020/07/15/media/poll-trump-fauci-reliable-sources/index.html (accessed 7/17/20).
12. Samuels B. White House distances itself from Navarro op-ed bashing Fauci. The Hill. 07/15/20. Available at: https://thehill.com/homenews/administration/507406-white-house-distances-itself-from-navarro-op-ed-bashing-fauci (accessed 7/17/20).
13. Huang P, Simmons-Duffin S.  White House strips CDC of data collection role for COVID-19 hospitalizations. NPR. July 15, 2020. https://www.npr.org/sections/health-shots/2020/07/15/891351706/white-house-strips-cdc-of-data-collection-role-for-covid-19-hospitalizations (accessed 7/17/20).

Cite as: Robbins RA. Lack of natural scientific ability. Southwest J Pulm Crit Care. 2020;21(1):15-22. doi: https://doi.org/10.13175/swjpcc044-20 PDF