Book Review - "Surgery: The Ultimate Placebo" by Professor Ian Harris

This is a "must read" book - it has a great explanation of how evidence-based science works (or doesn't) and challenges us to question whether doing things "because that is the way we have always done it" is in fact the best way to do things or whether it should be done at all, for instance treating appendicitis at first instance with surgery rather than a trial of IV antibiotics.

"Surgery: The Ultimate Placebo" by Professor Ian Harris (New South Books, Australian RRP $24.99).

Medical Book Review: Talley and O'Connor - Clinical Examination (Seventh Edition 2014)

Medical Book Review – Clinical Examination. A systematic  guide to physical diagnosis. Seventh Edition.Nicholas J Talley and Simon O’Connor

Churchill Livingstone/Elsevier

ISBN: 9780729541473 Publication Date: 2014 RRP: $125.96 (free delivery in Australia/NZ).

For further information see: http://www.elsevierhealth.com.au/clinical-general-medicine/clinical-examination-paperback/9780729541473/

(Bonus online resources (videos, ECGs and images) are available to purchasers of this book through the Student Consult portal.)

The book is also available in two other formats: a standard eBook containing the content from the print edition plus four additional chapters covering the history and examination of gynaecology, obstetrics, neonatology and paediatrics, and an interactive enhanced eBook which contains the four additional chapters together with OSCE videos, ECG case studies, an imaging library and MCQs.

I purchased the fourth edition of this book (together with the pocket guide) when I was a medical student. This paperback edition comes in at around 600 pages, and is physically larger than its predecessor, and, unlike my earlier edition, contains an impressive number of colour photographs and other illustrations and tables. I was literally ‘blown away’ by the quality of the book (and its contents) as an educational resource, and it is a book in which even a highly experienced practitioner can find learn something from.

The Contents section follows straight on from the Foreword, and is well set out with bolded headings which make it easy to identify the topic of interest at a glance.

The book is divided into several key sections:

1.            The general principles of history taking and physical examination;

2.            The cardiovascular system;

3.            The respiratory system;

4.            The gastrointestinal system;

5.            The genitourinary system;

6.            The haematological system;

7.            The rheumatological system;

8.            The endocrine system;

9.            The nervous system; and

10.          Specialty examinations.

The ‘specialty examinations’ have been considerably expanded from my earlier edition, with seven topics covered as opposed to the earlier three. These now include:

Chapter 38: The eyes, ears, nose and throat;

Chapter 39: The breasts;

Chapter 40: The skin, nails and lumps;

Chapter 41: A system for infectious disease examination;

Chapter 42: Assessment of the geriatric patient;

Chapter 43: Assessment of the acutely ill patient; and

Chapter 44: Assessment of death.

There are three appendices which were also present in my earlier edition (‘Writing and presenting the history and physical examination’,’ A suggested method for a rapid screening physical examination’ and ‘The pre-anaesthetic medical evaluation (PAME)’. The book concludes with an extensive Index.

Most chapters conclude with two useful and practical components, ‘T&O’C essentials’ and ‘OSCE revision topics’, and a list of references.

The Preface (written by the two authors) summarises their approach to this new edition:

“… we cover the core clinical skills from the basics to an advanced level. We have taken an approach that is patient-centric and evidence-based; the patient must always come first. The edition has been brought right up to date with the latest clinical data, including new research specially commissioned for this edition. Learning should also be fun and the book is deliberately laced with humour and historical anecdotes that generations of students have told us enhance the learning experience.”

Further information concerning the evidence-based approach which has been taken in this edition appears in the Acknowledgments section, together with a list of the highly credentialed reviewers who have also contributed to the manuscript.

I particularly enjoyed the next two sections: ‘Clinical methods: an historical perspective’ and ‘The Hippocratic Oath’. In keeping with the evidence-based approach, these are followed by a section detailing ‘Credits: figures, boxes and tables’.

Section 1 (general principles of history taking and physical examination) provides a structured approach to both these elements together with abundant resources in terms of photographs, tables and practical advice (including about OSCEs). There is a specific section on evidence-based clinical examination.

In my work as a medical educator, the clinical history and examination topic that we have most recently covered with our students was the gastrointestinal system, so I have elected to look at this chapter in some more detail as an example of the system-based chapters.

As is customary, this chapter begins with a pertinent quotation, this time from Shakespeare. A short section on ‘examination anatomy’ follows, containing a detailed colour illustration and descriptions of the major areas in the abdomen of anatomical interest. The correct positioning for examination is then described, and a systematic approach to examination follows. This begins with jaundice and weight and wasting, and a very thorough section on skin follows, together with several photographs and a very detailed table setting out relevant diseases with skin and gut associations. The general introductory section concludes with ‘mental state’. The next section covers the examination of the upper limbs, beginning with the hands (nails and palms) and a discussion of the most common relevant findings, proceeding to an explanation of hepatic flap and then possible findings on the arms. Several illustrative photographs and a table for assessing malnutrition are included in this section.  The next topic looks at the face and head, and includes discussions around the eyes, salivary glands and mouth. Several photographs and tables are included. After a brief section on ‘Neck and chest’, the chapter moves on to examination of the abdomen. This section begins with detailed information on inspection and then a systematic approach to palpation of the abdomen, including assessment of the major abdominal organs and possible causes of other abdominal masses. Once again several helpful illustrations and tables are included. Sections follow on percussion, ascites and auscultation. These are also well supported by additional resources. A section follows on hernias (including how to examine for these) with useful illustrations. Next is a detailed section on rectal examination, including proctosigmoidoscopy. There is a brief section on other areas of the body which may be relevant to examine, and then the chapter concludes with a section on ‘Examination of the gastrointestinal contents’ (including faeces, vomitus and urine. There is a helpful illustration of the bilirubin pathway and a table listing the changes in urine and faeces with jaundice.  The final three elements are the ‘T&O’C essentials (nine key points from the chapter), ‘OSCE revision topics’ (five points) and the references.

There is also a complementary chapter immediately following on ‘Correlation of physical signs and gastrointestinal disease’. This covers examination of the acute abdomen, signs commonly associated with chronic liver disease and portal hypertension, hepatic encephalopathy and dysphagia, an approach to assessment and diagnosis of gastrointestinal bleeding, a discussion of inflammatory bowel disease and finally, malabsorption and nutritional status (signs, causes and classification).

Both these chapters are very thorough but well-organised and laid out and are as a result easy to follow. The plentiful illustrations and tables support the written text and enable the reader to gain a better understanding of the subject matter. These additional resources essentially make the book a ‘one stop shop’ so that in general it is not necessary to look elsewhere for supporting materials to aid comprehension.

This is a magnificent book, which is one of those references which will well and truly ‘stand the test of time’ and the authors are to be congratulated on their efforts. Whilst the amount of detail is probably in excess of that required for junior medical students, for those undertaking their clinical training, and indeed for junior clinicians in training it would provide an invaluable resource. It is also a well-loved resource for medical educators. This is a book which has ‘something for everyone’ and it is not hard to imagine that even highly experienced medical practitioners would find it useful to turn to from time to time.

Verdict: Highly recommended!

Medical Book Review - Emergency Medicine. The Principles of Practice. Sixth Edition. Authors: G and S Fulde.

Medical Book Review – Emergency Medicine. The Principles of Practice. Sixth Edition.
Gordian Fulde and Sascha Fulde.

Churchill Livingstone/Elsevier Health Sciences
ISBN: 9780729541466 Publication Date: 27-09-2013 RRP: $109.93 (free delivery in Australia/NZ).
For further information see: http://www.elsevierhealth.com.au/emergency-medicine/emergency-medicine-paperbound/9780729541466

I have a previous fourth edition of this book by the highly credentialed Professor Fulde, which I was given whilst at medical school and has done good yeoman service over the years, but this new edition is an impressive replacement. It is also nice to see that Sascha Fulde is carrying on the family tradition. Professor Fulde recently appeared on the news bemoaning the prevalence of alcohol-fuelled violence, and is obviously still very much a ‘hands-on’ clinician as well as an academic writer. This bodes well for the practicality of the contents.

The new edition is considerably heavier, coming in at around 1,030 thin pages, but does have an in-built protective plastic cover which can be wiped clean, which is a definite advantage in terms of infection control. The old book was monochromatic and contained some tables and diagrams, but no photographs. The new edition has a blue, white and black colour scheme, and includes a number of black and white photographs as well as tables and diagrams.

Being a Basic and Advanced Life Support instructor, as soon as I opened the book I loved the fact that it has both the BLS and Adult ALS algorithms inside the front cover, and if you flip it over and look inside the back cover both the Choking and Infants and Children ALS algorithms can be found there. How easy is that!

Turn over another page and you find the “Quick Reference”, compiled by Fiona Chow. This section of 115 pages (with a list of Abbreviations at the end) is a handy little guide. An index is provided on the first page, but with white text on a blue background it is a little difficult to read in less than optimal lighting conditions. The two ALS algorithms are followed by that for newborns and a summary of suggested drug usage in adult and paediatric cardiac arrest. Sections follow on miscellaneous drugs used in adults and children. As well as recommended dosages and route of administration, some indications are also given. There are helpful sections on cardiology and ECGs, respiratory medicine, trauma, metabolic equations and electrolytes, thromboembolism and coagulopathy, neurology, important procedures, toxicology, drug infusions, paediatrics, orthopaedics, obstetrics and gynaecology, dental, common conversions, antibiotic prescribing and normal values. There is potentially some overlap with the discussion of antibiotics as common antibiotics are also listed in the earlier drugs section.

The book proper commences after the Quick Reference section.  The Contents sets out a  summary of what is in the following forty-eight chapters. These have been written by an impressive list of contributors, and the book has been reviewed by a shorter but equally impressive list of personnel.

As you would hope with an emergency medicine textbook, the chapters have a strong practical orientation and provide a lot of ‘how to’ guidance as well as enough of the ‘why’. Chapter 2: Securing the airway, ventilation and procedural sedation, is very comprehensive and detailed, and would provide a lot of comfort to the inexperienced practitioner. Chapter 3: Resuscitation and emergency procedures, provides a very helpful step-by-step guide to several common procedures such as IV cannula insertion. Chapter 4: Diagnostic imaging in emergency patients would probably have benefitted from some illustrations to go with the descriptions provided. The same might apply to the following chapter on ultrasound. A number of chapters dealing with cardiac and respiratory emergencies follows, including a thorough effort to explain the nemesis of many a student and doctor, the ECG.

It is nice to see a separate chapter on pain management in the ED, which is appropriately followed by a chapter on trauma. The chapters then jump around a bit. For instance, neurosurgical emergencies are some distance away from neurological emergencies. In the interim, the book travels through aortic and vascular emergencies, orthopaedics, hand injuries, urological emergencies, burns, patient transport and retrieval , mass casualty incidents and a handy chapter on ‘The seriously ill patient – tips and traps’. As someone who works in the pre-hospital setting and has trained in disaster medicine, I thought it was great to see both the retrieval and mass casualty chapters in this book as coverage of disaster medicine is certainly very common in American emergency medicine textbooks. (Upon checking, they were in the earlier edition also.) Following neurology, the book moves on to chapters on gastrointestinal  and endocrine emergencies and then acid-base and electrolyte disorders (another subject which strikes fear into many hearts but is comprehensively and clearly covered here). The very pertinent topic of poisoning, overdosage, drugs and alcohol follows. This is very detailed and provides advice and information for a number of commonly abused substances.

The final third of the book also jumps around quite a bit in terms of topics and ordering. Common orphans drowning and Envenomation follow next, then electrical injuries, hypothermia and hyperthermia, childhood emergencies, geriatric care, gynaecological emergencies, ophthalmic emergencies, ENT, dental, psychiatric presentations, dermatology, infectious diseases, the immunosuppressed patient and ED haematology.

The book concludes with a collection of six practical and interesting chapters which contain “something for everyone”. These are rural and indigenous emergencies, advanced nursing roles (which should enhance understanding  of what nurses actually do and thus team work), the general practitioner; working with IT (which deals with the vexed issue of interactions between GPs and EDs and provides a template for that essential discharge letter), administration, legal matters, governance and quality care in the ED (a catch-all chapter which contains some important advice on legal issues, including “How do you avoid a law suit?”), and two final chapters of immeasurable worth to residents and medical students: a guide for interns working in emergency medicine, and a student’s guide to the emergency department. It is nice to see that Sasha and Tiffany Fulde and Richard Sullivan, all doctors-in-training, have between them contributed to the pearls of wisdom in these chapters.

Whilst writing this review in the late afternoon and the transition to artificial light, I did find the pale blue headings in the chapters a bit difficult to read as they do not stand out well against the bright white of the pages. Paragraphs of pale blue text fortunately do not occur frequently in the book, but they are even harder to read in artificial light, especially as the pages are a bit shiny and the light source reflects off the surface of the page.

Another small criticism that I would have from recently ‘road-testing’ the book out on location is that the Index at the back could be better. For instance, I went to look up “penetrating eye injury” under E for eyes but it wasn’t there (not there under ‘penetrating’ either). I knew it would have to be in a book about emergency medicine, so went to the Contents and found the chapter on Ophthalmic Emergencies and of course it was there. There was one other similar example that I came across during testing.

My only other comments about things that ideally I might have liked to see is more intuitive chapter groupings and perhaps a few more diagrams and pictures where these could contribute to better understanding. Even if that is not possible, are there online resources that people could be referred to, such as YouTube? For instance, knowing how to reduce a shoulder dislocation is much easier if you can see it done properly first. (Apparently there is a separate eBook available for purchase which contains enhanced content, but this does not assist the purchaser of the print edition.)

As a review of the section on penetrating eye injuries demonstrates, this is a book grounded in emergency department practice rather than a first aid manual. It assumes that the first aid has been done and that the patient has come into the department and that you are getting on with history, examination and management. It is an enormously impressive resource, even though it did not always have quite as much detail as I would have liked on a particular topic. I guess everyone’s needs will vary in this regard, depending on your pre-existing knowledge and level of training and inquiry, but the authors have done a very good and solid job in covering the basics. Some chapters do drill down into a lot of detail.

The authors are also to be commended for including cutting-edge and imaginative topics amongst the chapters that are really going to provide practical value for doctors at the front line.

I feel this is a “must have” book for any Australian doctors interested in or involved in practising emergency medicine. It is written for local conditions by local authors from a variety of clinical backgrounds.

It is probably a bit thick and heavy to carry around in your pocket, but indispensible to keep in your bag for ready reference. For those with smartphones and tablets, the back cover of the book refers to standard and enhanced eBook versions and a PocketED app.

Verdict: Highly recommended!

Medical Book Review - Practical Management of Head and Neck Injury

Practical Management of Head and Neck Injury 
Edited by Professor Jeffrey V Rosenfeld
Churchill Livingstone/Elsevier 2012
Paperback edition 500 pages
http://www.elsevierhealth.com.au/emergency-medicine/practical-management-of-head-and-neck-injury-paperback/9780729539562/

Put simply, this book is a fabulous resource which holds value for everyone from pre-hospital first responders in a remote location through medical to students, junior doctors and trainees to specialists. "The book adopts an evidence-based approach to the management of traumatic head and neck injury, supported by the latest research." It "captures the essence of the day-to-day management of head and neck injury by following all aspects of care through the patient's journey ..."

Its special features highlighted on the back cover are:

• The complete management of patients with head and neck trauma, from the accident scene through to rehabilitation; 
• Safe, practical tips to assist the non-neurosurgoen in managing head injuries and preventing secondary brain injury - a major concern for emergency and pre-hospital medical personnel; 
• All aspects of neck trauma covered, including the management of cervical spine injury; 
• Detailed discussion of topics such as the classification of brain injury, concussion in sport, head injuries in children and the elderly, penetrating head injuries and the prognosis of head injury; 
• The operative surgery of head and neck trauma outlined for the non-surgeon; 
• Contributions from a wide range of specialists, both from Australia and overseas; 
• Integration of neurosurgery with ear, nose and throat (ENT) surgery, maxillofacial surgery, ophthalmology and spinal orthopaedics; and 
• Basic principles of relevant anatomy and pathophysiology, each covered in a separate chapter. 

The layout of the book comprises:

• Contents 
• Foreword 
• Preface 
• Acknowledgments 
• Contributors and reviewers 

Chapters:

• 1. Epidemiology 
• 2. Anatomy of the head and neck 
• 3. Pathophysiology of traumatic brain injury 
• 4. Pre-hospital management 
• 5. Emergency department management 
• 6. Injury to the spine and spinal cord 
• 7. Vascular injury 
• 8. Operative surgery 
• 9. Intensive care management of head injury 
• 10. Ward care of the head-injured patient 
• 11. Rehabilitation 
• 12. Head injury in children 
• 14. Head injury in sport 
• 15. Penetrating head injury 
• 16. Bleeding diathesis and anticoagulants 
• 17. Neurotrauma in pregnancy 
• 18. Brain death 
• 19. Persistent vegetative and minimally responsive states following head injury 
• 20. Prediction of outcome and the prognosis of head injury 
• 21. Prevention of head injury and the role of trauma systems. 

The chapters are followed by a number of extremely useful Appendices containing a number of relevant assessment scales, protocols and guidelines.

• Index 

Immediately one is struck by the breadth of the contents. Some of the topics are fairly specialised, but regardless of the topic there is a uniformly high standard of presentation. The only small criticism in terms of presentation is that the chapters are not colour-coded, but the name and section of the relevant chapter appears on the top of every second page so it is not too difficult to find what you are looking for.

The illustrations are an excellent aid to understanding, and include tables, graphs, stylised and line drawings, anatomical drawings, CT and MRI scans, angiograms, pathology specimens, real-life 'action shots' including surgical instruments and processes, and reproductions of various guidelines and protocols. The authors have obviously gone to some effort to make this book a practical rather than theoretical resource.

As someone who has worked with Ski Patrol in remote locations as both a volunteer patroller and a medic and in small town rural emergency practice, I thought I would try approaching my review of this book from this perspective and look at its utility from the point of view of both a first responder and a remote emergency practitioner. Accordingly, the three chapters that I will specifically examine here are:

• Chapter 4 - Pre-hospital management; 
• Chapter 14 - Head injury in sport; and 
• Chapter 21 - Prevention of head injury and the role of trauma systems. 

Chapter 4 opens with an explanation of the goals of pre-hospital emergency medical service (EMS) treatment for severe traumatic brain injury (TBI) and then proceeds with sound advice for bystanders immediately to call the EMS and to place an unconscious casualty in the left lateral position. However, things become a bit more murky thereafter. If respirations cease, the bystander is advised to give some expired air resuscitation in the supine position and cardiac arrest should be assumed and chest compressions commenced. However, this is at odds with the current Australian Resuscitation Council (ARC) Guidelines which are taught in first-aid courses that if someone is unconscious and not breathing normally, chest compressions should be commenced first, followed by breaths in the ratio of 30:2.

With reference to removing a motorcycle helmet, the importance of stabilising the cervical spine during this procedure could have been stressed, and perhaps even instructions provided (for instance, the American College of Surgeons has a nice PDF diagram with explanatory notes).

Under the "Paramedic Initial Assessment" the mnemonic "DRABC" is used. However, this has now been superseded in Basic Life Support by "DRSABC", where the "S" stands for "send for help". Even though some might argue that the paramedics "are the help", even for trained first responders, the "S" serves to remind them to reflect on whether they can manage the situation or need to call for further reinforcements.

There is a good discussion of potential dangers, but the text disappointingly then goes on to refer to the "AVPU" scale for assessing conscious state rather than the 'gold standard Glasgow Coma Scale (GCS). The GCS is taught to ski patrollers and certainly appears in the Ambulance Victoria CPGs (as part of the "Vital Signs Survey" which immediately follows the Primary Survey) and is of course used in Emergency Departments and can form a vital component of handover. Perhaps AVPU is appropriate as an instant assessment prior to completion of the Primary Survey, but most practitioners would probably prefer an accurate assessment of the GCS prior to determining whether to proceed with a Rapid Sequence Induction (RSI) and intubation as discussed in the next section. The GCS score forms part of the assessment in the Ambulance Victoria "Trauma Time Critical Guidelines". A pre-hospital GCS score is actually referred to later in the airway/breathing section and in the section on circulation, so it is a pity that its place in pre-hospital EMS management was not consistently considered in this chapter.

The advice about inserting an oropharygeal airway is confusing, and one would hope that clearing the airway of any debris that is present would occur prior to attempting to insert any type of airway. It is not mentioned that caution is indicated in inserting a nasopharyngeal airway in TBI where there is any suspicion of a base-of-skull fracture. There is also no reference to positioning of the head for optimal ventilation; nor to the possible modalities of mouth -to-mouth or mouth-to-mask in pre-hospital practice. My own feeling is that this section is rather clumsy and does not echo the clear and methodical approach that is used in Ski Patrol BLS training. Airway - inspect and clear if necessary. Breathing - look, listen and feel. Patrollers are permitted to make a short pulse check, but if the patient if not breathing normally, commence compressions and assisted ventilations after first favourably positioning the head. Only if ventilation is inadequate (even with a two-person technique) is the use of an airway adjunct then considered. Especially with a TBI, caution is required as triggering the gag reflex may contribute to vomiting and aspiration and an increase in intracranial pressure. With regard to ventilating the patient, if there is a significant mechanism of injury and spinal injury is suspected, special care must be taken with positioning of the head and neck and minimising movement. This is not mentioned at all.

The reference to the insertion of chest drains for decompressing a tension pneumothorax is somewhat alarming, as the Ambulance Victoria guidelines only refer to needle decompression, and specialist skills and equipment would be required for a drain.

Only at this point is fitting a cervical collar mentioned. Once again, instructions might be useful in terms of how to approach this and stabilisation of the head and neck during the procedure.

There is an extensive theoretical discussion about RSI in the field and whether this is of long-term benefit to the patient. (MICA paramedics in Victoria can intubate patients.) However, it was good to see discussed at the end of this section the issue of whether intubation should be undertaken without supplemental drugs. At this point airway stimulation possibly leading to vomiting and a rise in ICP is actually mentioned!

The section on circulation primarily discusses hypotension and fluids. It might have been useful to include some of the basics, such as expanding on the unreliability of the pulse check and whether standard first-aid measures such as elevating the feet are appropriate in TBI. In a remote or wilderness setting access to IV fluids may not be initially available. It was good to mention the points about control of haemorrhage.

I find it surprising that the author has not referred to the ARC Guidelines at all in this chapter, as they contain a wealth of information relating to management of a patient in the pre-hospital setting. They are the 'Bible' which forms the basis for the Ski Patrol Advanced Emergency Care Manual.

The "Additional initial procedures" and "Secondary Survey" contents are certainly not consistent with the Ambulance Victoria approach, which follows the Primary Survey with the "Vital Signs Survey" - GCS and assessment of perfusion state and respiratory state and pattern/mechanism of injury/medical condition - the purpose of which is to determine the time criticality to manage appropriately. The "Secondary Survey" covers a head to toe assessment (inspection, palpation, auscultation), pulse oximetry, monitor/ECG, temperature, EtCO2, blood glucose level and more detailed history. The combination of these three surveys allows the clinical problems to be identified. It is disappointing that a GCS assessment is only mentioned as part of the Secondary Survey here. Blood sugar is mentioned under a separate heading.

The author discusses the role of therapeutic hypothermia and concludes that it is not recommended in TBI patients outside the setting of a clinical trial. It might have been useful to provide some advice about the optimal management of hypothermic TBI patients in terms of preventing further heat loss and warming them as they make their way to definitive care.

The final section about transport discusses the role of specialised trauma centres and the efficacy of helicopter transport. One issue it does not raise is the possibility of transport delays in remote areas (not uncommon whilst awaiting evacuation from alpine locations) and monitoring and care of the patient (who may possibly deteriorate) whilst awaiting transport (or even arrival of the EMS). A short Summary and references are provided at the end of the chapter.

In summary, I found this chapter disappointing. It was disorganised and large chunks were more theoretical than practical, and the inconsistencies with Australian practices would be confusing for some people. However some of the discussion aspects were both interesting and useful. (It is noted that there is extensive information provided on both RSI and GCS in Chapter 5, "Emergency Department Management".)

Chapter 14 "Head injury in sport" is a much larger chapter and well laid-out and practical in emphasis. The chapter begins with a discussion about concussion and provides a useful 2001 consensus definition. The incidence section covers both American and Australian sports and helpfully mentions the factors that may affect the incidence of concussion in sports. The authors subsequently introduce the "Concussion in Sport Group" (CISG) and its consensus statements and assessment tools. This leads into an extensive section on "On-field assessment and game-day management", which is written in such a way as to be comprehensible by people outside the health professions (although it might be difficult to follow in places without having had any first-aid training), and it is stressed that such people have a vital role to play in the assessment and management of concussion. A copy of a 'pocket assessment card' (also available as an "app") and a long list of the symptoms of concussion are provided. Game-day management follows. There are a couple of references back to Chapter 4 "Pre-Hospital Management' regarding the "general rules of emergency management of head injury" (more succinctly summarised here than there) and the "general head-injury pathway" (which I could not find mentioned in Chapter 4, and there is certainly no flow diagram for a 'pathway'). This section suggests a number of relevant assessment tools and emphasises continued monitoring and follow-up. A note on impact seizures follows.

The section on "Post-game day concussion management" highlights the need for a complete brain recovery before return to play and provides a graduated return-to-play protocol. A couple of pages follow on different modalities of "Ancillary testing". At the conclusion of the chapter several assessment tools are reproduced together with some advice sheets.

Expanding on the "if in doubt, sit them out" them, the section on "Return to sport" includes a discussion on 'Modifiers' - factors which complicate recovery, and protective equipment and evidence for benefit. (This theme is taken up again at the end of the chapter in respect of "Return to sport, return to school, return to work".) There are three "Special situations" discussed in the following section - children, diffuse cerebral swelling and second-impact syndrome, and boxing. Although these discussions are more academic, they are still quite accessible. The paragraphs on boxing are particularly sobering and provide good background information concerning the consequences.

The penultimate section (before the succinct and pragmatic Summary) on "Prevention and education" provides some very useful information and practical advice. Two case studies (with discussion) are also included, the second one raising the issue of where does a GP go for advice on managing a patient whilst that person is waiting for an Outpatients appointment? Answer: continue monitoring and arrange a more timely assessment by someone experienced in concussion management. The corollary of this is that it is useful for GPs to have some idea of "who ya gonna call?" in the local area. (References are provided at the end of the chapter.)

I felt this was a terrific chapter, and it certainly has potential to be useful to all levels of health professionals.

Lest I exhaust the reader, I will not go into so much detail concerning Chapter 21, "Prevention of head injury and the role of trauma systems". It is a relatively short chapter (with Key Points and references at the end). The introduction concerning the categorisation of prevention activities as primary, secondary or tertiary and the use of Haddon's Matrix as a conceptual framework for "understanding the origins of injury problems and for identifying ways to address these problems" is interesting. A worked example of the Matrix is provided in Table 21.1. A section is devoted to each level of prevention - "Primary prevention: various measures", "Secondary prevention: trauma systems" and "Tertiary prevention: rehabilitation". This final section reminds the reader of the 'hidden costs' of TBI: "For every two patients who die of traumatic brain injuries, there are ten survivors with severe permanent disabilities".

The section on primary prevention concentrates on road traffic injuries, discussing the minimisation of exposure to high-risk scenarios, restraints, airbags and helmets (motorcycle and bicycle). Harking back to the two chapters examined above, I would have liked to see a wider discussion of the role of helmets including in sporting activities. Although their use is becoming more prevalent in the snowsports setting, some people still remain to be persuaded, and a textbook like this could play a powerful role in this struggle. The discussion on trauma systems, including the historical background, is really interesting. It also emphasises the importance of assessing the level of consciousness using the GCS as a modality of deciding the disposition of the patient. "Getting it right" in terms of where the patient is sent at first instance for definitive care is important, and this may be an issue in rural and remote areas with long waits for transport or accessibility issues e.g., bad weather. Sometimes ambulance dispatch may have a different view about time criticality to the people on the ground. Together with my colleagues at a Victorian alpine resort, I have experienced such a situation, where we told dispatch that we had a patient with a serious orthopaedic injury who needed to go by helicopter to Melbourne. A road crew was sent instead after several hours' delay. When they arrived and saw the patient they immediately concurred with our assessment and a helicopter was called for. By now it was night-time and the weather conditions had become difficult, but fortunately the road crew was able to drive the patient to a landing site lower down the mountain and met the helicopter there. I mention this story because of the issue of communication - for the trauma system to work effectively there must be good communication and trust in the assessment of the people in the field (as well as objective criteria such as vital signs and GCS). Perhaps as 'icing on the cake' it would have been appropriate to mention the importance of good communication and teamwork between different types of health professionals in the trauma setting. An emergency consultant once said to me that “trauma is a team sport”, and my own experience has shown this to be a truism. (This subject is addressed briefly in Chapter 5.)

In a book like this where different chapters are written by different people, there is bound to be some variation in style, and this is acknowledged by the editor in his Preface. Even to someone just flicking through the pages, it is immediately obvious the book contains a wealth of high-quality information and great care in its preparation. There is no doubt that many medical students and doctors find neuroscience a forbidding and inaccessible topic, and overall the editor and the authors are to be congratulated on producing a very practical and useful book which explains concepts which might otherwise be daunting in an accessible way.

Verdict: Recommended!

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)
http://www.elsevierhealth.com.au/clinical-general-medicine/emergency-medicine-mcqs-paperback/9780729541046/

Layout:

• 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!

Medical Book Review - Mechanisms of Clinical Signs by Dennis, Bowen and Cho

Mechanisms of Clinical Signs
Mark Dennis, William Talbot Bowen, Lucy Cho
Churchill Livingstone Elsevier 2012
Paperback 515 pages RRP $75.00
A Student Consult title - full text searchable online (after registration).
Further information (including a sample chapter) available at: http://www.elsevierhealth.com.au/au/product.jsp?sid=&isbn=9780729540759&lid=EHS_ANZ_BS-DIS-1&iid

Thanks are due to Elsevier Australia for kindly providing a review copy of this book. The authors have crafted a gem of a book, which would not be out of place in any medical library, regardless of the seniority of the practitioner. It is all the more remarkable for being put together by three Resident Medical Officers (two Australians and an American), and this international approach serves to increase its utility.

Each chapter was reviewed by experts in the relevant discipline, and the authors explain the provenance of their research in a caveat concerning the rate of change of medical knowledge and the possibility of obsolesence of their work: "... the authors used reference texts as well as Medline, PubMed, Embase, SCIRUS and other databases - firstly to identify all relevant signs and secondly to find the most up-to-date information about them. Every attempt has been made to provide the reader with the most recent information, however ...".

The book opens with two separate Contents listings. The first is divided up by 'Signs' - Musculoskeletal, Respiratory, Cardiovascular, Haematological/Oncological, Neurological and Endocrinological. The second lists Contents by Condition. There is also a detailed Index at the back of the book. By working between these three resources, it is fairly easy to find what you are looking for. the actual layout of the book is in seven chapters, as per the categorisation of the 'Signs' above. Each chapter is followed by a list of references, and there is also a listing of picture credits preceding the Index at the back. A list of abbreviations is also provided prior to Chapter 1.

The degree of coverage of each sign is quite variable. Some are covered very briefly in just a couple of paragraphs, while others ('dyspnoea' for example) are given 2-3 pages, and figures, tables and flow-chart mechanisms sometimes provided. There is a consistent internal layout, in general consisting of 'Description', 'Condition/s associated with ...', 'Mechanism/s' and 'Sign Value'.

The emphasis of the book is very much on general (or 'internal') medicine, and as such does not offer an equal level of coverage for either paediatrics or obstetric medicine, but some signs are acknowledged as occurring in pregnancy and a brief discussion provided.

Taking COPD (chronic obstructive pulmonary disease) as an example, it is important to realise that this condition is a constellation of signs and symptoms, and this book is not designed to provide an overall pathophysiological mechanism (this is the province of other references on the market). Thus COPD is not listed as a respiratory 'sign', but in the 'Contents by Condition' index, there is fairly comprehensive coverage of many common signs which are associated with COPD. These are: dyspnoea, Harrison's sign, tachypnoea, pursed lips breathing, barrel chest, crackles, wheeze, hyperventilation, clubbing, intercostal recession, paradoxical respiration, hyper-resonance to percussion, vocal fremitus and vocal resonance.

It is probably useful to illustrate the contents by randomly choosing three signs to examine. The first one selected is 'clubbing'. Most medical students will tell you that the mechanism is not clearly understood, and the text acknowledges this. This section is clearly written, well set-out and useful. It commences with a picture of clubbing of the fingers and toes followed by a multi-point description, a listing of conditions commonly associated with clubbing, a survey of the current thinking regarding the underlying mechanism, a short flow chart ('mechanism') reflecting this thinking, a succinct summary concerning the 'sign value' and a table setting out the causes of bilateral clubbing by body system.

The second example is a 'relative afferent pupillary defect' (Marcus Gunn pupil). The chapter on neurological signs contains some extra material designed to assist the reader in the form of coloured boxes entitled "Relevant neuroanatomy and topographical anatomy", which demonstrate the relevant anatomical pathways. It would be fair to say that understanding this sign is commonly found to be challenging. An anatomical pathway is provided for both the afferent and efferent limb (but this does not go into detail as to whether parasympathetic or sympathetic fibres are involved) as well as a helpful diagram illustrating the appearance of the pupils with the 'swinging torch test'. The second page contains a further diagrammatical representation of the anatomical structures and pathways. The text sets out common and less common conditions associated with a RAPD, and then provides a short discussion of the mechanism and optic nerve disorders and retinal neuroepithelium disorders (rare), concluding with the 'sign value'. Having researched this topic when teaching it to students several months ago, I would reflectively say that this exposition, whilst clear and helpful to the novice, does not present the level of detail that I was looking for at the time. However, for a simple and superficial explanation it is more than adequate.

The third topic selected is haematemesis. I also recently researched this topic whilst reviewing a proposed clinical exam paper. This is covered in the gastrointestinal chapter as "Coffee ground vomiting/bloody vomitus/haematemesis". One and a bit pages are devoted to the topic. The text contains a description together with a list of more common and less common conditions associated with upper gastrointestinal bleeding. These listings are quite helpful, but as some examples of 'nitpicking', the generic term 'peptic ulcer disease' is used without explanation (and the 'upper GIT' is not defined either). Having been involved in teaching, I have come to appreciate that there are many commonly used terms that have a 'rubbery' understanding of what they actually mean, and that there is value in clarification in such cases. Where this section shines is in the explanation of the General Mechanism/s and specific explanations for peptic ulcer disease, Mallory-Weiss tears and oesophageal varices (including their relationship to portal hypertension). There are also simple mechanisms provided for a Mallory-Weiss tear and bleeding from oesophageal varices. The section concludes with the 'Sign Value', which provides helpful and pragmatic advice.

A book like this cannot be all things to all people. Some topics will provide you with a 'light-bulb moment' and others will leave you wanting more. It is however an invaluable resource, not only for the practitioner in terms of individual understanding of clinical signs, but also in providing clear, simple and comprehensible explanations that can form the basis of an authoritative explanation to patients and their carers. I can also see that it would have enormous utility in General Practice, where patients will randomly present with unfamiliar signs (particularly if you are a Registrar). It is the kind of book that we all really should read from cover to cover, "if only I had the time ..."!

Highly recommended. A good investment which will more than repay its purchase price over time.

Medical Book Reviews: Jayasinghe ECG Workbook and Robbins Basic Pathology 9th Edition

Elsevier Australia has kindly provided me with inspection copies of the following medical books.

1. ECG Workbook. (Professor) Rohan Jayasinghe.

Churchill Livingstone/Elsevier Australia, 2012. Paperback, 224 pages. RRP $59.95.

http://www.elsevierhealth.com.au/au/product.jsp?sid=&isbn=9780729541091&lid=EHS_ANZ_BS-DIS-1&iid=

(A sample chapter is available: http://www.elsevierhealth.com.au/media/anz/samplechapters/9780729541091/ECG_Workbook_9780729541091_Jayasinghe_SampleChapter.pdf)

For many people ECGs are a bit like "Who's afraid of the big bad wolf”? In reality this includes quite a few of us. In medical school there are people who "just seem to get it" while others continue to struggle, and still "have their L-Plates on" after many years of medical experience.

This refreshing book is aimed at the clinical interpretation of ECGs. It is worthwhile to quote from the Preface written by the author:

“ECG Workbook provides an easy but systematic algorithm to follow when attempting to read an ECG. The exercises are aimed at training the reader to practise this algorithm repeatedly with different ECGs. The real-life clinical synopsis essentially links the ECG findings to the patient’s clinical context. This information guides the reader to make a clinical diagnosis with the help of the ECG findings, and then to decide on the optimal treatment or management plan. … It is hoped that by completing this workbook the reader will gain the required mastery to use ECG as a clinical diagnostic tool effectively and to make suitable management decisions with confidence.”

It is divided into three sections: 1. Basics of the ECG; 2. ECG-based diagnosis: pathology by ECG; and 3. ECGs and pathologies. There is also an Appendix listing the NYHA functional classes, and a detailed Index.

Beginning with Section 1, the pages are cleanly set out, with ample use of coloured headings, colour-shaded boxes for important points and plentiful use of explanatory diagrams. This chapter of 19 pages does indeed cover the basics in a very understandable fashion. It includes the cardiac cycle, the cardiac conduction system, ECG rate, scale and calibration, leads and direction of current travel, determining the cardiac axis and the causes of axis deviation, placement of electrodes and the difference between electrodes and leads, correlation of the leads to the region of the heart, and finally, reading the ECG. This includes a system for doing this together with the parameters of the normal ECG. To compliment rather than insult the author, for those craving a "Dummies' guide to the ECG", this is exactly the sort of thing you are looking for. The chapter is pitched at a good level and easy to follow, and puts the reader in a good position to approach the chapters on pathology that follow.

Section 2 is a chapter of 27 pages. It is set out in the same clean and comprehensive fashion as Section 1. An introduction on reading rate and abnormalities on an ECG is followed by a discussion of various pathologies, starting with different types of tachycardia and their management. Also discussed are bradyarrhythmias and bradycardia, heart block, abnormalities of the cardiac rhythm, normal and abnormal segments of the ECG, ventricular hypertrophy, myocardial infarction and ischaemia, other pathologies with mixed ECG changes, and finally pacemakers. All the common pathologies are discussed as well as some more obscure ones. Section 2 sets up the background for Section 3, which contains the ECG worksheets. After a brief introduction, 45 case studies follow.

The case studies are beautifully set out in two sections each. The first section contains an ECG on the left-hand page and a template for systematic interpretation on the right-hand page, including the various aspects of the ECG, further investigations and management. Before you start to feel that familiar rising sense of panic regarding "but what is the answer?", relax! The second section of each case study includes all the answers, and helps to drill the reader in the recommended approach to systematic interpretation, and helps to build confidence, as your answers can be directly compared to the recommended ones.

Being a paperback of around 250 pages, this book is very portable, and as well as being a workbook is also a handy reference, both in terms of Sections 1 and 2, but also the wide variety of ECGs included in Section 3. It is well-written, accessible and user-friendly. I would certainly recommend it, especially for those who feel a need to improve their ECG skills in a systematic fashion.

2. Robbins Basic Pathology. 9th Edition. Editors: Kumar, Abbas and Aster.

Elsevier Saunders, 2012. Hardback, 928 pages. RRP $103.99

http://www.elsevierhealth.com.au/Medicine/specialty/book/9781437717815/Robbins-Basic-Pathology/

Owners of the book can register it at studentconsult.com, which provides the facility to access the full text online, download images, add notes and bookmarks and to search across all individually owned Student Consult resources online. The online version of the book contains a special additional feature, "Targeted Therapy" boxes (stemming from an understanding of the molecular basis of disease), intended to provide examples of "bench-to-bedside" medicine.

When I was a medical student, our pathology 'Bible' was Robbins Pathologic Basis of Disease by Cotran, Kumar and Collins. I am the proud owner of the sixth edition and its little pocket handbook. This new book is the latest in a trusted and proud lineage. Many of the earlier products are also available via the Elsevier website. Back in those days material available on CD-Rom was considered pretty special and computer-based learning was fairly rudimentary. Since then there has been an explosion of Internet-based resources, and the editors are to be congratulated for "keeping up with the times". In one of the medical student tutorials that I take, students must report back and share with the rest of the class on Fridays the information that they have gleaned concerning the 'learning issues' for the week. Some students will bring their laptops and tablets and read off the screen. Such is the power of learning resources such as the online version of this book - provided there is an internet connection, students and health professionals can access this material wherever they are and use it as a resource in their everyday work.

The book contains 23 chapters over 870 pages, plus a detailed Index at the back. It is visually attractive, with a coloured strip at the top of each page making the chapters easy to distinguish. There is liberal use of coloured headings, diagrams, photographs, tables, orange "Morphology" boxes and blue "Summary" boxes. Even though the text is dense (as is to be expected in any serious medical textbook) the judicious use of colour, illustrations, boxes and space between the various elements makes it appear welcoming and engaging, as opposed to the forbidding nature of many 'old-fashioned' black and white textbooks. Each chapter has a "Chapter Contents" box in its introductory header, listing the key sections and their page numbers. This is a very handy navigation aid. There is also a bibliography at the end of each chapter.

The authors have strived to organise the chapters in such a way that the various groupings of pathologies and organ systems are logical. Some chapters do not have a specific attribution of authorship, whilst many of the chapters are written by other specialist contributors. As we have come to expect, the standard of the content is universally high. Many of the images will be familiar from earlier editions, but there are also many new ones, often showcasing the latest research discoveries.

These are the chapter headings:

1. Cell Injury, Cell Death, and Adaptations

2. Inflammation and Repair

3. Hemodynamic Disorders, Thromboembolism, and Shock

4. Diseases of the Immune System

5. Neoplasia

6. Genetic and Pediatric Diseases

7. Environmental and Nutritional Diseases

8. General Pathology of Infectious Diseases

9. Blood Vessels

10. Heart

11. Hematopoietic and Lymphoid Systems

12. Lung

13. Kidney and Its Collecting System

14. Oral Cavity and Gastrointestinal Tract

15. Liver, Gallbladder, and Biliary Tract

16. Pancreas

17. Male Genital System and Lower Urinary Tract

18. Female Genital System and Breast

19. Endocrine System

20. Bones, Joints, and Soft Tissue Tumours

21. Peripheral Nerves and Muscles

22. Central Nervous System

23. Skin.

In the interests of time and space and maintaining the attention of you the reader, it is probably not wise to attempt to review every single chapter, so I have selected one chapter as an example to demonstrate the general approach to layout and contents and the topicality and prescience of the authors in "walking the talk" as stated in the Preface: "This is an exciting time for students of medicine because the fundamental mechanisms of disease are being unveiled at a breathtaking pace. Pathology is central to understanding the molecular basis of disease, and we have tried to capture the essence of this new knowledge in the ninth edition ... We firmly believe that pathology forms the scientific foundation of medicine, and advances in the basic sciences ultimately help us in understanding diseases in the individual patient."

“Chapter 7: Environmental and Nutritional Diseases” examines diseases which are caused or influenced by environmental factors, including both the external environment and things that humans do to themselves (e.g., diet, drugs and alcohol). After the Introduction, the authors bravely enter into a discussion about the Health Effects of Climate Change and provide scientific evidence for the existence of climate change and list some of the serious consequences which are already occurring. The next key section deals with the Toxicity of Chemical and Physical Agents. This is divided into sub-sections (each with Morphology and Summary boxes) dealing with Environment Pollution - Air, Environmental Pollution - Metals, Effects of Tobacco, Effects of Alcohol, Injury by Therapeutic Drugs and Drugs of Abuse (oestrogens/contraceptives, paracetamol and aspirin; cocaine, heroin, marijuana and a list of "other illicit drugs"), and Injury by Physical Agents (trauma, thermal injury, hyperthermia, hypothermia, electrical injury and ionising radiation). Although one might perhaps argue that more substances could have been included, and more detail included on some of the given topics, a text such as this "cannot be all things to all men" and there are many other excellent references which do provide further information in these areas. However, what is included does serve an important function in "whetting the appetite" and encouraging readers to think beyond the superficial in terms of environmental injuries. The second key section is devoted to Nutritional Diseases and follows the same general layout principles. This covers malnutrition, eating disorders, vitamin deficiencies, obesity (another very topical inclusion) and concludes with short sections on Diet and Systemic Diseases and Diet and Cancer.

One small frustration is that, being an American text, the units of measurement may be different to those used in the Australian context e.g., Fahrenheit for temperature as opposed to Celsius.

The more that I looked at this book, the more that it was like opening a beneficent "Pandora's Box". It draws you in and engages your attention, and like those enraptured of the 'siren song' of old, you don't want to put it down. An odd thing to say about a text book, I know, but much of what the authors present to us about the underlying science of medicine is utterly fascinating. For those who wish that they had paid more attention in medical school, this is your "get out of jail free card", and for those embarking on the journey of learning, it is a marvellous road map. Highly recommended!