Editorials

The nature of Acute Medicine requires physicians to make ‘high stakes’ decisions on a regular basis. The constant pressure to create space within a busy Acute Medical Unit needs to be weighed up against the dangers of missing serious pathology due to a premature discharge. A visit to the Coroner’s court or the fear of litigation may make us more cautious, but even the most cautious physician will ‘get it wrong’ on occasions. Case reports submitted to this journal frequently highlight these dangers; rare or serious pathology masquerading as a common or benign illness, followed by an unexpected deterioration, is a regular theme. Early Warning Scores have helped to improve safety for those patients who remain in hospital – Katherine Rowe’s article on p8 discusses the value of Critical Care Outreach in supporting this process. However neither of these innovations is of use for those patients discharged home. The ability to provide early AMU-based follow-up clinics is an important element in reducing risk for this group. The case report on p24 from the team at Hutt Valley Hospital in New Zealand illustrates the value of early reassessment following discharge. In this case the diagnosis of lead poisoning was not considered as a cause for the patient’s myalgia at the time of admission – an understandable ‘miss’, given the apparent chest x-ray abnormality. However, early outpatient CT with follow-up enabled revisitation of the history and the correct diagnosis was made – with a favourable outcome. As finances become stretched over the coming months there will be pressure to reduce hospital follow-up visits. However any drive from Primary Care Trusts to reduce AMU follow-up clinics as a cost-saving measure needs to be resisted if we are to optimise the safety and efficiency of our service.

On a different note, I am grateful to those of you who completed the on-line journal survey which was circulated to Society for Acute Medicine members earlier this year. I will aim to include a summary of the results in the next edition. The free-text sections have generated a number of interesting ideas, which we will try to incorporate into future editions on the journal. Many respondents indicated that they would like to see inclusion of more original research; however we remain dependent on submissions we receive, which explains the predominance of case reports in this, and previous, editions. The content of the journal can only be as good as the material we receive, so please keep the submissions coming, particularly AMU-based research projects and completed audits. I am also keen to expand the pool of expert referees for future articles. If any readers would like to contribute to this process, I would be grateful if you could contact me directly at the email address shown on this page, indicating your particular area of interest or expertise.

A senior colleague once told me that his life would be ‘dull’ if all a consultant ever did was treat patients. There have been plenty of occasions this winter when I would willingly have traded my yearly salary for a ‘dull life’. Amidst the daily crowd control of Acute Medicine it is easy to immerse oneself in clinical challenges; however it is equally important not to lose touch with management responsibilities during these difficult times. The Economic gloom of the past 12 months will soon have a significant impact on the financial health of the NHS. While Government ministers strive to reassure the Public that the cuts in funding will not impact on patient care, those working in the Service are casting nervous glances over their shoulders, wondering where the axe will fall.

There are times when I still believe that D-dimer is helpful in the investigation of thromboembolic disease – but also plenty when I wish the test had never been invented. The low specificity of the test is well recognised, and this inevitably raises the dilemma of how far to investigate the patient with a positive d-dimer for whom pulmonary embolism is clinically unlikely. However, the article by Subedi and colleagues on p…. of this edition provides a salutary reminder of the dangers in assuming that a negative test can reliably exclude PE. In this, albeit small study, simplired d-dimer was negative in 50% of unselected patients whose CTPA subsequently showed evidence of pulmonary embolism. The reminder only to use the test following formal risk scoring is timely: Increasingly, the pressure to achieve emergency access targets leads to blood being sent to the laboratory before any clinician has clapped eyes on the patient. However, clinical assessment must be untainted. The Wells score, commonly used in the pre-test probability assessment of PE, requires the clinician to consider whether an ‘alternative diagnosis is more likely than PE’. If not, the score rises dramatically. If the D-dimer has already been measured before calculation of the score there is a real danger that this might influence this judgement. The message is clear – don’t use D-dimer badly…and be prepared to ignore the result, whether positive or negative, if it does not correspond to your clinical judgement.

Milestones are often seen as opportunities for reflection and reminiscence. As this edition of the journal coincides with the 10th anniversary of my consultant appointment I hope readers will forgive a couple of paragraphs of self-indulgence. The phrase: ‘Where did all that time go?’ will probably be familiar to physicians at a more advanced stage of their career. With medical students now returning as specialist registrars, and former house officers appearing as consultant colleagues, the passage of time is increasingly apparent. I recently realised that our current third year students were born in the year I clerked my first patient: surprisingly I still remember his name, age and diagnosis, unlike many of those (and all of the students!) who I have seen since.

There is no doubt that this Winter has been tough for those of us working in Acute Medical Units. At the time of writing I find myself in the depths of the post-Christmas blues; the combination of Bank Holidays, ward closures, junior doctor illness and huge admission surges have conspired to make January even more challenging than normal. No doubt the printing delays will have meant that, by the time you are reading this Editorial, these days will be a distant memory. Maybe this will serve as a useful reminder of the need for forward planning in time for next year, rather than breathing the usual sigh of relief as we steel ourselves for Easter. Perhaps a more imaginative colour coding system for our ‘alert’ system would be a start – simply alternating between ‘red alert’ (awful) and ‘black alert’ (even worse) can become quite tedious as the weeks pass. A few shades of maroon or magenta to remind us that ‘today is slightly better than yesterday’ might help break the monotony. We could even opt for a full rainbow spectrum to signify the hope that one day all of our efforts will be worthwhile….it’s important to stay positive in these difficult times!

Whether acute medicine registrars should have the opportunity to acquire a procedural skill during their training has been the subject of considerable debate over recent years. The issue often dominates discussion amongst trainees and trainers alike at national meetings; exchanges are frequently heated and prolonged, highlighting the strength of feeling on all sides regarding the challenges which this creates. So the inclusion of three articles relating to this subject within this edition of Acute Medicine is not in any way disproportionate. In the past, much of the debate has centred on the concept of the ‘Sanity Session’ – the idea being that specialist acute physicians might need some clinical activity outside the acute arena to help prevent ‘burnout’. The three articles in this edition focus more specifi – cally on the issue of bedside investigation in the clinical setting. Many of us will recognise the scenario of the acutely unwell, hypotensive patient, for whom an urgent echocardiogram or ultrasound would enable great strides towards a diagnosis. Extracting a radiologist or cardiologist from their respective departments often requires a talent for negotiation of which a member of the Diplomatic Corps would be proud. Access to the equipment and possession of the necessary skills to undertake such procedures at the bedside would be a great asset for any Acute Medical Unit. While some units are undoubtedly already making great strides in this direction, this often results from the enthusiasm of individuals, many of whom have been trained in other specialities before moving to Acute Medicine. The statement from the British Society of Echocardiography on p95 should be viewed as an important step in identifying a level of training in which is feasible for trainees in acute medicine. The Royal College of Radiologists has also recently produced recommendations for training in ultrasound, which is described in detail by John Lorains; Mark Mallet also highlights some of the practical challenges which may arise in establishing an acute medical ultrasound service.

Infection control and antibiotic prescribing have been high on the list of priorities for clinicians working in acute medicine over recent years. Concerns about antibiotic resistance have encouraged many hospital-based and speciality society guidelines to take a broad spectrum approach to the septic patient. However, this approach risks exacerbating the problems of resistance and increasing the incidence of Clostridium Diffi cile diarrhoea, particularly amongst our elderly patients. Finding the appropriate balance is a key priority for physicians working at the hospital’s ‘front door’. Three of our review articles highlight some of the issues involved in this area. In an extensively researched review, Lille and Barlow provide a microbiological perspective on the topic of antibiotic resistance. Their approach suggests a mechanism for risk assessment in relation to the likelihood of antibiotic resistance, while the results of cultures are awaited. Although most hospitals have their own specifi c prescribing guidelines, the algorithms in this article should provide a useful reference guide. Two other reviews deal specifi cally with issues around management of acute respiratory illness. Distinction between community acquired pneumonia (CAP) and exacerbation of COPD remains a signifi cant area of confusion in relation to antibiotic prescribing. Inappropriate use of CAP severity scoring for patients with COPD frequently leads to over-use of intravenous antibiotics, for a condition which is often non-infective in origin.

As we look forward to the warmer months. Last year saw a dramatic rise in the number of training posts in Acute Medicine, a trend which will continue this August. The Department of Health considers Acute Medicine to be one of the few hospital specialities with the potential for future expansion, and additional funded NTNs

As the year draws to a close, it is traditional for an Editorial to reflect on the past 12 months, including some up-beat comments to lift the usual Winter gloom. In a year which began with the MTAS recruitment debacle and ended with a series of sporting disappointments, it may be hard to find too many positive messages on this occasion. It has been a year when bird flu and bio-terrorism disappeared from the tabloid front pages, to be replaced by hospital-acquired ‘superbugs’. In response to the media frenzy and a new set of government targets, hospitals adopted ‘nothing below the elbow’ policies: consultants were spotted entering wards without the customary Saville Row suit and tie, with a fob-watch becoming the new ‘must have’ fashion accessory. Gone are the days when a jacket was considered a ‘badge of office’ for any doctor at registrar level or above. It remains to be seen how patients will recognise ‘seniority’ when MMC produces its first 29 year-old consultant: a certificate of completed training may not have the same therapeutic effect as pin-stripes or padded shoulders…

Summer is here, the weather is great and acute medicine teams across the country will be looking forward to 3 or 4 months with few (if any) acute admissions, long lunch breaks and plenty of time off……..OK so this is just wishful thinking! However, the misconception that bed pressures are seasonal still seems to abound