Tuesday, June 21, 2016

Guarded condition

For the last week or so, updates on the condition of the surviving victims of the Orlando mass shooting featured headlines like this:

“6 Orlando shooting victims remain ‘critically ill,’ another 5 patients in ‘guarded’ condition”

Even the trauma center, Orlando Health, tweeted this the other day:

“No surgeries on the victims are scheduled for today. 4 patients are in critical condition, 2 are guarded, and 12 are stable.”

I think we all have an idea of what critical and stable mean [more about this below], but what about guarded?

I’ve never known what guarded means and wondered if it was just me. To find out, I conducted an informal 24-hour Twitter poll.

Here are the results:

By a 2% margin, “I have no idea” was the most common response, but 35% thought guarded condition meant between serious and critical, and 21% thought guarded was better than serious.

Google “guarded condition,” and you will get thousands—maybe millions—of hits with stories of patients described as “guarded.”

As far back as 1990 and probably much further back than that, the term “guarded” was causing confusion. In a Baltimore Sun article, an intensivist said, "A nurse might choose to say guarded, knowing the patient is very sick but not knowing which way he will go." Of course, that could be said about many patients in intensive care.

The editor of the journal Chest, A. Jay Block, addressed the question in 1994: “What is ‘guarded condition’ anyway?” He noted that although ICU staff used the term, no one knew what it meant.

He didn’t know either and suggested it shouldn’t be used.

The American Hospital Association has issued guidelines on the subject of patient condition reports. Here they are:

· 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.

Notice that “guarded” is not an option, but the guidelines lack specifics. Block pointed out that the indicators are not defined and the various descriptions such as excellent, favorable, questionable, and unfavorable are not explained. Serious and critical seem about the same to me, and a patient could be both critically ill and stable.

I am calling for the establishment of a task force made up of representatives from various medical disciplines, journalism, law, and public relations* to create new guidelines with better definitions. Let’s leave the term "guarded" to those in custody.

*and hospital administrators

Thanks to the 281 people who took the time to vote.


Cutter said...

Perhaps they have private security watching them?

Skeptical Scalpel said...

Or maybe LeBron is guarding them.

lp said...

I usually write: stable but guarded

Skeptical Scalpel said...

That's covering all bases. Maybe you should have been a radiologist. :-)

Anonymous said...

You want hospital administration to define a medical term?

What illegal drug were you on and how much did you sniff, snort or shoot at the time you allowed that ... section of the business world ... to have a say in defining something medical? :) ;)

William Reichert said...

Let's clarify this issue and for once be precise.......

Critical means 13% chance of recovery
Guarded means 66% percent chance of recovery
Stable means 89% chance of surviving three days( at the least).
But remember, "past performance is no guarantee of future results."
AND DO NOT forget the most serious condition: "circling''
usually a category not shared with the public.
This represents a .02% chance of recovery ( often ascribed to divine intervention and IMHO rightly so.)

Speaking of interesting questions:
I have a much better question: What exactly is an "acute abdomen"?

Skeptical Scalpel said...

I was kidding. Do you think public relations people are a good choice? 😉

daco said...

I recall a fellow resident getting called once by an administrator to describe a patient's condition (back in the pre-HIPAA days). Having no idea how he was supposed to determine that, he replied "bleak."

Skeptical Scalpel said...

Bleak. That's great. I wish I had known about that when I was writing this post.

Skeptical Scalpel said...

William, I somehow missed your comment. No doubt about it, circling is worse than critical.

An acute abdomen usually refers to a patient with rapid onset of severe abdominal pain and accompanying symptoms like fever, nausea and vomiting. It implies that surgery is very likely going to be needed. That is unless you plan to treat appendicitis with antibiotics.

William Reichert said...

Yes. Thanks for that. So if the patient does not have much pain, fever or vomiting but has a perforated colon , does this mean
he does not have an acute abdomen?
Or if he has all those symptoms but does not need surgery
immediately ( like an intestinal obstruction, for example), does he no longer have an acute abdomen?
It seems to me that the term acute abdomen should refer to the
patient's condition/diagnosis but not be linked to the need for
surgery which is another matter all together and will depend on the opinion of the surgeon who is consulted.
If someone has a massive heart attack, it is not called an
"acute myocardial infarction" to imply that cardiac surgery is needed.
The reason I bring this up is because I have seen litigation
proceed because a physician makes a diagnosis of an acute abdomen but surgery is not done and the lawyers tell the jury that "acute abdomen" implies the NEED for surgery.

Skeptical Scalpel said...

A patient could have a perforated colon from diverticulitis and might not have an acute abdomen or need immediate surgery. In general the term "acute abdomen" does imply a need for immediate surgery, but if the term is used incorrectly, I would say malpractice did not necessarily occur.

artiger said...

It's a lawyer's job to bend the truth to his/her advantage.

Katie5757 said...

"guarded"...as in handcuffs, or mayhaps "no comment"....or more mayhaps "I dont know"....

Skeptical Scalpel said...

I vote for "I don't know."

Don said...

This hits close to home. In August my 90 year old father was rushed to emerg for what turned out to be pneumonia. For several days the staff described his condition as "guarded" but never explained exactly what that meant other than a vague "he may recover or he might not".

Skeptical Scalpel said...

Don, it looks like the staff is in tune with most other people in not knowing what guarded means. I hope your father has recovered.

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