‘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.