There is a growing demand for critical care services as the population ages and the average severity of illness of hospitalized patients increases. Despite a movement toward intensivist-managed care of intensive care unit (ICU) patients, such as the Leapfrog Group initiative, the majority of ICU patients continue to be primarily cared for by physicians without subspecialty training in critical care. There is, therefore, an important need to train more intensivists, and for non-intensivist physicians, including internists, surgeons, and anesthesiologists, to be competent and comfortable in providing critical care. As one hallmark of critical care medicine is its interdisciplinary approach, it is equally important for ICU nurses, respiratory therapists, physical therapists, and pharmacists to have a solid understanding of clinical issues in critical care medicine.
Core Topics in Critical Care Medicine states that it is primarily aimed at trainees from all specialties who are undertaking subspecialty training in critical care medicine. It aims to provide “comprehensive, concise, and easily accessibly information on all aspects of critical care medicine,” with an emphasis on up-to-date evidence-based medicine. The book has 2 editors and 34 authors, all based in the United Kingdom. The book is divided into 4 sections. Section I, entitled “Specific Features of Critical Care Medicine,” covers administrative issues in the ICU, such as criteria for admission, discharge, and transfer, and systems issues, such as outcomes monitoring and information management, as well as general patient-care related topics such as nutrition, pain control, sedation, and ethics. This first section would be particularly useful to non-physician healthcare providers, such as paramedics, respiratory therapists, nurses, nurse managers, and administrative staff. Section II, “Systemic Disorders and Management,” discusses disorders that are not easily classified into a single organ system, such as sepsis, multiple-organ failure, fluid and electrolyte disorders, and acid-base abnormalities. Section III, “Organ Dysfunction and Management,” has 24 chapters, each dedicated to a specific diagnosis, organ failure, or special patient population. Section IV consists of information on United Kingdom/European postgraduate examinations in intensive care medicine and sample test questions and answers (30 multiple-choice and 15 viva [oral] questions). The book is replete with useful and visually pleasing color illustrations, which include algorithms, graphs, charts, electrocardiogram tracings, and radiographs.
This textbook's excellent organization and thorough, relevant list of topics are real strengths. In addition to the expected (and necessary) chapters on common ICU diagnoses and organ failures (including truly outstanding sections on noninvasive ventilation and unconventional strategies for respiratory support), the editors included chapters on equally important but sometimes forgotten systems-related topics. These include early recognition of critical illness, and triage of ward patients by medical emergency teams (in the United States commonly referred to as rapid-response teams); criteria to safely and efficiently admit, transfer, and discharge patients from the ICU (an increasingly common and difficult problem as demand for critical care services increases out of proportion to the availability of resources); and methods and limitations of quality and performance assessment for ICUs. I also particularly appreciated the sections on two special patient populations that make many clinicians uncomfortable: obstetric and pediatric. Each chapter in the book concludes with a summary of key points and resources for further reading, which greatly facilitate study and review by learners.
As a United States physician, I think the differences between American and British medicine warrant a moment to consider the value and relevance of this textbook for a non-United Kingdom audience. It is important to note, first of all, that there are real differences. Some of these are only skin-deep, for example the spelling of haemoglobin, dieresis, or frusemide. There are some minor issues of terminology, such as ITU (intensive therapy unit) instead of ICU; suxamethonium instead of succinylcholine; partial pressures of gases measured in kPa instead of mm Hg. Medical education is organized differently: a consultant is equivalent to an attending physician; a registrar is the equivalent of a senior resident or fellow. The structure of the healthcare system is specific to each country and affects clinical resource utilization.
More importantly for a medical trainee, there are differences in patient care, many of which are based on availability (or lack thereof) of certain medications or formulations. For example, enoximone is not approved by the United States Food and Drug Administration, and intravenous formulations of omeprazole and acetaminophen are used in the United Kingdom but are not available in the United States. It is likely that a more senior reader would find these differences interesting, and would enjoy learning about how medicine is practiced in other areas of the world. For a more junior trainee, however, the disparities could lead to confusion. Overall, the differences are few enough and insignificant enough that this book remains an excellent learning tool for an American audience. I would suggest that in future editions, in consideration of an international audience, the authors could refer to values in both the metric and the United States customary units.
Another major strength is the book's conversational, easy to read, and yet professional tone. The chapters are only 5–10 pages long. This economy of words removes the “intimidation factor” that longer, denser, and more comprehensive texts may have. The reader has a comforting impression of a trusted clinical mentor telling them what they need to know. The drawback to this is that the book occasionally glosses over the nuances of controversial issues, making it seem that there is clear consensus when there is not. An example of this is in Chapter 21, “Postoperative Critical Care,” where the author states that “in patients with ischemic heart disease, haemoglobin concentration should be maintained above 10 g/dL.” Although many experts would agree with that statement, there are others who would not; this is an issue on which there is conflicting data, and further research is being conducted.
There is room for improvement in future editions, including some “low-hanging fruit,” such as typographical errors, thoroughness of the index, and the sample questions in Section IV. The book has a few scattered errors, most of which are typographical and do not affect the content or ease of reading, but a couple of which do. For example, Chapter 29, “Failure of Oxygenation,” states that D-dimers “have a low sensitivity for diagnosing pulmonary embolism, as they can be raised by many different causes;” I presume they meant to write “specificity” instead of “sensitivity.” The index is, as far as I can tell, accurate, but far from complete. There are at least several topics that are discussed in the text but are nowhere to be found in the index, such as corticosteroids, subdural hematoma, and transfusions.
The questions given in Section IV could be a valuable study tool, but some of the multiple-choice questions are ambiguous or perhaps have incorrect answers. For example, the answer given to question 18 indicates that secondary causes of cardiomyopathy include dystrophia myotonic, porphyria, and thyrotoxicosis, but not alcoholism, which is a well described cause of dilated cardiomyopathy. Care should be given to selecting unambiguous questions, and then providing not only answers, but also explanations with appropriate references.
In summary, this textbook tackles a difficult task of presenting a huge amount of complex information in a clear, concise, and easily accessible fashion. For the appropriate reader, I think it makes an excellent resource. I disagree somewhat with the editors on who is the most appropriate reader for this book. In my opinion, it is not detailed or comprehensive enough for the trainee in critical care medicine, who is expected to become an expert in the field. It could be, however, a very valuable resource to either the many non-intensivist physicians or nurses who spend a portion of their time caring for critically ill patients, or for junior trainees in internal medicine or surgery, who may develop an interest in critical care medicine and pursue subspecialty training in the future.
Footnotes
The author has disclosed no conflicts of interest.
- Copyright © 2011 by Daedalus Enterprises Inc.
