Editorial – Managing Risk in Uncertain Times

In February 2021 Jon Hilton (AIM ST4 doctor) published a tweet asking about how the Acute Medicine community can best address potential applicant’s fears of dealing with clinical risk. ​(1)​ Appraising and managing risk is at the core of acute medical clinical practice; we treat patients in the first crucial 24 hours of their hospital journey, when the clinical status is changeable, and the clinical trajectory not yet established. We make judgement calls about medical treatment, but also about whether a patient can be safely discharged home, and this often causes anxiety amongst less experienced clinicians: how do you make that call? Dealing with risk can be tricky to teach. It is a skill that stands on two legs: one leg is data and the other is clinical experience. As the pandemic intensified, Acute Medicine’s role as front door risk managers became more important than ever before. We displayed massive amounts of creativity and initiative to develop pathways and processes to ensure patients were followed up at home. But we were still operating with many unknown variables and did not yet have the experience nor the data required to make the crucial risk calculations and judgement calls that forms the heart of our working practice. Long before we began to recognise patterns in our patients in their diseases, and before we began to create a new language to describe and communicate what we were seeing – the ‘happy hypoxic’ and the ‘day-10 wobble’ – we operated in a form of darkness, making the best decisions we could. One year and two COVID-19 peaks later, we are better able to make nuanced decisions about patient risk, and reach collaborative plans with our patients, as the international COVD-19 academic library grows and elaborates. In this issue Azijli et al ​(2)​ present the findings of the COVERED trial, which establishes a validated model that predicts poor outcomes in patients in the Emergency Department. This model is a tool that can help power our risk perception and clinical decision-making on the medical take. Deciding whether to thrombolyse an acute pulmonary embolism is another exercise in risk management. Weighing the risk of death from obstructive shock against death from haemorrhage, whilst remaining mindful of the longterm cardiopulmonary sequel of an untreated high-risk PE. Apsey et al ​(3)​ followed up patients with massive and sub-massive emboli who received emergency thrombolytic therapy and favour an acute thrombolysis strategy in their conclusion. This is a small study, but provides some substrate for reflection: how do we perceive the risks of thrombolysis in out own institutions, and how does the effect our patient care? It is not uncommon for physicians to be given a troponin results that they did not want nor request, but must now square away with their assessment and evaluation of a patient. Most of us shrink away from the descriptor ‘troponin-positive chest pain’ as a not-quite diagnosis, but when we have ruled out acute myocardial infarction, what conditions remain under this umbrella term? Hansen et al ​(4)​ describe the common conditions that lead to elevated troponin levels, and – crucially – tell us about these patients’ outcomes. Their paper shows us that patients with a high troponin, without an acute MI, have a very high mortality. This brings us back to risk: how do we keep these patients safe? The pandemic has brought dramatic changes into our clinical and personal lives. Our trainee doctors have undergone rapid redeployments to new work environments. They often moved from low-risk to high-risk COVID-19 environments with very little notice. Some of them became very sick with COVID-19. They have had expensive and mandatory examinations cancelled. Many have been left with uncertain futures, not knowing if they will be able to progress with their training programmes as anticipated. Aziminia et al ​(5)​ have captured their voice in this issue, and make suggestions toward helping trainees navigate this incredibly uncertain period in their medical careers.