Emergency Medical Therapy

Edited by Terry J. Mengert, Mickey S. Eisenberg and Michael K. Copass. Pp. 992. Price, $47.50. 4th ed. Saunders, Curtis Center, Suite 300, Independence Square West, Philadelphia, PA 19106, 1996.

The fourth edition of Emergency Medical Therapy has been published in handbook form to allow for easy access to information on adult patients in the emergency department.

The book uses an outline form that includes readily accessible algorithms. It contains information on the most recent COBRA regulations, pain management and conscious sedation. It also offers information on the disposition of patients, as well as on the perils and pitfalls of problems commonly seen in the emergency department. The editors have included extensive coverage of infectious disease, toxicology and rheumatologic emergencies.

Although Emergency Medical Therapy is published in handbook form, it is not small enough to fit in most pockets. Information in the table of contents is presented in order of commonness of problems and may not be as easy to follow as a more systematized approach.

It is important to note that Emergency Medical Therapy is written to cover the management of medical emergencies in adults, and was not intended to cover trauma, pediatrics, orthopedics, behavioral medicine or environmental emergencies. Therefore, it may not be the best reference for family physicians working in the emergency department.

For a more comprehensive text, we would recommend Emergency Medicine Concepts and Clinical Practice by Rosen and Barkin, a three-volume set that also comes in synopsis form. For the most common problems, The Clinical Practice of Emergency Medicine by Ann Harwood-Nuss is also an excellent reference, which includes information on common pitfalls and the disposition of patients. It too is considerably larger than Emergency Medical Therapy, however.

CD-ROM

Scientific American Medicine, CD-ROM 1997 Annual Edition

Edited by David C. Dale and Daniel D. Federman. Price, $99.00. Scientific American Medicine, 415 Madison Ave., New York, NY 10017, 1997.

Scientific American Medicine (SAM) was one of the first major medical titles to be available in electronic format. The 1997 edition reflects that experience in its much more useful, user-friendly interface. However, the reference still takes a very academic, internal medicine–oriented approach that may not be suited to the style of many family physicians.

Installation was simple on our Windows '95 system. The program automatically created shortcuts in our “Start” button, although it didn't give us the option of installing the shortcut in anything other than the “Scientific American” directory. During installation, the user is given the option of conserving hard drive space (at the price of slower queries) or using more hard drive space (resulting in much faster queries because the index is no longer on the slower CD-ROM).

The manual is much better than the one that accompanied earlier versions of the program (circa 1994). It contains plentiful screen images, and even the most inexperienced user will find it useful and easy to read. The “Quick Start” section of the manual is especially useful for inexperienced computer users. The program is quite snappy on a Pentium 100 MHz with 16 MB of RAM, but a bit slow on a 486 33 MHz test unit with 16 MB of RAM (even with the “very fast querying” option enabled during set-up).

The interface is relatively straightforward and provides easy access to key functions. There is some duplication, though. The “More” buttons, on the tool bar and on the main screen both led to the same table listing the editors and contributors. However, we found the lack of adherence to common Windows conventions frustrating. For example, pressing the “Search” button on the main menu does not give any visual feedback, such as the button appearing to depress. The arrow cursor turned into a pointing hand when we passed over the link “Figure 6”; this usually (as in Netscape or Microsoft Internet Explorer) means that a single click will take you to that figure. However, a double click is required. It takes a few seconds to load the figure, so we clicked, double clicked, then double clicked again before the figure appeared.

The content of SAM is oriented toward internal medicine and pathophysiology and appears identical to that of the text version. It is organized around the internal medicine subspecialties such as cardiology, endocrinology, pulmonology, and nephrology. There are additional chapters on “Interdisciplinary Medicine,” “Metabolism,” “Psychiatry” and “Clinical Essentials.” “Interdisciplinary Medicine” is a hodge-podge of topics, such as poisoning, water-related accidents, bites and stings, and sports medicine. “Metabolism” contains topics often considered to be endocrinologic, such as diabetes mellitus, hypoglycemia and porphyrias. “Psychiatry” includes sections on Alzheimer's, grief reactions, mood disorders, alcoholism and eating disorders. Finally, “Clinical Essentials” includes two sections: prevention and advice for travelers. The prevention section is very nicely done, and is focused largely on the evidence-based recommendations of the U.S. Preventive Services Task Force. SAM contains little information on gynecology, behavioral medicine, surgery, and other conditions common in family practice and general internal medicine. There is essentially nothing in the text on obstetrics or pediatrics, other than a few stray journal or reference titles.

The strength of any electronic reference is its ability to rapidly search and identify all occurrences of a given topic. We evaluated the usefulness of SAM for primary care physicians by doing searches for the following common primary care problems: “abnormal uterine bleeding,” “sore throat,” “bronchitis” and “back pain.” We also searched for some more unusual topics: “anti-smooth muscle antibody,” “monocytosis,” “cytoplasmic antibody” and “atrial natriuretic peptide.”

The search mechanism itself is more cumbersome than necessary. To initiate a search, you first click the “Search” button in the main menu. A search window opens, allowing you to enter a term to search. You can also specify what elements of the content to search (text, tables, figures or all) and how close you want to be taken to each occurrence of the term (document, nearest paragraph or exact sentence). Running a search opens a window that lists the number of “hits,” or occurrences of the search test, and the number of documents in which the hits are found. No special warning is given if no occurrences are found; in one instance, we watched the screen for quite a while before realizing that the search was done but had not found our term. Running another search requires that you close this window and tap “Search” again in the main menu. A more streamlined approach would give you the option of entering a new term immediately after seeing that your search did not produce the results you wanted, rather than going through a series of dialog boxes.

Searching the term “bronchitis” generated quite a bit of information on chronic bronchitis, but nothing on out-patient management of acute bronchitis and nothing about whether antibiotics and/or beta agonists are useful in acute bronchitis in healthy adults.

Searching “sore throat” took us to “Infections due to gram-positive cocci.” This is much more typical of how an infectious disease specialist thinks than a family physician thinks. The second hit was more useful, with a discussion of bacterial causes of pharyngitis, although there was nothing on nonbacterial causes or noninfectious causes such as esophageal reflux and allergies.

A search for “back pain” turned up a nicely written and useful section in the rheumatology chapter on “Back Pain and Common Musculoskeletal Conditions.” The information was up-to-date and evidence-based, and was one of the better sections we found in the reference.

The search for “abnormal uterine bleeding” led to a reasonable discussion of an outpatient approach to “excessive menstrual bleeding,” although the author recommends referral to a gynecologist for most patients, an approach which many family physicians will find excessive. This search also yielded one of the more useful recommended diagnostic work-ups, under the “ovary” heading.

The search for “anti-smooth muscle antibody” found one unhelpful mention in a section on chronic hepatitis. Results of the search for “monocytosis” were in the subsection on neutropenia (appropriate, in the case of the patient who inspired the search, since he was also neutropenic). The discussion was comprehensive and informative, but with a distinct emphasis on basic pathophysiology, replete with a discussion of the Philadelphia chromosome. To derive practical guidance on the next step in the patient's evaluation required wading through the full discussion and extracting tests that might be indicated (e.g., bone marrow biopsy).

The search for “cytoplasmic antibody” pointed to a very rational discussion of how to use the sedimentation rate and immunologic tests, with an emphasis on avoiding unnecessary false positives.

Finally, the search for “atrial natriuretic peptide” led to a brief but interesting paragraph on what it is, including speculation on its role in future drugs for congestive heart failure.

In summary, the focus is on internal medicine, pathophysiology, inpatient care and disease rather than primary care, outpatient medicine and symptoms. SAM is comparable in scope and approach to Harrison's Internal Medicine and Kelley's Internal Medicine, and it is a useful resource for physicians wishing to delve into a specific internal medicine topic in great depth. SAM's strengths are its detailed pathophysiologic descriptions and the fact that it is updated relatively frequently. However, it lacks practical recommendations for testing, follow-up or management—or hides them in dense and detailed prose. It is, therefore, less useful for clinical practice than for academic study.