“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.”

This week marks the one-year anniversary of this cardiology blog.  Now that 2009 has come to an end I’d like to take this opportunity to summarize the best pieces of the previous 52 weeks.  It seems every other publication from Time magazine to Mad magazine allows themselves the luxury of taking a week off by recycling a year’s worth of previous material, so I figure “Why not do the same?”

Below you’ll find links to all sorts of useful information and answers to nearly every important question in the world of cardiology.

Does elective coronary stenting decrease your chance of a future heart attack?  See the entry from March 18.

What’s the best dose of aspirin for you?  June 22

Are women more or less prone to strokes than men and how do they fare when they suffer a stroke?  February 11

What causes palpitations in healthy people?  August 24

What does “Do Not Resuscitate” (DNR) mean and how does it affect end-of-life care in the hospital setting? March 2

What are the best internet sites for medical information?  December 7

What do you do if you have symptoms that no one can figure out?  October 19

What can you conclude if you have chest pain that is relieved in the emergency room with a dose of nitroglycerin?  April 6

Do we really use rat poison to prevent strokes in humans? February 23

Is marathon running dangerous?  October 26

What kind of influence do drug companies have on our prescribing practices? May 11

Should someone with heart problems get the flu shot?  October 5

How much sedation are you really going to get with that medical procedure?  May 18

What constitutes adequate exercise for your heart?  May 26

What’s the latest thing in cardiac imaging and what are the risks?  November 23 and January 11

What are the treatment options for atrial fibrillation?  December 21

How can you best prepare for your next visit with your doctor so that your important questions will get answered?  March 23

Should you limit your peak heart rate when you exercise?  June 1

What are the characteristics of a good doctor?  September 14

How important is quitting smoking? August 10.  What’s the latest on smoking cessation products?  July 13

How useful is it to ask your surgeon how many times he or she has performed the procedure you’re scheduled to have? April 20

How can you stay in good shape as you age?  August 3 and September 28

What can you and your doctor do to cut your pharmacy expenses?  August 17

What’s the latest on the defibrillator ex-president George Bush received to protect his heart from the trauma of his pending divorce?  Oh, wait.  That wasn’t my blog.  That little pearl of scientific insight comes from The Globe.  No wonder their readership is bigger than mine.

A few weeks ago I happened across a news release from the American Heart Association that caught my attention.  On an annual basis the AHA publishes its own top ten list (who doesn’t?) of the most influential research publications of the year.  This year’s registry included the usual basic science papers with names that range from the arcane (“Circulating transforming growth factor-β in Marfan syndrome”) to the nearly unpronounceable (“Functional cardiomyocytes derived from human induced pluripotent stem cells”).  In case you missed the purpose of the latter study, the authors package it up for you in a tidy soundbite: “The aim of this study was to characterize the cardiac differentiation potential of human iPS cells generated using OCT4, SOX2, NANOG, and LIN28 transgenes compared to human embryonic stem (ES) cells.”  Oh, so that’s it?

I’m not knocking these studies—I’m not sure I’m even smart enough to read them—I just found that I gravitate more toward research that has direct application to my daily patient interactions.  One study in particular caught my eye and I was pleased to see it make the AHA’s top ten.  I had read it when in was published in September and was somewhat surprised at the findings.

Researchers studied the rate for heart attacks in three separate communities in the United States: New York state, Bowling Green, Ohio, and Pueblo, Colorado.  As far as I can tell, the only thing these three locales had in common was the precise reason they were put under the microscope: within the last few years their local legislators had passed strong laws that limited smoking in public places such as restaurants and places of employment.  The authors observed a 15% drop in the number of heart attacks in the first year after the smoking ban was put into effect and this decline only steepened with time.  After three years the rate of heart attacks among the general population had plummeted by 36%.

Didn’t we already know this?  Is this really news?  After all, the National Health and Nutrition Examination Survey measured nicotine levels among nonsmoking adults and found that only 13% of those living in regions with smoking bans tested positive compared to 46% living in jurisdictions without smoking legislation.  In 2006 the Surgeon General’s office devoted an entire annual publication to exposing the deleterious effects of secondhand smoke.

What’s different about this study, and why it is so important, is that this is the first real proof we have directly linking treatment (banning smoking in public places) to effect (decreasing heart attacks).  Yes, indeed, curbing the freedom of smokers to light up within the confines of an office or a restaurant not only enhances the pleasantness of the environment, it also directly impacts the health of those nearby.  And passing a law that pushes the smoker into the well-vented outdoors produces a real, measurable, and immediate effect on the risk of heart attack among the broader population.  It’s this kind of direct evidence that really moves the opinion of those in a position to enact public policy.

In June of last year Omaha enacted its own ban on smoking in public confines.  The local paper’s editorials were filled with tirades about the loss of freedom imposed by this draconian edict.  These letters came from tobacco’s most valued customers who vow to never give up the habit and don’t see the problem with the rest of us sucking in a few fumes now and again.

But I maintain that freedom from undeserved heart attacks and death is more important to our society than is the freedom to light up whenever and wherever you’d like.  It sounds like communities in New York, Ohio and Colorado believe the same and are now reaping the rewards of their decision.

There’s an iconic image from legendary medical illustrator Frank Netter, M.D. that I will never forget from my medical school days. It’s a picture of a man clutching his chest as he exits a restaurant to trudge into the snowy night. The artwork was originally published in 1969 as part of the CIBA Collection of Medical Illustrations that serves as the benchmark for anatomic art in the last half century. I’d venture that there is not a doctor on the planet who is not familiar with the artistic footprint of Dr. Netter.

This particular picture accompanies the section of the atlas pertaining to “angina pectoris,” the chest pain that arises when the heart muscle is not getting an adequate supply of blood and oxygen. While the symptoms can be variable, angina is most often described as a squeezing pressure in the chest. As is typical of Dr. Netter’s style, his illustration captures many of the subtleties of the subject described. The man is middle-aged and mildly overweight and one can clearly see the burning ember of a cigarette butt he’s dropped into the snow. He is coming out of a restaurant and lumbering up a couple of steps into the driving winter wind. His right hand claws at his chest (see Levine sign) as his left hand loses its grip on his brief case.

In this illustration, Dr. Netter has made sure all the elements are there for a classic case of angina.

Risk factors? Check.

Exertion? Check.

Recent culinary indiscretion at a local pub? Check.

Driving snow and winter wind? Now it’s getting personal.

Those of us in the Midwest have had our share of arctic conditions over the last month as our temperatures hover well below freezing for what seems like an eternity and snow blankets our region to a degree that’s not been seen in years. The deep drifts have brought with them the familiar early morning buzz of snow blowers being reluctantly fired up for action, and, with that, come the admissions to the hospital of patients with heart attacks and chest pain.

While this is something I can’t quantify with any reliable objective data, my feeling is that I have seen more patients this year with heart conditions exacerbated by the elements than I’ve seen in years past. Is this just my imagination—my mind, being driven mad by the numbness of the arctic chill—or is there evidence linking a miserable winter to a rise in heart disease?

Indeed, solid research confirms the link between a bad winter and a rise in the rate of cardiac events. In one study, published in the British Journal of Medicine in 2004, researchers tracked temperature and climate data from 24 different countries in an attempt to establish a link between lousy weather and heart attacks. They discovered that a strong relationship exists between low temperature and the population’s rate of heart attacks and stroke. Their conclusions were so robust that they were able to provide an algorithm for determining what sort of rise in problems we can expect with cold air: “On average, a 5°C reduction in mean air temperature was associated with a 7% and 12% increase in the expected hospitalization rates of stroke and AMI (heart attack), respectively.” (How would it be if we added that to our evening weather broadcast? “And for tomorrow we can expect a high of 5 degrees, winds out of the north at 15 mph, and scattered heart attacks throughout the metro area.”)

Another study, published in the journal Circulation the same year, showed that the risk of cardiac-related death is at its absolute highest in the period between Christmas and New Years Day. The authors are careful to point out that it’s not clear whether the increased prevalence of heart attacks is due to the cold weather or the abundance of stale fruitcakes and spiked eggnog.

What, exactly, are the possible factors that lead to winter heart attacks in susceptible individuals? Here are some possibilities:

1. The body shunts more blood to the skin when the air is cold to maintain body temperature. To do this the heart needs to work harder to cycle the blood volume more quickly.
2. Depression, long linked to the cold darkness of winter, is known to be a risk factor for cardiovascular disease.
3. Flu and cold viruses can trigger inflammatory responses in the coronary arteries that can disrupt the delicate balance of coronary cholesterol plaques.
4. People generally exercise less when the weather is bad and slip into worse physical condition. Just this week Circulation published a study linking risk of cardiac death to the number of hours a person sits glued to American Idol.
5. People tend to eat more, smoke more, and gain more weight during the holiday season.

At the precise moment a person with occult coronary disease is at his deconditioned, flabbiest worst, he decides it’s time to man up and get out in the subzero temperature to perform his own stress test behind a 75-lb snow blower. It’s no surprise the night ends up with a trip to the cath lab.

I suppose the best way to avoid a January visit to the coronary care unit is to keep yourself in good shape during the rest of the year so that snow removal season isn’t such an extraordinary departure from your usual physical activity. Stay warm, get your flu shots, and watch your diet and your weight.

If there’s any question about your physical capability to shovel snow or rake ice off your roof, check with your doctor—it may be better to first try the conventional office-based stress test before you attempt the do-it-yourself-in-the-driveway method. I don’t think Dr. Netter needs any more modeling subjects for his medical atlases.

Imagine, for a minute, you’re a surgeon performing a routine operation when your scalpel slips, severing a critical blood vessel, and the patient nearly bleeds to death while you frantically try to save him.

Or, suppose you’re a pathologist scanning through a tissue specimen from a patient with suspected cancer.  Instead of correctly identifying the malignant cells you skip over the pertinent findings and declare the patient free of cancer, only to learn later that your erroneous diagnosis led to a dangerous delay in treatment.

What if you are a primary doctor who ignores a radiologist’s report on a routine chest x-ray that identifies a suspicious spot on the lung?  The patient goes on, blissfully ignorant, until she begins coughing up blood and gets diagnosed with incurable cancer.

In each of these situations I imagine you’d experience a type of regret and remorse that would be difficult to describe.  While I’ve never caused a patient to bleed to death or failed to identify a cancer (to my knowledge) I have had my share of less deadly complications.  Each has been painful for me even if it may not have led to any problematic outcome for the patient.

Now consider a different scenario.  A patient comes to you for some new ache or pain and, instead of applying the diagnostic skills you’ve practiced since medical school, you simply order up one of our seductively beautiful medical imaging exams.  The test satisfies your medical curiosity with its detailed digital vivisection and the patient leaves the hospital feeling good about the thoroughness of his doctor.

But do you ever stop to realize you’ve just performed a test that has the potential to damage the patient’s health as much as any of the hypothetical situations described above?  Add to that the catch that neither you nor the patient can know immediately whether or not he will be one of the unfortunate patients to suffer the complication.

This is what went through my mind as I listened to a news story a last month.  Patients receiving computed tomography (CT, or “CAT”) scans at Cedars-Sinai Medical Center in Los Angeles were exposed to several times the usual dose of radiation than is needed for the scans they received.

“Beginning in February 2008, each time a patient at Cedars-Sinai Medical Center received a CT brain perfusion scan -- a state-of-the-art procedure used to diagnose strokes -- the dose displayed would have been eight times higher than normal. No standard medical imaging procedure would use so much radiation, which one expert said is on par with the levels used to blast tumors.

“Somebody should have noticed. But nobody did -- everybody trusted the machines.

“Late last week, the U.S. Food and Drug Administration and Cedars-Sinai revealed that 206 stroke patients who received scans at the prestigious Los Angeles hospital were overdosed with radiation. Now doctors and safety experts around the country face a troubling question: In an era of supposedly fail-safe medical technology, how did the problem go undetected for 18 months?”

This story broke about the same time two studies were published in the Archives of Internal Medicine regarding the risk of cancer from radiation associated with routine CT scans.  In the first paper the researchers determined that approximately 29,000 future cancers (half of which will be fatal) will arise in the United States from the radiation used in conjunction with CT scans done over the course of only one year.  This is based on an assessment of the number of CT scans done during 2007 and was calculated using the theoretically established estimate of one death per 2000 scans performed.  The second publication was a survey of CT scanning at four prominent California medical centers that found a remarkable 13-fold difference in the amount of radiation delivered by similar scans at these facilities.  One site routinely deluged its patients with over 50 mSv of x-rays (see below to put this amount in perspective).

Some of you may be aware of these estimates, but I for one was not and found them both surprising and disturbing.  I have been ordering CT scans on patients ever since I was an intern rotating through the emergency room and, while I’ve acknowledged the theoretic risk associated with the radiation from these studies, I’ve never really thought about it in such starkly objective terms.

Let’s back up a minute and review some basics about radiation dose in medical imaging.  For us to understand the metrics of radiation dose let’s use as our baseline the amount of radiation you would receive from a standard chest x-ray, a simple and common study that exposes you to about 0.1 millisieverts (mSv) of ionizing radiation.

Now consider the CT scan.  In order to produce its dazzling images of the inside of your body it must flood you with anywhere from 1.5 mSv (for a typical head CT) to 10 mSv (chest, abdomen and pelvis) of x-rays.  That translates to the equivalent dose of radiation you would receive from undergoing a hundred chest x-rays.  It has been said that the radiation exposure from a full-body CT scan (something that no radiologist I know would recommend, but a study that is nonetheless not infrequently requested by patients) is the same as standing a mile and a half away from the WWII atomic blasts in Japan.

Whether you like it or not you already receive a fairly hefty dose of unavoidable radiation on a daily basis coming at you from ordinary sources such as the sun and naturally occurring radioactive isotopes in the soil.  It is estimated that each person is exposed to an average of 2.4 mSv of ionizing background radiation per year (equaling 24 chest x-rays).  By undergoing a CT scan you are at least doubling your yearly dose of radioactive exposure.

Why am I telling you all this?  Simply to remind you that our wonderful imaging technology is not free—it comes at a cost that is significant to at least some patients.  My more frequent readers will recall a recent piece I wrote extolling the virtues of coronary CT angiography.  At present this study constitutes one of the most radiation-intensive scans we can perform, zapping you with up to 13 mSv for one set of images.  Based on the calculations from one of the papers I cited above, one in every 270 forty-year-old women undergoing a CT coronary angiogram will develop cancer from the procedure.  This doesn’t mean we shouldn’t use this valuable tool—we just have to be very careful to apply it only to those patients who really need it.

It was December 22nd, 1895 when Wilhelm Roentgen introduced radiation-based medical imaging to the world and in the years since then this marvelous technology, for all its risk, has saved exponentially more lives than it has put in jeopardy.  But for this equation to work in our favor we need to reserve the use of CT scans for only those who would truly profit from the information they provide.

The message to you as a patient is to not expect to be treated to the most technologically advanced imaging study when good old-fashioned clinical reasoning could suffice.  In the end it may not be in your best interest to pester your doctor into ordering a CT scan when your clinical scenario doesn’t justify it.

And the message to us doctors is to think twice before we casually request such comprehensive radiology imaging.  While killing a patient by ordering an unnecessary CT scan may not stir as much soul searching on the part of the doctor as inadvertently severing a critical artery during the course of a botched surgery, the outcome for the patient is nonetheless the same.