Editorial
Authors:   Acute Medicine University Hospital Southampton Foundation Trust Tremona Road Mail Point 520 Southampton SO16 6YD UK, Roseveare Chris 
Published: June 2021

Winter has arrived again, and our thoughts turn to the management of pressures associated with surges of respiratory and diarrhoeal illness, when the bed stock of the hospital remains permanently full. The phenomenon of ‘exit block’ is as real a challenge for Acute Medical Units as it is for Emergency Departments (ED), with patients commonly exceeding the desired length of stay in the AMU while awaiting availability of a suitable speciality bed. The problem is compounded by increased numbers of patients whose discharge or transfer is delayed, particularly in the period after Christmas when the backlog for our Social Service colleagues may be considerable. When the AMU becomes gridlocked, there is an inevitable pressure back on the ED, with the consequence that alternative solutions may be sought to avoid breaches of the 4 hour emergency access target. The temptation to move patients directly from the ED to areas of the hospital which are not designed to receive and treat acutely ill medical patients should be resisted, according to the data presented in the paper by Coary et al from Dublin. According to their review of over 36,000 patient admissions over a 12 year period, patients who bypassed the AMU experienced a significantly higher mortality, despite an identical expectation of death according to a multi-variable risk model. Although the authors do not speculate on the precise reason for the difference, which may be multifactorial, this paper provides an important message about the need to maintain a structured process of care, as bed pressures rise across our hospitals. Structure is also an important part of clinical examination. David Nicholl’s Viewpoint article raises a plea for re-establishment of neurological examination as part of the assessment of patients admitted on the medical take. He reminds us that ‘Neurological Examination NAD’ should imply that it was normal, rather than not actually done. Tendon hammers and ophthalmoscopes are not always easy to find on the acute medical unit (I now carry my own ophthalmoscope in my pocket) – perhaps this is, in part, why it is often easier to reach for a pen and complete a request for an imaging scan rather than checking the reflexes or the patient’s fundi. Given that tendon hammers are considerably cheaper than stethoscopes, it is perhaps surprising that more doctors don’t possess their own. Finally, I have often thought that rats get an unfairly hard time: the mere sighting of one such rodent in my back garden is usually met with a swift request to lay down poison or call in the extermination team. I once read that we are usually only a matter of a few yards away from a rat, as we go about our day to day existence. With this in mind it is somewhat surprising that our acute medical units are not regularly filled with cases of leptospirosis and Weil’s disease. Perhaps the reason for this is that some cases are going unrecognised – the report from the team at Chelsea and Westminster highlights the non-specific presentation in a patient who was initially thought to have ‘flu, before being treated for atypical pneumonia. The admitting team could be forgiven for missing the history of blackberry picking in the days preceding his admission, which led to a leptospira serological sample being sent; confirmation of the diagnosis occurred after his condition had already been treated. Maintaining an awareness of this condition is important to ensure choice of appropriate antibiotics – and ‘smelling a rat’ sometimes requires a very careful history.