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Evaluation and management of trauma
Book/Software Reviews Books A Practical Approach to Emergency Medicine, ed 1. By Stine RJ, .Marcus RH. Boston, Little, Brown, 1987, 869 pages. This new book is divided into five major sections to include life support, medical emergencies, surgical emergencies, specialty emergencies, and issues and procedures. Most chapters include brief discussions on pathophysiology, clinical and laboratory features, management, and disposition. Packed with information, the text is appropriate in length and well referenced with up-to-date publications. The editors state that “this book was designed primarily for the practicing emergency physician and emergency physician-in-training but should also be useful to medical students and other physicians who care for the acutely ill and injured.” In most cases this text is too shallow, too far from the cutting edge of emergency medicine, and too oriented toward physicians early in their medical training to be more than a quick reference for the practicing emergency physician. This book was written by traditional specialists for emergency physicians, resulting in a text that at times loses the emergency medicine focus. Important issues such as fibrinolytic therapy in myocardial infarction are not discussed in enough detail for most emergency practitioners, and no discussion of transcutaneous cardiac pacing could be found. Other chapters, such as the one on pituitary disorders that discusses water deprivation for diabetes insipidus, are clearly outside the diagnostic options in the emergency department . The procedures section is brief but complete enough for an overview of common procedures. Excellent chapters include those on obstetric and gynecologic emergencies and orthopedics. This book is easy to read and has well-organized, useful tables. Excellent examples of these tables are the ones on the safety of drug use in pregnancy, causes of acute brain syndrome, antibiotic doses in children, and several on ocular medications. The authors have attempted to write a textbook that is useful for day-to-day practice in the emergency department, and they have met their goals for the beginning practitioner. In general, this is a good book. A Practical Approach to Emergency Medicine says a little about a lot and is recommended for the personal libraries of housestaff and medical students, as well as for the library of the emergency department. GEORGESC. BENJAMIN,MD Walter Reed Army Medical Center Washington, DC
Books for review in this column should be sent to the American Journal of Emergency Medicine: 3800 Reservoir Road NW, Washington, DC 20007. 544
Sexually Transmitted Diseases-Guide to Diagnosis and Therapy, ed 3. By Noble RC. New York, Medical Examination Publishing Company, 1985, 350 pages. $33.50. The goal of this book is to provide practicing physicians with a handbook for diagnosing and treating sexually transmitted diseases. The scope goes beyond the traditional diseases and covers more than 20 topics, including lice. Reiter’s syndrome, and acquired immunodeficiency syndrome . The chapters are concise and readable, and they generally follow the same format: etiologic agent, epidemiology, clinical manifestations, diagnosis, and treatment. The chapters include numerous pictures of lesions and microscopic findings. The first chapter, on patient management, is particularly good and provides helpful hints on how to approach the patient in a nonthreatening but thorough way. The author is to be commended for including a chapter on special problems for homosexual men and a chapter on diseases and conditions likely to be found in patients attending a clinic for sexually transmitted disease. This publication will be a welcome addition to the references found in well-equipped emergency departments. DOUGLASA. BOENNING, MD The Children’s Hospital of Philadelphia Philadelphia, Pennsylvania
Evaluation and Management of Trauma. By McSwain N Jr, Kerstein M (eds). East Norwalk, Connecticut, AppletonCentury-Crofts, 1987, 544 pages. $59.95. Written and edited by surgeons with more than an armchair acquaintance with trauma and its effects on modern American society, this textbook is a worthwhile contribution to the trauma literature. A major factor in broadening the usual narrow focus of textbooks on trauma care is the section on the biomechanics of blunt and penetrating injuries. The chapter on mechanisms of injury in blunt trauma is well written, understandable, and important. The chapter on the physics of missile injury is good, but it is too technical and is largely repeated with better focus for the physician in the chapter on abdominal wounds. The chapter on emergency medical service systems provides an extensive overview of facets of the health care system that are dimly appreciated by many physicians treating injury. The patient assessment and initial management on resuscitation are well treated, providing a good adjunctive resource to the advanced trauma life support (ATLS) course. The one exception, however, is the mention of the McSwain dart. The lack of acceptance of this instrument should by now have convinced Dr. McSwain that it would best be left out of a discussion of trauma management.
BOOK/SOFTWARE REVIEWS
The systems are dealt with in individual chapters. Mattox’s chapter on thoracic trauma is fine, as are the chapters on head, maxillofacial, and ophthalmic injuries. Orthopedic and urinary system traumas are dealt with in an excellent fashion. The book is completed with chapters on bum, barotrauma, drowning, child abuse, antibiotics and nutrition in trauma, and management of pulmonary complications. Thus, the book is only lacking aspects of complex critical care, rehabilitation, and hospital organization to best provide trauma response and service. This text should be made mandatory reading for all emergendy medicine and surgical training programs. A standard is clearly set by Dr. McSwain, but a few of his supporting cast do not achieve the same level of excellence. HOWARDR. CHAMPION, MD Washington Hospital Center Washington, DC
Software Drug Interaction Advisor. By Hogan RW. Baltimore, liams and Wilkins Electronic Media.
Wil-
Drug Interactions, version 2.0. By Dambro MR, Griffith HW. Philadelphia, WB Saunders Software, 1986. $149.00. These programs have the right idea. Present-day computer programs add little to real-time emergency department decision making because human intelligence is still better at collecting and weighing all the indefinite and disorganized data of clinical practice. However, there are jobs at which the computer is far superior to the human brain, such as calculating doses without errors and sifting masses of organized data without omissions. As our patients take more numerous and more powerful drugs, it becomes harder to identify interactions and known effects of prescribed medications. Relying on human memory is insufficient, and browsing through the Physician’s Desk Reference provides a disorganized mass of irrelevant information that can hide needed data. These software programs are quick ways to review both predictable interactions of a patient’s current medications and potential interactions before prescribing another drug. I tested both programs on an IBM PC XT with monochrome graphics screens. Both require a minimal acquaintance with DOS to get up and running but thereafter use menus that make them reasonably self explanatory. Neither is copy protected. Both run easily from copies in floppy disk drives or from hard disks. Both can display their data bases and print hard copies. Hogan’s Drug Interaction Advisor comes on two 360k disks and requires two disk drives or installation on a hard disk. It has several screens of legalistic disclaimers one must wait through at the beginning, although these can be skipped later. It requires the user to log in name, address, and so forth, and the menus are not always intuitive or consistent
(sometimes one must press “escape” to proceed, sometimes “return”). One specifies at the outset up to six levels of interactions to be displayed, from nuisance to life-threatening. Dambro and Griffith’s Drug Znteractions fits on a single floppy disk and has a simpler log-on with shorter disclaimers. Although the main menu forces choices with cursor keys (Hogan’s program allows single-key initials), the screens are cleaner and faster. The whole Drug Interactions program runs faster and with fewer disk reads than Drug Znteraction Advisor. Where the latter appears to be based on specific generic and combination drugs and reads more like the Physician’s Desk Reference, Drug Interactions often lumps whole classes of drugs together, perhaps missing some nuisance effects, but providing a more streamlined and organized interaction and output. Drug Interactions also coped better with my misspellings. I can vouch for Williams and Wilkins software support, because I have already received one update of Hogan’s program. The Drug Interaction Advisor data base appears more detailed, but it repeats the same information for each generic drug in a class, and it misses important interactions by limiting its data to prescription pharmaceuticals and omitting interactions with foods and alcohol. Drug Interactions is easier to scan because it works with classes of drugs, and it includes some food and alcohol interactions. Drug Interaction Advisor can print a “Patient Information Memo” that can be useful or intimidating (it provided almost two pages of double columns listing potential interactions for a single oral contraceptive at the nuisance level). Given a component like aspirin, Drug Interactions can print a list of medicines that contain that ingredient (but it could not do this for ethanol as a component). Both the programs can be used effectively at bedside in the emergency department but will probably not achieve wide usage until they can be integrated into a computerbased system that also includes other clinical data. Moving from a paper record of current medications to the computer terminal and back to a handwritten prescription will be eliminated only as we integrate emergency department clinical data. I originally installed Drug Interaction Advisor along with some other clinical software (e.g., dose calculations, interactive tutorials) on an IBM PC XT in the middle of a teaching emergency department for almost a year, but the hundreds of students and residents who passed through used it with only a few patients. Such programs definitely can enhance clinical teaching and practice, and deserve wider use. Based on the two programs tested here, I would recommend Dambro and Griffith’s Drug Interactions as more appropriate for emergency department use, but these are dynamic products, and you can count on their continued improvement. I foresee that someday it will be considered the standard of care to have such a program review our patient’s prescriptions, and this step probably will improve our medical care. THOMAS0. STAIR, MD Georgetown University Washington, DC
545
Books for review in this column should be sent to the American Journal of Emergency Medicine: 3800 Reservoir Road NW, Washington, DC 20007. 544
Sexually Transmitted Diseases-Guide to Diagnosis and Therapy, ed 3. By Noble RC. New York, Medical Examination Publishing Company, 1985, 350 pages. $33.50. The goal of this book is to provide practicing physicians with a handbook for diagnosing and treating sexually transmitted diseases. The scope goes beyond the traditional diseases and covers more than 20 topics, including lice. Reiter’s syndrome, and acquired immunodeficiency syndrome . The chapters are concise and readable, and they generally follow the same format: etiologic agent, epidemiology, clinical manifestations, diagnosis, and treatment. The chapters include numerous pictures of lesions and microscopic findings. The first chapter, on patient management, is particularly good and provides helpful hints on how to approach the patient in a nonthreatening but thorough way. The author is to be commended for including a chapter on special problems for homosexual men and a chapter on diseases and conditions likely to be found in patients attending a clinic for sexually transmitted disease. This publication will be a welcome addition to the references found in well-equipped emergency departments. DOUGLASA. BOENNING, MD The Children’s Hospital of Philadelphia Philadelphia, Pennsylvania
Evaluation and Management of Trauma. By McSwain N Jr, Kerstein M (eds). East Norwalk, Connecticut, AppletonCentury-Crofts, 1987, 544 pages. $59.95. Written and edited by surgeons with more than an armchair acquaintance with trauma and its effects on modern American society, this textbook is a worthwhile contribution to the trauma literature. A major factor in broadening the usual narrow focus of textbooks on trauma care is the section on the biomechanics of blunt and penetrating injuries. The chapter on mechanisms of injury in blunt trauma is well written, understandable, and important. The chapter on the physics of missile injury is good, but it is too technical and is largely repeated with better focus for the physician in the chapter on abdominal wounds. The chapter on emergency medical service systems provides an extensive overview of facets of the health care system that are dimly appreciated by many physicians treating injury. The patient assessment and initial management on resuscitation are well treated, providing a good adjunctive resource to the advanced trauma life support (ATLS) course. The one exception, however, is the mention of the McSwain dart. The lack of acceptance of this instrument should by now have convinced Dr. McSwain that it would best be left out of a discussion of trauma management.
BOOK/SOFTWARE REVIEWS
The systems are dealt with in individual chapters. Mattox’s chapter on thoracic trauma is fine, as are the chapters on head, maxillofacial, and ophthalmic injuries. Orthopedic and urinary system traumas are dealt with in an excellent fashion. The book is completed with chapters on bum, barotrauma, drowning, child abuse, antibiotics and nutrition in trauma, and management of pulmonary complications. Thus, the book is only lacking aspects of complex critical care, rehabilitation, and hospital organization to best provide trauma response and service. This text should be made mandatory reading for all emergendy medicine and surgical training programs. A standard is clearly set by Dr. McSwain, but a few of his supporting cast do not achieve the same level of excellence. HOWARDR. CHAMPION, MD Washington Hospital Center Washington, DC
Software Drug Interaction Advisor. By Hogan RW. Baltimore, liams and Wilkins Electronic Media.
Wil-
Drug Interactions, version 2.0. By Dambro MR, Griffith HW. Philadelphia, WB Saunders Software, 1986. $149.00. These programs have the right idea. Present-day computer programs add little to real-time emergency department decision making because human intelligence is still better at collecting and weighing all the indefinite and disorganized data of clinical practice. However, there are jobs at which the computer is far superior to the human brain, such as calculating doses without errors and sifting masses of organized data without omissions. As our patients take more numerous and more powerful drugs, it becomes harder to identify interactions and known effects of prescribed medications. Relying on human memory is insufficient, and browsing through the Physician’s Desk Reference provides a disorganized mass of irrelevant information that can hide needed data. These software programs are quick ways to review both predictable interactions of a patient’s current medications and potential interactions before prescribing another drug. I tested both programs on an IBM PC XT with monochrome graphics screens. Both require a minimal acquaintance with DOS to get up and running but thereafter use menus that make them reasonably self explanatory. Neither is copy protected. Both run easily from copies in floppy disk drives or from hard disks. Both can display their data bases and print hard copies. Hogan’s Drug Interaction Advisor comes on two 360k disks and requires two disk drives or installation on a hard disk. It has several screens of legalistic disclaimers one must wait through at the beginning, although these can be skipped later. It requires the user to log in name, address, and so forth, and the menus are not always intuitive or consistent
(sometimes one must press “escape” to proceed, sometimes “return”). One specifies at the outset up to six levels of interactions to be displayed, from nuisance to life-threatening. Dambro and Griffith’s Drug Znteractions fits on a single floppy disk and has a simpler log-on with shorter disclaimers. Although the main menu forces choices with cursor keys (Hogan’s program allows single-key initials), the screens are cleaner and faster. The whole Drug Interactions program runs faster and with fewer disk reads than Drug Znteraction Advisor. Where the latter appears to be based on specific generic and combination drugs and reads more like the Physician’s Desk Reference, Drug Interactions often lumps whole classes of drugs together, perhaps missing some nuisance effects, but providing a more streamlined and organized interaction and output. Drug Interactions also coped better with my misspellings. I can vouch for Williams and Wilkins software support, because I have already received one update of Hogan’s program. The Drug Interaction Advisor data base appears more detailed, but it repeats the same information for each generic drug in a class, and it misses important interactions by limiting its data to prescription pharmaceuticals and omitting interactions with foods and alcohol. Drug Interactions is easier to scan because it works with classes of drugs, and it includes some food and alcohol interactions. Drug Interaction Advisor can print a “Patient Information Memo” that can be useful or intimidating (it provided almost two pages of double columns listing potential interactions for a single oral contraceptive at the nuisance level). Given a component like aspirin, Drug Interactions can print a list of medicines that contain that ingredient (but it could not do this for ethanol as a component). Both the programs can be used effectively at bedside in the emergency department but will probably not achieve wide usage until they can be integrated into a computerbased system that also includes other clinical data. Moving from a paper record of current medications to the computer terminal and back to a handwritten prescription will be eliminated only as we integrate emergency department clinical data. I originally installed Drug Interaction Advisor along with some other clinical software (e.g., dose calculations, interactive tutorials) on an IBM PC XT in the middle of a teaching emergency department for almost a year, but the hundreds of students and residents who passed through used it with only a few patients. Such programs definitely can enhance clinical teaching and practice, and deserve wider use. Based on the two programs tested here, I would recommend Dambro and Griffith’s Drug Interactions as more appropriate for emergency department use, but these are dynamic products, and you can count on their continued improvement. I foresee that someday it will be considered the standard of care to have such a program review our patient’s prescriptions, and this step probably will improve our medical care. THOMAS0. STAIR, MD Georgetown University Washington, DC
545