Volume 14, Issue 1, Pages 1 – 40 (2015)

Trainee Update March 2015

Trainee Section, Volume 14, Issue 1, Pages 1 - 40 (2015)

We are trying to build a database of regional Acute Internal Medicine (AIM) trainee reps so we can get a better idea of regional training issues to feedback to the SAC (the national training committee). If any of you could drop us a quick e-mail to the addresses below with the name of your Deanery representative, along with any current issues it would greatly help us on our way!

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An Unusual Presentation of Lyme Neuroborreliosis

Case Reports, Volume 14, Issue 1, Pages 1 - 40 (2015)

Abstract

Back pain is a common symptom among patients presenting to the acute medical unit. We describe the case of a 55-year-old man with a brief history of fatigue and severe back pain, unresponsive to escalating doses of opiate analgesia. Blood tests and imaging studies were unremarkable and a functional diagnosis was considered. Several weeks into his admission he developed a lower motor neurone facial nerve palsy. He was treated with antibiotics for an incidental finding of a hospital-acquired pneumonia on imaging, which remarkably led to the resolution of his facial palsy and allowed a dramatic reduction in analgesia. This triggered further investigations; identifying Lyme neuroborreliosis as the cause of his symptoms.

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Pulmonary embolism in a patient with “isolated syncope”, a diagnostic challenge

Case Reports, Volume 14, Issue 1, Pages 1 - 40 (2015)

Abstract

Syncope is a recognized presenting symptom in patients with pulmonary embolism (PE), and is more common in older patients and following a large embolus. Isolated syncope, in the absence of dyspnea or tachycardia, is uncommon in this setting, and may be misdiagnosed as cardiac in origin, leading to a delay in appropriate treatment. We present a case which illustrates the importance of consideration of pulmonary embolism in the differential diagnosis of patients presenting with syncope, and the value of echocardiography in its diagnosis.

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Ovarian Hyperstimulation Syndrome on the Acute Medical Unit: A problem-based review

Research Audit and Clinical Practice, Volume 14, Issue 1, Pages 1 - 40 (2015)

Abstract

Ovarian Hyperstimulation Syndrome (OHSS) is a spectrum of clinical features typically resulting from assisted conception techniques. With 2.35% of all live births in the UK resulting from in-vitro fertilisation (IVF), OHSS is on the rise. Moreover, there has been an increase in the presentation of its complications to GP surgeries and unscheduled acute care services nationwide. This review will discuss signs and symptoms of the increasingly common and potentially fatal complications of OHSS, namely pleural effusion, ascites and thromboembolic events. With such propensity toward critical, life-threatening events it is not only prudent to recognise the population at risk, but also to be aware of the signs, symptoms and complications to expedite treatment and ensure optimum outcome.

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What is an acute medicine registrar? A qualitative investigation into trainee self-perception and identity

Research Audit and Clinical Practice, Volume 14, Issue 1, Pages 1 - 40 (2015)

Abstract

Objectives: This paper explores the experiences and attitudes of acute medicine trainees regarding their own identity and function within hospital medicine, with a view to developing a coherent theoretical framework describing the identity of the acute medicine registrar.

Methods: Three focus groups involving 17 acute medicine registrars were carried out. Video recordings of the discussions were analysed for the purpose of thematic analysis.

Results: Qualitative analysis revealed 5 key aspects to the identity of acute medicine trainees. Novel findings were of trainees’ perceptions of being poorly understood by other specialties, and of being the lead decision maker, particularly out-of-hours.

Conclusions: By gaining insight into the identity and core beliefs of AIM trainees, we are better equipped to make decisions regarding the future of acute medicine.

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Are hospital admissions reduced by Acute Medicine consultant telephone triage of medical referrals?

Research Audit and Clinical Practice, Volume 14, Issue 1, Pages 1 - 40 (2015)

Abstract

The NHS in England is facing well-documented pressures related to increasing acute hospital admissions at a time when the acute medical bed-base is shrinking, doctors working patterns are increasingly fragmented and many acute hospital trusts are operating a financial deficit. Novel strategies are required to reduce pressure on the acute medical take.

We conducted a prospective cohort study to assess the impact of acute medicine consultant triage of referrals to the acute medical take on the number of acute hospital admissions as compared to a historical control cohort.

The introduction of an acute medicine consultant telephone triage service was associated with a 21% reduction in acute medical admissions during whole the study period. True admission avoidance was achieved for 28.5% of referrals triaged by an acute medicine consultant. The greatest benefit was seen for consultant-triage of GP referrals; 43% of all GP referrals resulted in a decision not to admit and in 25% the referral was avoided by giving advice alone.

Consultant telephone triage of referrals to the acute medical take substantially reduces the number of acute medical admissions as compared to triage by a trained band 6 or higher nurse coordinator. Our service is cost effective and can be job-planned using 6 full-time equivalent acute medicine consultants. The telephone triage service also provides additional benefits to admission numbers beyond its hours of operation and the general management of the acute medical take.

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Trends in weighted vital signs and the clinical course of 44,531 acutely ill medical patients while in hospital

Research Audit and Clinical Practice, Volume 14, Issue 1, Pages 1 - 40 (2015)

Abstract

Background: little is known about the changes and trends of individual vital signs during the course of acute illness in hospital.

Methods: the weighted points of the VitalPAC Early Warning Score (ViEWS) were assigned to each vital sign value measured on 44,531 acutely ill medical patients while they were hospitalized in the Thunder Bay Regional Health Sciences Centre, Ontario, Canada. These ViEWS weighted vital signs were averaged for every 24 hour period for five days after admission and five days before death or discharge and then combined to obtain an approximation of the trajectory of each vital sign while in hospital.

Results: compared with the other vital signs, the ViEWS weighted points for respiratory rate increase the most in patients who died in hospital and decrease the most in survivors. Combining respiratory rate with the weighted points for any of the other vital signs reduced rather than increased their monitoring performance.

Conclusion: trends in respiratory rate, measured by observation at the bedside and given a ViEWS weighting is the best predictor of clinical outcome; minor changes predicted clinical outcome several days in advance.

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