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
- 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.
- Index
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 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!
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.
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!
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