Volume 3

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.