Editorials

The end of the year is often a time for ref lection – many healthcare professionals have the opportunity of a couple of relaxing weeks over Christmas to draw breath and plan for the coming year with renewed enthusiasm. This is never quite true for Acute Medicine – any brief respite in the lead-up to Christmas week is soon forgotten during the chaos which follows. The ritual search for beds in any available hospital ward is as much a part of the AMU festive season as the Christmas party and the tinsel tree (circa 1980) – which will eventually be discovered, and banned, by Infection Control. However, it remains important to make time for ref lection and service planning. Syed Ahmed’s article on p114 demonstrates the value of this approach, with dramatic improvements in patient f low and achievement of emergency access targets following changes to their model of care. Of course the pressure to provide such improvements may be reduced, following the Health Secretary’s announcement of the intention to end the ‘4 hour target’ next year. Derek Bell’s ‘Viewpoint’ article on p137 provides readers with some of the history behind the original target, and expresses concerns regarding the dangers of a return to long, and inappropriate, waits on ED trolleys for medical admission. In order to avoid this, acute physicians will need to work with politicians to ensure that any new quality indicators include some measure of ‘timeliness’ in the assessment, initial management and movement of medical patients.

One of the effects of the 4 hour target has been a recognition that delays in obtaining blood test results can impact on the speed of decision making at the ‘front door’. This has often led to blood sampling being undertaken before clinical assessment has been completed. Ensuring that the appropriate results are available may lead to unnecessary testing, particularly tests of coagulation which cannot easily be ‘added on’ to existing samples at a later time. Lewis and colleagues remind us of the need to consider the costs of this approach – with a price tag in excess of £12 per coagulation sample it is likely that the pendulum will require a nudge in the opposite direction. Their educational programme was successful in reducing unnecessary coagulation testing, although sustaining this with new groups of junior doctors rotating through AMU on such as regular basis may prove to be a challenge.

The New Year will also be bringing changes to the structure of this journal. Starting from 2011, each volume will comprise four editions, printed ‘quarterly’ in March, June, September and December. The layout will evolve with fewer case reports and a move towards greater focus on research-based articles. The need for this change has been a regular subject of informal discussions with readers, as well as the reader survey which was circulated earlier this year and is summarised later in this edition. In the past this move has been inhibited by the lack of submissions, with case reports still comprising the majority of our weekly mailbox. However, the balance is gradually shifting, and this will also support our application for Indexing in MEDLINE which remains a vital part of this journal’s development. In response to comments from the large numbers of trainees who read the journal we are developing a new ‘Trainee Section’, and I am delighted to welcome Dr Tom Heaps, Acute Medicine SpR, onto the editorial board. It is planned to commission a cycle of ‘problem-orientated’ review articles, aiming to cover the entire knowledge-base of the GIM / AIM curricula during the next 5 years. This exciting project should complement the wealth of diagnosis-based guidelines already available, which are difficult to apply in the acute setting where the cause of a patient’s symptoms has yet to be determined. A regular ‘Journal Watch’ section, summarising recent articles of importance to Acute Physicians, and updates on developments in acute medical training will also feature in this section, which I hope will also be of interest to more senior physicians. Any readers who are interested in contributing to these sections are welcome to contact me at the email address shown on this page.

Winter has arrived again, and our thoughts turn to the management of pressures associated with surges of respiratory and diarrhoeal illness, when the bed stock of the hospital remains permanently full. The phenomenon of ‘exit block’ is as real a challenge for Acute Medical Units as it is for Emergency Departments (ED), with patients commonly exceeding the desired length of stay in the AMU while awaiting availability of a suitable speciality bed. The problem is compounded by increased numbers of patients whose discharge or transfer is delayed, particularly in the period after Christmas when the backlog for our Social Service colleagues may be considerable. When the AMU becomes gridlocked, there is an inevitable pressure back on the ED, with the consequence that alternative solutions may be sought to avoid breaches of the 4 hour emergency access target. The temptation to move patients directly from the ED to areas of the hospital which are not designed to receive and treat acutely ill medical patients should be resisted, according to the data presented in the paper by Coary et al from Dublin. According to their review of over 36,000 patient admissions over a 12 year period, patients who bypassed the AMU experienced a significantly higher mortality, despite an identical expectation of death according to a multi-variable risk model. Although the authors do not speculate on the precise reason for the difference, which may be multifactorial, this paper provides an important message about the need to maintain a structured process of care, as bed pressures rise across our hospitals.

Structure is also an important part of clinical examination. David Nicholl’s Viewpoint article raises a plea for re-establishment of neurological examination as part of the assessment of patients admitted on the medical take. He reminds us that ‘Neurological Examination NAD’ should imply that it was normal, rather than not actually done. Tendon hammers and ophthalmoscopes are not always easy to find on the acute medical unit (I now carry my own ophthalmoscope in my pocket) – perhaps this is, in part, why it is often easier to reach for a pen and complete a request for an imaging scan rather than checking the reflexes or the patient’s fundi. Given that tendon hammers are considerably cheaper than stethoscopes, it is perhaps surprising that more doctors don’t possess their own.

Finally, I have often thought that rats get an unfairly hard time: the mere sighting of one such rodent in my back garden is usually met with a swift request to lay down poison or call in the extermination team. I once read that we are usually only a matter of a few yards away from a rat, as we go about our day to day existence. With this in mind it is somewhat surprising that our acute medical units are not regularly filled with cases of leptospirosis and Weil’s disease. Perhaps the reason for this is that some cases are going unrecognised – the report from the team at Chelsea and Westminster highlights the non-specific presentation in a patient who was initially thought to have ‘flu, before being treated for atypical pneumonia. The admitting team could be forgiven for missing the history of blackberry picking in the days preceding his admission, which led to a leptospira serological sample being sent; confirmation of the diagnosis occurred after his condition had already been treated. Maintaining an awareness of this condition is important to ensure choice of appropriate antibiotics – and ‘smelling a rat’ sometimes requires a very careful history.

Anyone who has ever submitted a case report to a journal will know how hard it can be to get this published. This journal regularly receives 2-3 times as many as we could ever include, so there is often a tough task in selecting those which the editorial team feel will most interest our readers. A rather unusual quandary recently arose when two cases of VGKC encephalitis arrived in the same week, submitted independently from different parts of the UK. The referees felt that both had merits, so I was very grateful when the authors agreed to co-operate to combine the cases into a single submission, highlighting the varied presentation of a rare, but increasingly recognised condition. Both might have remained undiagnosed, had the appropriate antibody test not been requested. An awareness of this unusual, but treatable form of encephalitis will hopefully ensure that it enters the differential diagnosis for patients whose non-specific neurological presentation remains undiagnosed after the standard investigations have been completed.

Vigilence for the unusual is also the theme of the case report from Declan O’Kane; here the diagnosis of aorto-oesophageal fistula (AOF) following ablation therapy for AF was not considered until after the patient suffered a stroke, apparently precipitated by trans-oesophageal echo (TOE). The authors stress the potential for delayed presentation of this condition, and the need to ensure that it can be eliminated from the differential before oesophageal instrumentation is carried out. The fact that AOF is a more common complication of ablation therapy than endocarditis requires that CT images are carefully reviewed, and repeated if necessary, before proceeding to TOE when patients present with unexplained and persistent pyrexia following this procedure.

The team from Delft in Holland describe their case as ‘remarkable’, highlighting the importance of perseverance in the management of patients whose cardiac arrest results from massive pulmonary embolism. The patient made a full recovery after 90 minutes of cardiopulmonary resuscitation, which was conducted alongside simultaneous intra-pulmonary thrombolysis in a district general hospital setting. The patient’s age and prior good health undoubtedly contributed to this good outcome, although enormous credit must be afforded to the skills and teamwork described in the report. She should certainly consider herself lucky, on many different levels.

The arrival of the second edition of this journal is a sign (in case we need one) that summer has arrived – but also a reminder that 2014 is already half over, and the challenges of the autumn and winter are not far over the horizon. Of course, autumn will also bring another International Society for Acute Medicine meeting, this year in Brighton, following on from the success of the recent Spring meeting in Amsterdam. For those who couldn’t be there, we have included some of the abstracts from the oral poster presentations in this edition, along with some reflections in the trainee report. The programme for the autumn meeting is already complete and will include an opening address from the new RCPL president, Professor Jane Dacre, and a closing session including both the NHS Ombudsman and Chief inspector of Hospitals, Professor Mike Richards. There is also a strong line-up of international speakers from the USA, Australasia and Europe, along with a broad range of clinical topics and workshops, designed to appeal to doctors, nurses and allied healthcare professionals. There will be lots of room for posters in the conference venue, so I would encourage you to submit your work via the abstract submission site; further information on how to do this is available via the SAM website.

The four case reports in this edition reflect a cardiovascular and neurological theme. Most acute physicians will be familiar with the phenomenon of seizure precipitated by sinus node disease, and it is unsurprising that the clinicians treating the patient in our first case presumed that insertion of a permanent pacemaker would resolve his symptoms, after telemetry revealed sinus arrest. However in this case it appeared that seizure was the precipitant for the arrhythmia, requiring the subsequent addition of anti-epileptic medication to prevent recurrence of the patient’s problem. The mechanism of this unusual phenomenon is described, along with the importance of a careful history. The Reversible Cerebral Vasoconstriction Syndrome (rCVS) is highlighted in the case report by Montague and Murphy from Manchester. The approach for patients with acute severe headache on the AMU is often to ‘exclude subarachnoid’ and then discharge the patient with reassurance. In this case, however, the cerebral angiographic images demonstrated the characteristic ‘string of beads’ appearance of this condition, the symptoms of which can be improved by treatment with nimodipine. The authors rightly recommend that acute physicians need to consider this condition when patients present with recurrent thunderclap headache, following exclusion of subarachnoid haemorrhage. Making this diagnosis also enables advice to avoid certain sympathomimetic drugs, which may precipitate recurrence – including cocaine which is the theme of the case submitted by Rahman Shah from the University of Tennessee. ST segment elevation following cocaine use is a well recognised phenomenon, but the pressure to ensure rapid revascularisation for patients with STEMI might easily lead this piece of history to be over-looked, particularly in an older patient. Rates of cocaine use in the UK may be lower than in the US, so it may be premature to consider this part of our ‘routine questioning’ for all patients with cardiac-type chest pain as recommended by the authors. However their point about maintaining an index of suspicion is well made, given the potential for harm from unnecessary percutaneous intervention or thrombolysis.

Enjoy the summer – and I hope to see you all in Brighton in October.

Over the course of our careers we will see many thousands of patients, but there are one or two who we remember vividly; it is often these patients who shape and change our practice most. The problem-based review written by Kevin Jones’ team in Bolton in this edition reminded me of one of the first patients I clerked as a medical Senior House Off icer, while working in a District General Hospital back in the early 1990s. I was revising for the written part of the MRCP Part 2 examination at the time, so when the general practitioner described the young man’s fatigue, low grade fever and rash as ‘probable viraema’, my thoughts immediately turned to far more esoteric diagnoses. For once my suspicions were confirmed. The ‘fatigue’ was clearly proximal myopathy with marked tenderness suggesting a myositis; his rash had the typical ‘heliotrope’ distribution accompanied by nail-fold oedema; the diagnosis of dermatomyositis was sealed long before the consultant ward round when the laboratory phoned through his Creatinine Kinase result of over 15,000. I remember the feeling of elation at having made the diagnosis, the metaphorical pat on the back from my consultant and the look of relief in the eyes of the patient and his mother when I told them that we had the answer. I had no doubt in my mind that the hydrocortisone I had prescribed would rapidly improve his symptoms allowing him to resume his usual activity within a few weeks – I had read all about it in Kumar and Clark or some other erudite medical text book. For a few hours medicine was wonderful – until my cardiac arrest bleep went off. CPR was already in progress when I arrived on the ward; I had attended resuscitation calls before, but never for an 18 year old. A nurse reported that he had complained of dyspnoea and became drowsy shortly before he stopped breathing. There was a cardiac output, but no respiratory effort – he was intubated, ventilated, transferred to intensive care and then to a regional specialist unit, but sadly never regained consciousness before he died 2 weeks later. This was a tragic story which affected many people, but which taught me a really important lesson: making a diagnosis is where our job starts – not where it ends. We will never know whether we could have made any difference to this poor young man by anticipating a different outcome, closer monitoring of his respiratory function or earlier involvement of our critical care team. The speed of his deterioration was such that even today’s focus on early warning scoring and prompt recognition of changes in physiology, which has developed over the past 2 decades, would probably not have changed his outcome. However the key is to expect the unexpected; there are formes frustes of many conditions which behave differently to those which appear in the text books. Making a diagnosis should never be a cause for celebration.

‘So why do you want to do Acute Medicine?’ – it’s a common interview question, and one for which most prospective trainees will have a well-prepared answer. Sometimes the candidate will focus on the opportunities for multi-professional working and teamwork, as well as interactions with critical care and other specialities; however almost all will mention the wide variety of conditions with which acute physicians are faced in their daily practice. What may appear a simple problem at the time of presentation may have a twist in the tail which will catch out the unwary. The need to maintain a broad differential diagnosis is a key skill for the acute physician: I frequently need to remind trainees that ‘Query ACS – measure 12 hour troponin’ is not an acceptable management plan. It is crucial to remember that even when a condition like acute coronary syndrome has been ‘excluded’, a serious cause may still be lurking. Several of the articles in this edition illustrate such caveats. In the review of the diagnosis and management of aortic dissection, the variability of presentation is illustrated with a case where the onset of symptoms preceded the hospital admission by several weeks and was initially labelled as ‘musculoskeletal’. In this case it was the chest x-ray which raised the clinical suspicion when a change in the mediastinal contour was identified. However, serious spinal causes of chest pain, such as the spontaneous extradural haematoma on p76, will only be diagnosed by more complex imaging; this will be hard to arrange without a clear clinical indication. The rarity of this condition means that most will not have come across a case and will therefore be unaware of the need to consider this diagnosis. The importance of a careful history, refreshingly emphasised in the recent NICE guidance on chest pain of possible cardiac origin as summarised by Charlotte Cannon in this edition, cannot be understated.

Many readers will have come across patients with erythema nodosum, referred as ‘unresolving cellulitis’ – often these turn out to have sarcoidosis as described in Dr Chakraborty’s case series, although other underlying causes need also to be considered. Cellulitis may also be a manifestation of a subcutaneous source of infection, particularly when it appears in an unusual site; Denzil May’s case illustrates the need to image the abdomen when presented with abdominal wall cellulites – on this occasion an underlying psoas abscess was the cause although appendix abscesses, inflammatory bowel disease, diverticular abscesses and pelvic collections also need to be considered.

The opportunity to learn a practical procedure has been a subject of considerable debate amongst acute medical trainees over recent years, and has been highlighted in this journal in the past. Much of the focus in previous editions has been on echocardiography. Ultrasound is another practical procedure which is listed in the training curriculum for Acute Medicine, although the feasibility of training acute medical trainees in this area has not been fully evaluated. Dr Ismaeel’s study comparing the outcome of ultrasound undertaken at the bedside by an acute medical trainee and that undertaken in the radiology department may stimulate some debate on the value of this. This study looked specifically at diagnostic ultrasound of the abdomen and demonstrated that some conditions could be identified at the bedside, though probably not with enough reliability to prevent the need for a subsequent departmental ultrasound. The key is whether the specific questions can be answered by the ‘occasional’ sonographer using portable equipment: ‘are the bile ducts dilated?’, ‘are the kidneys obstructed?’, ‘are there metastases in the liver?’, ‘is there ascites or is it just fat?’ – knowing the answers to such questions can inf luence management out of hours, although currently most patients will have to wait until the morning for a scan. A formal training programme in acute medical ultrasound will need to focus clearly on these specific areas, rather than generic diagnostic ultrasound skills.

Many readers will be familiar with the rapid turnover of AMU nursing staff, particularly at a junior level, which can undermine the ability to develop a stable workforce. In a questionnaire study in Birmingham and Dundee, consultant nurses Liz Lees and Liz Myers have produced some interesting data which may help to improve recruitment and retention of nurses on Acute Medical Units. It seems that, as with junior doctors, it is the variety which is the main attraction, as well as the being the main factor which keeps nurses interested in working on the AMU. Correspondence relating to this and any other issues relating to articles in this journal would be most welcome.