Saturday, January 26, 2013

Medical Book Review - Emergency Medicine MCQs

Emergency Medicine MCQs
by Waruna De Alwis and Yolande Weiner
Publisher: Churchill Livingstone/Elsevier
Paperback edition 2012 (440 pages)

  • Contents 
  • List of Authors and Contributors 
  • List of Reviewers 
  • Dedication 
  • Preface 
  • Acknowledgements 
  • Questions: Chapters 1-24 
  • Answers: Chapters 1-24 
  • Index 

Part of the very great appeal of this book is that it is written for Australian conditions (by two FACEMs working at Logan Hospital in Queensland), and should be very helpful to those studying for the ACEM Fellowship exam as well as those working regularly in the area who wish to expand and consolidate their knowledge of emergency medicine.

The book "is structured to reflect the topics covered in the core curriculum of the Australasian College for emergency Medicine fellowship program" and "contains evidence-based, clinically relevant and practical multiple choice questions in adult and paediatric emergency medicine". The contents have drawn upon the knowledge and experience of expert authors in addition to textbooks and peer-reviewed journals. It is aimed not only at exam candidates but also at being a useful resource for everyday clinical practice and improving both knowledge and critical thinking skills.

Additional timed exam papers and quizzes are available in "Practice Exams in Emergency Medicine" for iOS devices and Android.

The topics covered in the Chapters are very comprehensive (as per the ACEM curriculum) and include:
  • Resuscitation 
  • Cardiovascular emergencies 
  • Respiratory emergencies 
  • Neurological and neurospinal emergencies 
  • Endocrine emergencies 
  • Gastrointestinal emergencies 
  • Renal emergencies 
  • Haematological and oncological emergencies 
  • Infectious diseases 
  • Dermatological emergencies 
  • Electrolyte and acid-base disorders 
  • Emergency anaesthesia and pain management 
  • Trauma and burns 
  • Orthopaedic emergencies 
  • Surgical emergencies 
  • Eye, ENT and dental emergencies 
  • Urological emergencies 
  • Obstetric and gynaecological emergencies 
  • Toxicology and toxinology 
  • Environmental emergencies 
  • Psychiatric emergencies 
  • Paediatric emergencies 
  • Disaster management 
  • ED management and medicolegal issues. 

Starting to look through the book was a bit like "being a kid in a candy store" as there were many areas I was interested in exploring to see how my existing knowledge 'stacks up'.

It is obviously not possible to review every single question and answer, so I will just look at a selection to try to give a flavour of the level of difficulty and the depth of the information provided in the answers.

In Chapter 1 on "Resuscitation", there are thirty-two questions relating to adult resuscitation and eighteen relating to paediatric resuscitation. These are fairly wide-ranging, (in adults) covering topics like CPR protocols, ventilatory support, defibrillation and pacing, hypothermia, lactic acidosis and septic shock, vasoactive substances, fluids, thoracotomy and echocardiography. I have to admit that I found some of these questions challenging (I'm not going to say how many I got right on the first pass!) and some of them I simply didn't have detailed enough knowledge even to make an 'educated guess'. However, the beauty of the answers is that they not only explain which is the correct answer (and why) but also why the other answers are incorrect.

I commend the authors on their use of terminology in the questions. It is very clear which alternative the reader is being asked to indentify e.g., "which ONE of the following statements is TRUE/INCORRECT" or "which ONE of the following is NOT ...". I think all medical students hate questions like "Choose the MOST CORRECT/LEAST CORRECT answer from the alternatives below". Some of the questions stray a little in this direction, such as "Which ONE of the following patients will MOST likely benefit ..." or "which ONE of the following is the MOST appropriate answer?" but it seems that the intention here is to tease out critical thinking rather than present a gradation of fiendishly difficult alternatives.

I have chosen one (shorter) example of a questions and answer from this chapter (which incidentally I did get right!):

27. Regarding the use of hypertonic saline in traumatic brain injury (TBI), which ONE of the following statements is true?
A. It reliably decreases intracranial pressure and significantly improves cerebral blood flow.
B. It is as effective as mannitol when osmotherapy is indicated.
C. There is good evidence showing an outcome benefit in TBI.
D. It is the preferred crystalloid if severe TBI occurs with hypotension. 

27. Answer: B
Hypertonic saline as been shown to reliably decrease ICP in patients with TBI (LOE II) and it is at least as effective as mannitol. However, no studies so far have demonstrated improved cerebral blood flow; neither is there good evidence showing an outcome benefit. Despite the potential benefits in reducing ICP in patients with TBI, there is currently no evidence to recommend hypertonic saline over isotonic saline for fluid resuscitation and restoration of the intravascular volume (footnote 40).

References are supplied at the end of each chapter of Answers, and it is good to see that the authors are also supplying the Level of Evidence for propositions were relevant.

Next I thought I would move on to Chapter 12 "Emergency Anaesthesia and Pain Management", which I also hoped I would know something about already! There are twenty questions, relating to RSI, medications, local anaesthetics, nerve blocks, opiods, procedural sedation and pain management (these cover both adults and children).

These questions require quite a bit of detailed knowledge, so I think people who are not regularly dealing with the content on a regular basis will find them quite challenging. However, the answers are very educative.

Here is an example from this chapter.

4. The laryngeal mask airway (LMA) is a successful rescue device in emergency airway management. Which ONE of the following statements is TRUE regarding the LMA?
A. Positioning of the patient into the 'sniffing' position is essential.
B. It is a useful alternative to an ETT for establishing a definitive airway.
C. Cricoid pressure almost always impedes insertion of an LMA.
D. The device should be held firmly in place during inflation to allow the LMA to seat properly.

4. Answer: C
The LMA is a useful alternative to endotracheal intubation when an advanced airway is required but it is not a definitive airway and doesn't protect the patient from aspiration. Positioning of the patient into the 'sniffing' position is not essential but it is preferable. The LMA should not be held while the cuff is being inflated to allow the LMA to seat properly. The LMA tube on average will move out of the mouth approximately 0.7% during inflation. The LMA can potentially be placed too deeply if the tube is held in place during inflation and not allowed to rise slightly. (Footnotes 10-12.)

This answer demonstrates nicely how the authors have in many answers highlighted particularly salient points.
By now I was realising that perhaps there is one small criticism in that there is no colour-coding of the chapters, and if you are just flicking through the book you have to look at the small print at the bottom of the pages to locate the chapter that you are looking for.

For my last example, I decided to have a look at a chapter that perhaps a lot of people might gloss over, but having done a post-graduate degree in this area I was interested to test my knowledge. Chapter 23 deals with "Disaster Management". In the relevant literature, it is recommended that all health professionals should know something about this area, but this rarely occurs in practice. All the American emergency medicine textbooks I have seen have splendid chapters on this topic. All credit to the authors for incuding it in their book and bringing this topic to the attention of a wider audience.

There are only ten questions. Once again, fairly detailed knowledge is required in order to answer them correctly.

9. Regarding a patient experiencing a significant radiation exposure, which ONE of the following statements is TRUE?
A. Patients developing symptoms secondary to gamma irradiation pose an ongoing risk to healthcare staff.
B. Bone marrow suppression following a serious exposure develops over 3-5 days.
C. Patients developing gastrointestinal symptoms can be expected to recover over 6-8 weeks.
D. Potassium iodide blocks the uptake of radioactive material if ingested in the first few hours following exposure. 

9. Answer: D
In the event of a nuclear accident, radioactive iodine might be released into the environment. Potassium iodate tablets block the uptake of radioactive iodine by the thyroid gland, therefore reducing the risk of developing thyroid cancer. Irradiated patients are not radioactive, and so do not pose a risk to staff. Patients exposed to particulate radioactive material - such as following an explosion - may still have radioactive material on their person, and so should be considered as requiring decontamination until declared clear by a radiation safety officer. Haemopoetic syndrome - due to bone marrow suppression - displays developing symptoms of bleeding, depressed white cell count (WCC) resulting in impaired immune response and fatigue by 3 weeks post exposure. Treatment is supportive. Gastrointestinal symptoms of vomiting, bloody diarrhoea and ileus denote an exposure of >2-10 Gy, and result in 50% mortality due to renal, hepatic and pulmonary injuries. (Footnote 5.)

There is a small inconsistency between the question and answer - the question refers to "potassium iodide" whilst the answer refers to "potassium iodate".

The answers in this chapter are a good example of how the authors provide helpful mnemonics to assist memory and recall.

For FACEM candidates this book will no doubt be very useful in testing out the limits of knowledge and identifying weaknesses whilst also providing the means to remedy these theoretical gaps.

If you are not a FACEM candidate, this book is probably best approached with humility and an open mind and willingness to learn. If you look at it in those terms, it is a terrific resource that will help you to take your practice of emergency medicine to a higher level. It is a salient reminder that in the practice of medicine you should never be too cocky or complacent about your level of knowledge and the capacity for improvement.

Verdict: Recommended!

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