For Immediate Release
Office of the Press Secretary
June 28, 2002
Press Briefing by Dr. Richard Tubb
The James S. Brady Briefing Room
Remarks from the President
4:22 P.M. EDT
MR. FLEISCHER: All right. Very briefly, I want to, before I introduce Dr. Richard Tubb, the physician to the President, Air Force Colonel -- just, if you remember last year, on August 4th, you should have the news release that was put out when the President had his annual physical. In there, as the President indicated under his past medical history, it indicated benign colonic adenomatous polyps removed on screen and colonoscopy July '98 and December '99. And then under the physical exam it indicated "surveillance colonoscopy is not indicated until next year." That was what was written in August 2001.
Next year has arrived, and tomorrow the President will have this procedure. And that's why I would like Dr. Tubb to walk you through the procedure and take the questions you may have.
DR. TUBB: Good afternoon. As Ari said, my name is Dick Tubb, I'm the President's doctor. I'd like to spend a little time telling you about what the President will go through tomorrow, but I think before I do that I would like the take-home message here to be that this is routine, preventive medicine in practice. And if you're over 50, it ought to be part of your routine, as well. And after having spent the one to two weeks with wellness and the fitness at the White House, it's only natural that we take it to this arena, as well.
As Ari mentioned and as the President mentioned outside, he does have a history of colon polyps and last year at his physical we made the recommendation to him that sometime during this year he ought to have a repeat colonoscopy. His colonoscopies were performed in June of '98 and December of '99, both of which showed two small adenomatous polyps.
Q You said July. June or July?
DR. TUBB: Let me check and see what it is.
Q In each case there were two?
DR. TUBB: Each case there were two.
MR. FLEISCHER: July '98 and December '99.
DR. TUBB: Okay, thanks. As we'll discuss, those are removed during the procedure that we're going to discuss. A colonoscopy is routinely performed across the country and around the world. In 2000, 4.3 million colonoscopies were performed, for routine screening or for diagnostic tests. But it is a very, very common procedure.
The procedure is usually done under sedation in this country. Colonoscopies themselves can be uncomfortable, and for that reason we use usually an intravenous sedative. It can be done without sedation, but in general most patients would prefer to be sedated. Other countries may use general anesthesia, or they, too, may use nothing at all. So the routine practice in this country is colonoscopy under intravenous sedation.
Tomorrow, the President will have an intravenous line started and will be sedated with the anesthetic, after which a flexible fiber optic scope, a colonoscope, will be inserted to look at the surface, or the mucosal lining, of the large intestine, or the colon. The beauty of the colonoscopy is that it is able to examine an entire colon from start to finish.
There are other colorectal screening procedures, but colonoscopy is the one and only that can look in detail at the entire colon. It is the recommended procedure for somebody who's had polyps before, as in the case of the President.
During the procedure, the colonoscopist, the gastroenterologist, the physician who is conducting the procedure, is able to view the surface or the lining of the colon through a television camera, a television screen hooked up to the fiber optic scope, at which point he will be able to identify any, what we call mucosal irregularities, any irregularities in the lining of the polyp -- and in this case, we're particularly interested in polyps, as the President had said.
Should the colonoscopist identify any polyps on this exam, as in the past, he will remove them as he has done in the past. Once removed, those polyps present no problem whatsoever, and that's why I say this is preventive medicine at its finest.
The whole procedure can take anywhere from 30 to 45 minutes, but it's difficult to predict; it may be less, it may be a little bit more, depending on the ease of the procedure and what is or is not found. After the procedure is done, the President will recover from the sedation and will be able to resume a normal diet and schedule following.
So with that --
Q A couple of questions, Doctor, if I may. How deeply will he be sedated? And was it his decision to take the sedation, or your recommendation? Because I know it's done without, I know of people who have had it done without.
DR. TUBB: To answer your second question first, the President, as with any patient, may ask my recommendation. And my recommendation is that he do it under sedation. I have had the procedure myself, both with sedation and without, and I will tell everybody here I recommend having it with sedation. (Laughter.) I think that one's -- we'll leave that at that. (Laughter.)
And it was his decision to take me up on it. I'm sorry, your first one?
Q How --
DR. TUBB: How heavily is going to be sedated? We've chosen a particular medication called propofol. It's an intravenous medication --
DR. TUBB: P-r-o-p-o-f-o-l, propofol, that is the generic name. There's a couple different makers of it. But propofol is the anesthetic we've chosen. We've chosen it because it is ultra-short-acting. It has a very rapid onset, within 30 to 60 seconds after starting the medication the individual will fall asleep, shall we say. It has a very short half-life, which would be important to any doctors that get this information, anywhere from 1.8 to 4.1 minutes, which means that you can turn the medicine off and your patient wakes right up. Time to awakening is around two to four minutes, so it is very, very short-acting.
The other good thing about it is it is very predictable in its action. You can almost dial in your effect, and that's where I'm getting in to answer your question. the doctor, the anesthesiologist in this particular case will be able to dial the medication to exactly the right level where the President is comfortable, but at the same time relaxed enough that they can get a good exam.
It's important that your patient is comfortable, because if he or she -- he, in this case -- is exhibiting signs of pain, there's going to be pressure on the endoscopist to do the procedure as quickly as possible. And we want to get a good exam, whether the patient is the President or any one of you all.
Q Does that mean he's unconscious, fully unconscious?
DR. TUBB: It can go anywhere from lightly sedated, Sondra, to heavily sedated. So when heavily sedated he could be fully unconscious; lightly sedated, it would be what we call, it's kind of a play on words, but it's not -- in the medical world it's call "conscious sedation," which then progresses into monitored anesthesia care.
Q And you're saying they'll make that decision based on --
DR. TUBB: Based on his comfort level, yes.
Q -- once they see how he reacts?
DR. TUBB: Exactly. Exactly.
Q What are the mechanics of the transfer of power, and how long will the Vice President be President?
MR. FLEISCHER: Judge, do you want to address that?
Q And has this ever been done before?
MR. FLEISCHER: Judge Gonzales can address that.
JUDGE GONZALES: Yes, Section 3 of the 25th Amendment is a provision that will be invoked tomorrow. Section 3 provides a constitutional framework for the voluntary transfer of Presidential power from the President to the Vice President. It is an automatic transfer when the President of the United States submits a written declaration to the Speaker of the House and the President Pro Tem that the President is unable to discharge his duties as President of the United States.
The transfer of power automatically ends when the President submits a written declaration to the Speaker and to the President Pro Tem that he is able to discharge his duties and powers as President of the United States.
The invocation of Section 3 has occurred only once in history, and that was on July 13, 1985, when President Ronald Reagan underwent surgery for colon cancer. So that's the procedure used to invoke Section 3.
Q Do we know about how long that the Vice President will be President? For like an hour, two hours?
MR. GONZALES: It's hard to tell. That will depend on a variety of factors, and Dr. Tubb can probably address this more fully. I mean, as he indicated, it will depend on the level of anesthesia, and so -- the condition of the patient. So it will be a matter of hours.
Q Do the papers actually have to go from the White House to the Congressional leaders, back and forth? Is that --
Q Or do they fax them?
MR. GONZALES: The information will be faxed.
Q Faxed. And they've been briefed, I assume, already?
MR. GONZALES: They were advised this afternoon, as well as certain members of the Cabinet.
Q Why was the President not sedated in this way the last time he had a colonoscopy as President?
MR. FLEISCHER: He hasn't had a colonoscopy as President.
Q -- so within --
DR. TUBB: The President had a colonoscopy as Governor. He has not had one as President.
Q Was he sedated -- I apologize, because I missed the beginning.
DR. TUBB: The answer is, yes. Yes, it was done in December of '99, so he was not yet President. And he was sedated, and did quite well with the medication, and was able to return to work. In that case, though, he used three medications.
Q Dr. Tubb, can we go to this time line? His first one was in 7/98, so a year and a half later he had the second one, 12/99.
DR. TUBB: Yes.
Q And then, is it -- and forgive me, I can't do math -- was it two and a half years?
DR. TUBB: Roughly two and a half years.
Q So why did -- why did you do a year and a half between the first two, and now you've waited two and a half years to do the third one?
DR. TUBB: Well, I can't answer as to why the endoscopist before he became President did it. I can tell you that this has been a very fluid issue in the GI or gastroenterologic community, as to what is the proper surveillance follow-up for polyps.
And it's almost become kind of an art where you're looking not only at the fact that you've got a polyp there, you're looking at the size of the polyp, you're looking at the histological character, the microscopic characteristics of the polyp, the family history of the patient, the number of the polyps. And then trying to risk-stratify those individuals and come back to them with a recommendation of when they should get their next procedure. And it really -- especially at that time -- was an art.
Perhaps the most definitive paper so far that I've seen was in 2000, from the American College of Gastroenterology, that tried to clarify this whole thing and come up with some recommendations.
Q And what are your recommendations? I mean, do you -- since this will be his third one, when do you expect -- I mean, is two and a half years too long, especially given the fact that he's President? I mean --
DR. TUBB: No, not at all. In fact, maybe I should put this into context. Polyps are extremely common in western society, and there's a number of hypotheses as to why that is true.
But one study suggests that 30 percent of adults over 60 -- this is on autopsy studies, so I don't recommend anybody do this at home -- over 30 percent of adults over 60 on autopsy studies were found to have polyps. Now, 70 percent of those polyps were adenomas, 70 to 85 percent of those adenomas were tubular adenomas, which is what the President had.
And tubular adenomas represent the very, very earliest sign of progression in the changes in the cells that are abnormal. And it takes roughly five years to estimate, to go from absolutely normal colonic mucose -- normal lining -- to an advanced adenoma or an advanced polyp. And it takes five years more beyond that before you even start to getting concerned about problems.
Now, if you remove it, which is the whole purpose for doing this, there is no problem whatsoever.
Q So you recommended when you did this physical a year ago that one year from now he should have the colonoscopy?
DR. TUBB: Right.
Q And there was nothing at all, other than this time line that you had recommended he do it now, to -- there were no symptoms of any sort?
DR. TUBB: No. No, none whatsoever. The President is completely asymptomatic. And that's perhaps another message to take home about colon cancer, and that's why screening is important, is because in a large percent -- if not the majority of cases -- it is asymptomatic, meaning that you have absolutely no symptoms or warning whatsoever.
The one thing we do know is, as I said, it is common. Colon cancer is the second most common cause of cancer deaths in America today, the third most common cancer in America. The distinction between common cancer and cancer deaths -- after lung cancer, breast and prostate cancer for men and women, then colon cancer. After removing skin cancers.
Q So Doctor, is it your opinion that he is more or less likely to eventually get colon cancer because of his history? Or is he less likely because of the increased nature of his screening?
DR. TUBB: I think that's a good point. The statistics say he is no more likely. But the second point you add, it's because he is being responsible about practicing preventive medicine, he would be less likely than an individual that doesn't know what's going on in their colon.
Q Why do this at Camp David, given that there could be complications and you could need a large medical facility?
DR. TUBB: Colonoscopies, as I mentioned, are routinely performed across the country. Pretty much the standard of practice nowadays is for them to be performed in a doctor's office, free-standing clinics, free-standing endoscopy centers. At Camp David, we can provide all the services, including the address of any complications at that point.
So, really, it becomes an issue of patient comfort, patient convenience, that drives the issue. That's where the President was going to be this weekend; that's when his schedule was available, and that's when we want to do it. But rest assured, the primary focus is his safety and then his comfort.
Q Doctor, some people might say, wait a minute, the lining could be punctured in some way. I know that's extremely unlikely, but I assume that in one out of X number of thousand or million cases, that does happen. If you did have a complication like that, he'd be a long way away from a major medical center.
DR. TUBB: The risk at Camp David -- first of all, the medical facilities there are more than capable of handling what we need to do in the immediate time frame. The risks of complications from the procedure are no higher at Camp David than they are in a free-standing endoscopy center or in a doctor's office. And you're exactly right that you have to be prepared to handle any potential complications of any procedure that you would do, and we are more than equipped to go and handle that.
The complications that theoretically could arise generally are not ones that are immediate and life-threatening. In fact, more often than not, they're ones that manifest themselves over hours or even days.
Q Like what?
MR. FLEISCHER: Wendell.
Q Ari, how will you handle tomorrow? How will you --
MR. FLEISCHER: Let's do this. We'll take another one or two questions for the doctor, and then I'll address that, and then we'll be done.
Q The President outside, when he spoke to us, said that he was looking forward to exercising tomorrow after this procedure. How realistic is that expectation?
DR. TUBB: I think it's realistic. I think once -- particularly with the use of propofol, once a patient has fully recovered from the anesthesia, they're able to resume a normal diet, able to resume normal activities.
Now, it'll be a little bit difficult at this time to predict, not knowing how long the procedure will be and therefore how long he'll be sedated, it'd be difficult to predict exactly what he'll feel like doing. But there's no medical reason why he can't do what he would like to do.
Now, I have advised him, the prep for this procedure -- which is really the hardest part from the patient's perspective -- can dehydrate you. It's a very dehydrating procedure. So he's going to need to drink lots of water afterwards and get his body rehydrated.
Q Can you talk about the preparation, please?
DR. TUBB: Yes. The prep is --
MR. FLEISCHER: Remember your sense of decorum.
DR. TUBB: The prep is what I'm most interested in. Again, I told you I've had these before, and the prep really is the most difficult part of the procedure. The fact that you're sedated, most patients are completely unaware or indifferent to what's going on.
There's two preps that are in standard use in America nowadays. One is an electrolyte solution, comes in about a gallon jug -- it's called Colyte, is one of the makers of it. And you begin drinking that roughly around 7:00 p.m. the night before the procedure. During the day, you've had a clear liquid diet to kind of get your bowels ready for the procedure. The Colyte then induces diarrhea, to go ahead and clear the colon out.
The other prep that is commonly used, and the one that I favor and one the President will use, I think many, many patients find more patient-friendly is Fleets Phosphosoda, which is a very concentrated osmotic solution. It has a little citrus taste to it. You drink about one and a half ounces mixed in with some ginger ale or lemonade. And after about 30 minutes for most people, it induces diarrhea that, again, cleanses your bowel. Some patients, it may take up to a few hours. But in general, most people experience that within 30 minutes.
Q Can you spell --
DR. TUBB: The Fleets? Fleets Phosphosoda, p-h-o-s-p-h-o-s-o-d-a.
Q So there's no precise time set for this procedure to begin tomorrow?
DR. TUBB: We'll have him ready. His colon will be ready. (Laughter.) I mean, until he eats again, the procedure will be doable.
Q Could we get some more details on the transfer of power? You said the papers have already been faxed?
JUDGE GONZALES: No, no, of course not.
Q What will it look like tomorrow for the people that are involved? Papers get faxed as the anesthesia is beginning to be administered?
JUDGE GONZALES: The President will make the final decision as to transfer of power right before the anesthesia takes effect.
Q Does he at that point sign a piece of paper that then gets faxed?
JUDGE GONZALES: He will sign a written declaration, a letter, to the Speaker and to the President Pro Tem, advising them of the fact that his power is being transferred pursuant to Section 3 of the 25th Amendment.
Q And who actually walks that piece of paper to a fax machine? And will the -- on the other end of this process, will the Vice President's day look any different than it --
JUDGE GONZALES: I don't know whether or not -- I don't know the Vice President's schedule. Obviously, he's aware of what's going on here, and his responsibilities in connection with serving as acting President.
In terms of who will actually walk the piece of paper, that'll be the responsibility of the staff secretary.
Q Is the Vice President there? Or the Vice President is --
JUDGE GONZALES: The Vice President will not be at Camp David.
Q But the football goes with the Vice President?
Q Yes, is there an increased sort of presence around the Vice President for the time during which he actually holds executive power?
MR. FLEISCHER: Our standard policy, of course, is not to discuss security measures. So I don't discuss that in any case. It is standard, I think you know this, people who travel with the Vice President know this, the Vice President at all times is in the company of a military aide.
Q But none of that increases tomorrow during that period of time?
MR. FLEISCHER: I just don't discuss whether security goes up or down in any way.
Q Will he be at an undisclosed location?
MR. FLEISCHER: No, the Vice President will be in Washington, D.C.
Q At his home?
MR. FLEISCHER: I don't have his daily hour-to-hour schedule. I think it's likely he will be at the White House for a portion of it. It's up to the Vice President.
Q Are there congressional people standing by a fax machine somewhere to receive this notification tomorrow?
JUDGE GONZALES: That I do not know. Again, we called them this afternoon, we'll call them in the morning. The Constitution doesn't require that they actually receive. (Laughter.) The Constitution --
Q Will there be a printed report from the fax? (Laughter.)
JUDGE GONZALES: The Constitution talks in terms of transmittal. And so once that is done, we have fulfilled the requirements of the Constitution.
Q As long as -- leaving here okay?
JUDGE GONZALES: And as a courtesy, of course, we will call the congressional leaders in the morning.
Q How do you even reverse it? I mean, when he comes to, how does he take it back?
JUDGE GONZALES: Section 3 simply provides that once the President determines that he's able to discharge his powers and duties as President, he simply informs the Speaker and the President Pro Tem.
Q Does he sign another form?
JUDGE GONZALES: He will be signing another letter, and we will be faxing a subsequent letter.
Q Dr. Tubb, when was the procedure scheduled, please?
DR. TUBB: I'm sorry, say that again?
Q When was the procedure scheduled, please?
Q When did you decide to do it?
DR. TUBB: I think the President decided to do it sometime within the last couple weeks.
MR. FLEISCHER: Probably about three weeks ago or so.
Q Would you prefer that this happen --
Q Is there a family history? Is there a family history?
DR. TUBB: No, there is no family history. I saw in one report, they mentioned his brother, and the President mentioned his brother himself, with a history of colitis. And certain types of colitis would put the individual with colitis at an increased risk of colon cancer. And there are family colon cancer syndromes that are very important if you're a member of that family. But the two of them are not necessarily related. And in the President's particular case, they are not related.
Q You wouldn't feel easier if the President was having this done in Washington than at Camp David?
DR. TUBB: No, sir.
MR. FLEISCHER: Okay, let me go -- okay, last question. David.
Q Is this a team of military doctors? And how many will be there?
Q And from where?
DR. TUBB: This in particular is a team of military doctors. Do you want names?
Q Is military?
DR. TUBB: Yes. The lead endoscopist is a gastroenterologist. He is the Chief of the Gastroenterology Service at the National Naval Medical Center in Bethesda. His name is Dr./Navy Captain -- Jim, or James, Butler. I guess you would have nothing else. (Laughter.)
The lead anesthesiologist is -- I'll check his rank -- is a Dr. Paul Bruha. Let me get his exact rank for you. And he is -- and I'll give you his title as well. Okay, Dr. Paul Bruha, Commander-select, United States Navy. He is a staff anesthesiologist. He is an Assistant Professor of the Department of Anesthesiology at the Uniformed Services University of Health Sciences, and a Clinical Assistant Professor at the University of Maryland Shock Trauma Center.
Those are the two key people in there. Of course, there are support people. And we do have --
Q Will you be there?
DR. TUBB: I will be there, yes, sir. I will kind of oversee everything. And we will have backup people as well.
Q Don't you have a cardiologist there?
DR. TUBB: No.
Q You don't keep a cardiologist --
DR. TUBB: No.
Q What are the medical facilities like at Camp David? Could you just tell us a little bit about the medical facilities at Camp David?
DR. TUBB: No, I'm sorry, I can't.
Q Is it a whole hospital or a clinic?
DR. TUBB: I really can't discuss any of the capabilities at Camp David in any respect.
Q Can you deal with any eventuality at Camp David in your --
DR. TUBB: Yes, with any complication of the procedure. Now, that's not to say -- as I pointed out to this gentleman here -- that complications, rare as they are, when they arise generally are not emergencies. But I think you all may be aware that wherever we go, we have definitive treatment centers within a certain period of time and they've already evaluated those for the capabilities we need. So we are able to respond to an emergency, to an urgency or to a complication there for this particular case in the same way we would when we're out traveling with you and an emergency arises.
MR. FLEISCHER: Elizabeth, last question.
Q What time tomorrow, exactly?
DR. TUBB: I'm sorry, we can't say that.
Q In the morning, afternoon?
MR. FLEISCHER: Let me go over procedures for tomorrow. Let me fill you in. Here's tomorrow what we're going to do.
You will receive a page, a notice from the Press Office, advising you about what time there will be a briefing here, and Dr. Tubb will return; Dr. Butler will likely be here as well. And they will be able to discuss with you the procedure and answer any questions you have about it.
My guess to you is to plan on sometime after noon. I can't put a guess on what time in the afternoon, mid, late. Just be prepared for any time in the afternoon.
Q Will that be on the record and on camera?
MR. FLEISCHER: I'll let you know.
Q It will be after the radio address?
MR. FLEISCHER: It will be after the radio address. The radio address is taped.
Q Can we get some sort of protective pool with the Vice President? We really should have a protective pool with the Vice President.
MR. FLEISCHER: You should call the Vice President's office.
Q Will we be notified when the transfer takes place, and transfer is revoked?
MR. FLEISCHER: The only announcement I anticipate making tomorrow will be after power is transferred back to the President.
Q Okay, so we'll get that before the briefing?
MR. FLEISCHER: That's correct. When power is transferred back to the President, you will be advised.
MR. FLEISCHER: We'll page it out.
Q As it's happening, we will not know when it's happening?
MR. FLEISCHER: That's correct.
END 4:48 P.M. EDT