Against Medical Advice

Every patient has the option of ignoring the advice offered by health professionals.  If they are hospitalized and they decide to leave without their doctor’s blessing, they are asked to sign what is called an AMA form.  This is an “Against Medical Advice” document that acknowledges that the patient is not following medical recommendations and has chosen to leave the facility where he or she has been under treatment or receiving testing. If the healthcare providers believe the patient is too disturbed, deranged or demented to make a rational choice, the burden falls on the healthcare providers to prove their case.

Few take up the challenge. If they honor a person’s demand to leave the hospital and that disturbed person ends up hurting himself or someone else, they can always claim that he seemed coherent on the way out the door.  If they try to keep him in the facility against his wishes, they may face inquiries from lawyers or worse.

“What constitutes worse?” you might ask. Well, suppose the patient is your boss. Suppose he can not only fire you, but also end your career in your chosen field. Suppose he is the president of the United States, the Commander-in-Chief of the armed forces, and you are employed in a military hospital and tasked with treating him for a potentially fatal illness. As we learned in recent weeks, that is not so far-fetched a possibility. We also learned how this scenario plays out.

Presidential Privacy

Grover Cleveland had a tumor, a sarcoma, growing in his jaw. His physician realized that surgery was necessary to save the president’s life, but President Cleveland was concerned about the political impact of any suggestion that he had a life-threatening condition. The solution was to announce that he was taking a boat trip and could not be reached for several days. Physicians were clandestinely boarded onto the vessel and sworn to secrecy.  They performed the surgery, dressed the wound, and left the boat. 

The president recovered, and no one would have been the wiser if it had not been for a “leak” by one of the principals at the surgery.  One of the physicians was being soundly abused by his colleagues for not keeping an appointment that he had promised to keep no matter what the circumstances. After taking grief for not keeping his word, he confided in his abusers that he had to help save Grover Cleveland’s life. The president’s handlers denied all of the leaked information and set about to ruin the fine doctor’s career. Which brings us to 2020.

Donald Trump contracted CoVid-19 and was exhibiting worrisome signs. His blood oxygen level while at the White House dropped to levels warranting supplementary oxygen. He had fever, cough and other signs of serious illness. At 74 years of age, his risk of being killed by this viral illness was somewhere between one in 20 to one in seven depending upon any underlying conditions he had. Consequently, he was taken to Walter Reed Military Hospital. What followed was a medical adventure unique in too many ways to enumerate.

That information released was fragmentary and inconsistent was not surprising.  Most patients are afforded more privacy when hospitalized than was afforded Mr. Trump, but most patients are not the leader of the free world. When the man carrying the nuclear launch codes is under the weather, one would hope for more transparency than when your neighbor with the bad cold does not come out of his house for a few days. [Note: At least one of the military men assigned to actually carry the case with the nuclear codes tested positive for Covid-19 after Mr. Trump tested positive].  The words spoken about this hospital admission, the portrayal of the physicians involved, and even the timing of the hospital discharge were so tightly choreographed as to suggest there had been several dress rehearsals.

The Trump Medical Team

When the medical team assembled outside the entrance to Walter Reed Hospital for the first press briefing on Oct. 3, we learned little from what they said but much from their group photo. There were 10 people, all in wrinkle-free, white lab coats covering what appeared to be surgical scrubs (except for the primary spokesperson, Dr. Conley, who wore a white shirt and elegant tie) arrayed in two carefully spaced rows. Two of the 10 were women. One of the 10 was an African-American man. The following day, Oct. 4, there were seven white men. Gone were the women and the African-American man, never to appear again as care-givers to Mr. Trump.

We were told that President Trump was being managed by the best doctors in America. The medical team that appeared outside Walter Reed Hospital day after day and that addressed the news cameras was all male and all white. I have had the good fortune to meet and talk to many of the best doctors in America, and they were usually not white and often not male. American medicine over the past century has benefited from a diversity of practitioners, both homegrown and foreign, both male and female. The daily photo opportunities at Walter Reed Hospital presented inaccurate and misleading depictions of the best in American medicine.

The Protocol

We learned that Mr. Trump had been given a drug (remdesivir) still in clinical trials to establish efficacy, an antibody cocktail that has barely entered the regulatory pathway for approval, and a steroid (dexamethasone) that has shown some benefit for people with Covid-19 requiring mechanical ventilation. We were simultaneously reassured that he was doing well, despite his being treated with a combination of drugs unavailable to anyone else in America, including medications generally reserved for the desperately ill. Mr. Trump survived the hospital, but candor did not.

We were assured that this implausible course of treatment was designed by these “best” doctors, an assurance that strained credulity beyond its breaking point. No reasonable physician would prescribe a material, the Regeneron antibody cocktail, that has not yet been established as safe or effective to an individual who had not already received and failed to improve with less hazardous management. No reasonable physician would prescribe a potent steroid, the dexamethasone, that was replete with dangerous side effects, including psychosis, to an individual with Covid-19 who was not in severe respiratory distress. Of course, the question then becomes, “Who came up with this high-risk, untested treatment for the leader of the free world?”

I tried and failed to fit into corporate America because of my irrepressible tendency to ask, “Are you serious?” The doctors at Walter Reed Hospital could not ask their boss that question even though he was their patient. I believe these neatly attired, white men arrayed dutifully at the bottom of the steps to this military hospital followed the orders they were given without daring to voice that awful question that so often burst from my mouth. Perhaps the two white women and one African-American man in the photo-op on day one whispered that unacceptable question to their superiors and as a consequence were banished from the group.

The regimen adopted conformed more to the uninformed banter of golfing buddies at an exclusive country club than to the combined wisdom of America’s best doctors. Mr. Trump appears to have survived his treatment and his infection. I hope America does as well.

Dr. Lechtenberg is an Easton resident who graduated from Tufts University and Tufts Medical School in Massachusetts and subsequently trained at The Mount Sinai Hospital and Columbia-Presbyterian Medical Center in Manhattan.  He worked as a neurologist at several New York Hospitals, including Kings County and The Long Island College Hospital, while maintaining a private practice, teaching at SUNY Downstate Medical School, and publishing 15 books on a variety of medical topics. He worked in drug development in the USA, as well as in England, Germany, and France.

image_pdfimage_print