They say time flies when you’re having fun – and the 5 years since Paul Jenkins convinced me to take over as editor of this journal have certainly flown by. This period has seen a dramatic expansion in the numbers of physicians specialising in Acute Medicine, the confirmation of subspeciality status and development of a […]
As the profile of Acute Medicine grows, the development of an academic limb to the specialty is a logical and necessary step. This edition of the journal features an article written by Professor Derek Bell, the first chair of Acute Medicine, who took up this appointment in Imperial College, London earlier this year. Subtitled ‘a
Few will deny that the past 6 months have been particularly challenging for all clinicians working in hospital medicine. The pressures of ward closures, which many acute hospitals have faced recently, have undoubtedly increased the ‘bottle-neck’ effect at the front door. Any ‘slack’ which might have existed in the past has now disappeared – 82%
The challenges and uncertainties of working in the developing field of Acute Medicine have been a regular theme for editorial comment in this journal since I took the helm in 2002. Almost four years on, with sub-specialty status confirmed, over 200 consultants and many SpRs enrolled in higher specialist training programmes throughout the UK, Acute Medicine finds itself in a much stronger position than any could have predicted at that time. Enthusiasm for the field is clear from the numbers of applicants for training programmes at SpR level, as well as the dramatic rise in attendances at acute medicine meetings across the country in the last year. However, on-going challenges remain. Eighteen months from now, Modernising Medical Careers will send shockwaves throughout hospital medicine. The exact nature of the change to our training programmes remains unclear, and will probably have changed again between my writing this and its publication. However it is essential that Acute Medicine is ready for whatever comes our way. We must work closely with our colleagues in Emergency Medicine and Critical Care to develop common stem training schemes which allow doctors to choose the area of ‘front door’ medicine which suits them best. Where possible we should seek to encourage dual accreditation in two or more of these areas. But most of all we need to maintain the momentum which has carried us so far in such a short space of time, and which has the potential to make Acute Medicine one of the largest hospital specialties. This edition’s review articles cover a varied mix of common and less common conditions on the acute medical ‘take’. Most medical admission units will be faced with at least one patient presenting with a seizure in each 24 hour period. Dr Kinton emphasises the importance of a good history in the management of this problem, but also provides some useful tips to help distinguish seizures from other causes of blackout. Distinction from syncope can be a particular challenge, not least because of the differing implications for driving, the loss of which can have devastating consequences. Acute ischaemic stroke is another common problem, the management of which is comprehensively reviewed by David Jarrett and Hemang Dave. As well as summarising some of the major trial data for thrombolytic and antiplatelet therapy, this review includes some advice on some of the common clinical challenges which don’t usually feature in text book descriptions of this condition. Less common, but no less important, Acute liver failure must be distinguished from decompensated chronic liver disease – the former often requiring discussion with a regional liver unit. Phil Berry has included a useful checklist to have to hand before making this phone call. Headache, palpitations and sweating is a common problem on the post-take ward round – particularly amongst the junior staff completing a night shift. Fortunately most junior doctors do not have a phaeochromocytoma – in common with every patient for whom I have ever requested 24 hour urinary catecholamine measurement. Having read Dr Solomon’s thorough review of the acute management of this condition I will now feel equipped to manage this condition when I finally get a positive result back from the laboratory!
Apologies that this edition has been a little delayed – I hope you consider it to have been worth waiting for….
Welcome to the second edition of Acute Medicine Volume 4 which, I regret to say, has probably reached you rather later in the year than you were anticipating. Unfortunately printing delays around the time of the change in our journal’s title have pushed back publication dates for both of this year’s editions so far, although I am hopeful that the third will reach subscribers soon after this one.
Our cycle of reviews, which began in 2002, is now nearing its end; by the end of next year this should be complete. Regular subscribers over the past 4 years will soon have the equivalent of a comprehensive textbook of up to date management of conditions presenting themselves on an acute medical ‘take’. How we proceed beyond this is still to be determined; management of many of the conditions described will not have changed dramatically in 5 years, so that simply repeating the cycle may be inappropriate. One option we are considering is to change the emphasis of review articles from ‘diagnosis’ to being ‘problem’ based. An edition may be themed around topics such as ‘The patient with palpitations’ or ‘The patient with pleuritic chest pain’, rather than starting with the diagnosis which may not be apparent at the time of initial assessment. In order to keep them practical for our ‘Acute Medical’ readership, it is essential that, wherever possible, such reviews are written from the perspective of those working within the field. I am therefore open to offers from anyone who has an interest in writing a review article along these lines who should contact me at the address or e-mail shown on this page.
This edition’s reviews represent a mixture of the common and extremely uncommon conditions facing the acute take physician. Ben Turner follows up his previous article on Thyroid Storm with a comprehensive review of the management of Myxoedema Coma. Although rare, its nonspecific presentation and serious consequences are highlighted; lack of ‘routine’ availability of thyroid function tests in the out of hours period or at weekends require that clinical vigilance is maintained. Mark O’Neill concludes his ‘tachyarrhythmia’ series with his review on the management of narrow complex tachycardia, while another cardiologist Dr Tim Wells embarks on a pair of articles describing inflammatory cardiac conditions; endocarditis will follow in a later edition.
Our ‘Regular Features’ section includes two examples of potential complications of commonlyused drugs, namely amiodarone and enoxaparin. Clare Sixsmith’s ‘Viewpoint’ paper entitled ‘Should physicians manage hip fractures?’ raises some interesting questions regarding the need for a specialist ‘Orthogeriatric’ service. More controversies follow in the final paper on the management of life-threatening asthma. We would happily consider publication of letters containing contradictory views on any of these subjects in a future edition of the journal: I would be particularly keen to hear from anyone who has a good word to say about aminophylline. I can’t believe I am the only physician who still thinks it is a useful drug!
As ward round ‘faux-pas’ go, this week’s was a bad one. The patient was a middle aged man with pneumonia – nothing out of the ordinary. Turning to the somewhat hirsute ‘adolescent’ sitting in the chair next to him I asked the question: ‘Are you his son?’, to which the indignant response: ‘No, I’m his wife!’ came as something of a shock. Things went from bad to worse when the house officer helpfully suggested that it was a sign of getting older when you can no longer distinguish the sex of the ‘younger generation’. Not that I needed reminding: I recently reached an interesting milestone, when I realised that that I had once babysat for one of our third year medical students (while she was still in nappies). Having said that, getting older has its compensations – it is now several years since any patient told be I look too young to be a doctor; what’s more, it won’t be long before I have an answer for those sceptics who ask if I will still be doing my job when I am fifty…
The first edition of 2005 brings another varied series of review articles. Mark O’Neill follows up his previous paper on bradycardia with a comprehensive account of the management of broad complex tachycardia. Guy Thwaites gives a practical approach to the assessment and treatment of PUO, while Lloyd and Garfield’s review of Non-invasive ventilation helps to demystify this complex subject. For many readers, ‘query urinary tract infection’ will probably stand alongside off legs’ and ‘collapse query cause’ in the ranking of ‘heartsink’ referrals on the medical take. However, if ‘prescribe trimethoprim’ would have been the only two words you would have been able to write on the subject I would commend to you Dr Chaudhuri’s comprehensive account of this topic.
A couple of new features appear in this edition. A picture quiz section provides a variation on the case-report theme – no prizes, I am afraid, but you can find the answers on p36. Future submissions of this type, in addition to the standard case report format, are encouraged. Practices in medical admissions units vary widely, and it is important that we share each others’ experiences, both positive and otherwise. To this end I am keen to encourage readers to submit papers describing their activity along the ‘How we do it here…’ theme. To launch this series, Dr Vincent Connolly, winner of the Hospital Doctor Acute Medicine Team of the Year award describes the evolution of his innovative unit in Middlesborough.
Finally, the more observant of you may have noticed a subtle change to the title of the journal, with the removal of the CPD Journal prefix to Acute Medicine. Although the educational themes of the journal remain unchanged, it is hoped that this will broaden its appeal beyond consultants and other ‘Points collectors’. I hope this does not detract from your enjoyment of the current and future editions, the reading of which can, as ever, be counted towards your ‘personal’ CPD.
While the profile of the subspecialty of Acute Medicine continues to rise, so does the burden of work under which we are continually placed. Changes in General Practice out-of-hours cover, reduced junior doctor hours, continued pressure to achieve four hour A&E wait targets along with the arrival of yet another winter will be familiar themes for many readers. There are times when it may seem difficult to stay positive in the face of such adversity. In these moments of despair, I have recently taken to reading our ward admissions list in search of light relief. This list, compiled by non-clinical staff, describes the problems which doctors referring patients to the AMU ascribe to their patients. ‘COPD Exasperation’ appears to be a common problem (not least amongst the junior medical staff), while I hope that the patient admitted with ‘aspirations of pneumonia’ wasn’t too disappointed by his final diagnosis. A patient with Wegener’s granulomatosis was admitted several times with ‘acute f lare-up of vagueness’, an aff liction with which many of us will be familiar. My favourite, however, remains the unfortunate patient described as ‘Bilateral amputee – off legs’; things clearly could not get much worse for this man!
If your own search for light relief leads you to browse through the following pages you will find more useful reviews, case reports and the second in our ‘Controversies in acute medicine’ series. This time Guha and Sheron tackle the issue of f luid resuscitation in chronic liver disease, an area which is frequently a source of considerable confusion. I have only ever treated one patient with thyroid storm, sadly without a favourable outcome; Ben Turner’s overview of the management of this rare condition will hopefully equip readers to deal with the consequences, should you ever be faced with such a problem. At the other end of the pulse-rate spectrum, bradyarrhythmias are a more familiar on-take emergency. In part one of a series of reviews on arrhythmias to be published over the next few editions, this subject is tackled in some detail. Diarrhoea and Cardiac Arrest have both been areas traditionally avoided by consultant physicians. In these days of the ‘hands-on’ consultant (preferably gloved!), I would urge colleagues to be prepared for such eventualities by taking note of our final two reviews.
I am pleased to report that my continued pleas for submissions has resulted in more than a trickle of case reports, which has enabled us to publish two ‘Cases to remember’ in this edition. More on a similar theme would be most welcome. Mike Jones, originally brought into the editorial board for his renal expertise, wears his hat as Secretary of the SAC in General Internal Medicine to give an insight into Training developments in Acute Medicine in Viewpoint. Submissions for this section would again be welcomed.
I hope you enjoy this edition, and that you continue to find the journal helpful in your everyday practice and personal CPD into the New Year.
Over the past three years it has become apparent to me that referring to ‘current affairs’ in these columns can be a mistake, serving only to highlight inevitable printing delays. By the time this edition arrives on your doormat Euro 2004, ‘Big Brother’ and the early summer heat wave will be nothing but a distant memory. However the ‘recent’ publication of the Royal College of Physicians document ‘Acute Medicine – making it work for patients’ cannot be allowed to pass without a mention. This report represents a significant shift in the position of the College in relation to Acute Medicine since the previous working party reported its findings in 2000. The value of consultants specialising in Acute Medicine is now clearly recognised and supported – every trust should now have one, with the minimum figure of three per hospital being proposed by 2008. Whether this is achievable will depend on the rapid development of training schemes across the UK, as well as the generation of enthusiasm for the specialty amongst junior staff. The number of applicants for our Wessex programme indicates no shortage of the latter. Although developing a training scheme takes a lot of hard work, it is vital that those already working in the specialty make this a high priority. We have already seen benefits from the appointment of high quality middle grade staff and are looking forward to a ‘flood’ of future applicants for local consultant posts, 4 years from now.
This edition comprises four more important review papers on aspects of acute medicine, along with the first in our ‘Controversies in acute medicine’ series. The latter was designed to try to stir up some correspondence, for future publication. The confusion over oxygen delivery in the acute setting seems to reign fairly widely amongst junior, and indeed some more senior medical staff. Hopefully Dr Cooper’s well-written paper will serve to dismiss some of the misconceptions in this area. Our reviews cover relatively uncommon, but nonetheless important aspects of acute medicine. Tuberculosis and HIV are both on the increase in the UK. The success of anti-retroviral therapy will undoubtedly lead HIVrelated illness to be a significant part of our practice over the next decade. An understanding of the range of conditions specific to this group of immunocompromised patients is therefore crucial for physicians involved in the acute take. Hypoglycaemia and suspected bacterial meningitis are both conditions which require immediate action by medical staff. Both of these reviews comprehensively cover their respective topics with a combination of well written text, illustrations tables and algorithms. Dr Hartman highlights recent evidence supporting the use of dexamethosone in bacterial meningitis and re-iterates some of the points made in an earlier edition regarding the use (and abuse) of CT scanning prior to lumbar puncture.
For a change we have no case reports this time, although Dr Macdonald’s audit of the innovative review clinic in the Emergency Assessment Area of Heartlands hospital provides a worthy substitute. Submission of similar articles in future would be most welcome.
Once again, a reminder that multiple choice questions are for self assessment and ‘personal’ CPD only; I hope you will find this edition helpful in your clinical practice.
This journal now enters its third edition, which means we are now more than half way through our proposed four-year cycle of reviews. As previous readers may recall, our intention was to cover all aspects of acute medicine with review articles over this cycle. Although we have strayed from the original programme on occasions, we remain on track to achieve this goal. This edition contains five such reviews, including Part Two of the Acute Coronary Syndromes series, this time dealing with the ST elevation myocardial infarction. Dr Wallis guides us through the current evidence for management of this condition, concluding with a helpful paragraph outlining how she would like to be treated in this eventuality. In a comprehensive review, Booth and Leary give a critical care perspective on the investigation and treatment of the comatose patient. Readers should take particular note of the useful algorithm on page…., which provides a user-friendly approach to the management of this often challenging problem.
A neurologist once told me that the ‘three F’s of Neurology’ were ‘fits, faints and headaches’, although ‘funny turns’ might perhaps also come into this category. Our next two reviews deal with each of these conditions. Sudden headaches often cause a diagnostic dilemma on our admissions ward – exclusion of subarachnoid haemorrhage is often the easy part; making a positive diagnosis after the CT and LP have proved negative is more of a challenge. Dr Griffin describes some of the less well known causes of this problem, emphasising the need to proceed to MR scanning if there remains a clinical suspicion of significant pathology. Mike Bacon’s review of ‘funny turns’ provides an interesting insight into the approach taken by a consultant experienced in the management of these problems in older people. The diverse nature of the problem is highlighted, along with the need for targeted investigations. Our ‘How-to-do-it’ article this month complements this paper with a detailed description of the Dix-Hallpike and Epley manoeuvres in the management of BPPV.
Our final review is a comprehensive discussion of the management of pleural effusion from the Oxford Pleural Disease Unit. In this extensively referenced article, the diagnostic and therapeutic challenges of this condition are discussed in detail, emphasising some of the newer modalities now available.
I’ll conclude with my usual plea for submissions. I remain a firm believer in the value of case-based learning and most of us see at least one patient each week which emphasises a teaching point worth sharing. Please encourage your colleagues and juniors to submit such case reports to us – anything which would appeal to a ‘generalist’ audience will be considered for publication. In an attempt to stir up some lively debate, future editions will also contain a feature entitled ‘Controversies in Acute Medicine’. Any reader who feels particularly strongly about an aspect of acute care which attracts controversy is encouraged to contribute to this section: anything except MMR!
It could be said that the past 12 months have been an exciting time in the field of acute medicine. In addition to the high profile afforded by the publication of Reforming Emergency Care and the ongoing Emergency Services Collaborative, the significance of the recent acquisition of subspecialty status for Acute Medicine cannot be understated. This, in turn has enabled approval of a new competency-based training curriculum by the JCHMT. Hopefully within the next few months, specialist registrars in General Internal Medicine with Acute Medicine will be appointed to the first few numbered posts in this discipline. Clearly a rapid expansion in posts of this nature will be required in the next few years in order to meet the enormous demand for consultants in Acute Medicine. Recently, in common with other medical specialties, hospitals have experienced difficulties in recruiting suitable applicants for such posts resulting in many vacancies across the UK. One challenge for those of us already working in the field is to maintain enthusiasm for the concept, while we are waiting for the trainees to mature into competent consultants.
This edition includes another varied selection of reviews. Community acquired pneumonia may be of particular relevance over the remaining winter months, although hopefully the brief mention of SARS in this paper will now only be of historical significance. Patients with hypercalcaemia, dysphagia and Guillan Barre syndrome may be less frequent attenders, but nonetheless often create management dilemmas with which the admitting physician needs to be familiar. In a departure from our previous format, we have included two case reports this time, both highlighting an important clinical scenario. Power kite flying may not be a familiar activity for many readers, but the outcome described by Merrison and colleagues justifies its inclusion as ‘a case to remember’. Mark Mallett, on the other hand, reminds us that syncope can, on occasions, reflect significant underlying pathology, even in an apparently healthy member of the hospital portering staff. Once again we would like to encourage similar submissions for future editions of the journal.
After several years of association with CPD Acute Medicine and its predecessor, it is with great sadness that this edition is Paul Jenkins ’last as sub-editor. We wish him well as he moves on to new challenges in his role as President of the Society for Acute Medicine, and gratefully acknowledge all of his hard work in establishing the journal.