Condition Guarded

“What’s his condition? Is it serious, or critical, or what?”

I got this question last week from the family member of a man who was resting in the ICU in the early stages of a stroke. I had come out to update the family on the patient’s condition and was answering questions from what must have been about 20 people. Most of my answers were some permutation of “I don’t know” (unfortunately, when it comes to strokes, “I don’t know” is most often the only honest answer—will they recover? will this happen again? how much strength will come back?).

I never quite know how to answer the question about “condition” when it comes to medical illnesses.  When I was younger and barely into my internship I faced this issue with similar bemusement and figured I must have simply missed that day in medical school when this vernacular was explained.  If I’d only paid more attention in my classes I might know the meanings of descriptors such as critical, serious, grave, serious but stable, extremely critical, etc.

I’m now pleased to say that this particular subject is not one of the many that I missed in medical school while I was snoring in class or out skiing (my medical school is located less than 30 minutes from several very tempting ski resorts).  The use of these terms is actually never taught in medical training.  Why?  They don’t really have much meaning and we don’t use them.

We doctors favor more specific phrases to categorize a patient’s condition, such as septic shock, multi-system organ failure, cardiogenic pulmonary edema, and acne vulgaris (that last one’s for my brother’s benefit—dermatologists shouldn’t feel left out just because they don’t know how to find the intensive care unit).  We’ll use the term stable somewhat frequently, especially with individual disease states, but try to avoid pigeonholing patients into grave, critical and serious.

Members of the media have popularized this system of grading a patient’s condition and it has caught on among the general population.  You can’t listen to a news report about a hospitalized famous person without hearing the reporter make a declaration about the patient’s level of stability: “Doctors have upgraded the patient from critical to serious.”  (You can bet the doctors had absolutely nothing to do with upgrading anything).

It turns out I’m not the only doctor confused by this and I had to look to other sources to learn more about these descriptors.  The American Hospital Association has actually published guidelines to help us all understand what a “critical but stable” patient is.  Here’s the skinny:

Undetermined - Patient is awaiting physician and/or assessment.

Good - Vital signs are stable and within normal limits. Patient is conscious and comfortable. Indicators are excellent.

Fair - Vital signs are stable and within normal limits. Patient is conscious, but may be uncomfortable. Indicators are favorable.

Serious - Vital signs may be unstable and not within normal limits. Patient is acutely ill. Indicators are questionable.

Critical - Vital signs are unstable and not within normal limits. Patient may be unconscious. Indicators are unfavorable.

Clinicians find the "critical but stable" term useful when discussing cases amongst themselves because it helps them differentiate patients who are expected to recover from those whose prognosis is worse.  But a critical condition means that at least some vital signs are unstable, so this is inherently contradictory.  The term "stable" should not be used as a condition. Furthermore, this term should not be used in combination with other conditions, which by definition, often indicate a patient is unstable.

This is not the only popular system of measurement that we doctors don’t really endorse.

How do you measure how big a skin cut is?  The number of stitches you get in the ER, of course.

What about the seriousness of heart surgery?  It’s the number of bypasses at the time of coronary bypass graft surgery.  A triple bypass is more serious than a double, and a quadruple is near death.  The famed quintuple bypass trumps them all.

And how much bigger, exactly, is a massive heart attack than a regular one?  And what exactly is a double pneumonia?

When I finally reached my ER rotations in medical school I was surprised to learn that the number of stitches a doctor uses has more to do with size of the suture, type of suture technique used, and how much time he or she has to close the laceration than the size of the cut itself.  In bypass surgery, the number of grafts used in the operation often depends as much on surgeon preference and style as it does on the seriousness of the patient’s underlying condition (incidentally, you won’t hear terms like triple or quadruple bypass among cardiologists—we’ll call it three-vessel or four-vessel).  And I still don’t really know what constitutes a massive heart attack or double pneumonia (see previous blog on this subject).

The last one I really have trouble with is the issue of “how many years do I have left?”  I’ve been out of medical school for 16 years and I’m still baffled about how this prediction is made.  Perhaps doctors of television and movies have particular insights that allow them to predict a patient’s remaining breaths with stopwatch accuracy.

Maybe someday I’ll learn this whole vernacular and, if ever I happen to attend to a hospitalized celebrity, be able to better provide reporters a measurement of the patient’s condition. “After his massive heart attack and double pneumonia he was in grave condition with only 4 weeks to live.  Thanks to the sextuple bypass with a hundred stitches we’ve upgraded him to critical-but-stable condition.”

As for now, I’m simply stuck with taking my best guess and relying heavily on “I don’t know.”