Verbal response and command following in acute bedside assessment

Dear Editor, We read with great interest the article by Muhumuza et al., recently published in the Postgraduate Medical Journal, which showed that the inability to answer questions using speech was strongly associated with 24-h mortality among acutely ill medical patients (adjusted odds ratio (OR) 12.3, 95% confidence interval (CI) 6.1–24.8) [1]. The authors are to be commended for highlighting a simple and clinically meaningful bedside observation that may help identify patients at high risk. We also agree that rapid assessment of consciousness is essential in acute care, and that the Alert, Voice, Pain, Unresponsive (AVPU) scale has important limitations in this context [2]. That said, the proposed criterion—whether a patient can answer questions verbally—has an important practical limitation. It cannot be applied in many acutely ill patients who are unable to speak for reasons unrelated to consciousness. These include intubated patients, patients receiving sedation, patients with aphasia, and others who cannot communicate verbally despite being awake or partially responsive. Although these individuals were appropriately excluded from the study to preserve internal validity, this necessarily narrows the bedside applicability of the rule in emergency and critical care settings, where such patients are common.