Tag Archives | Books

Book review: Band-Aid for A Broken Leg – Damien Brown

This is a review of a great book I’ve recently read, and whilst technically not exam-related, I think it’s still worth putting on your reading list – you’ll see why.

Band-Aid for a Broken LegBand-Aid for A Broken Leg (And Other Ways to Stay Single) is written by Damien Browne, a South-African born, Australian raised doctor who I’ve had the absolute pleasure of working with up in Darwin, which is how I found out about the book.  Damien and I were both locuming in the Royal Darwin ED, and as is the tendency when you meet a fellow non-mainstream-medical person, traipsing about the country on the locum trail, you tend to ask how they ended up there.  We got chatting and Damien revelaed his amazing story of travelling to Africa to work with MSF, and his subsequent mission to do locum work in Australia which helped him to be able to take the time off to write the book.

For those who’ve done aid-work, the stories will probably seem familiar, but for those of us who haven’t, Damien’s first hand narrative from a perspective we are all familiar with (being an up and coming junior doctor in the wealthy Australian health system) makes visualising the scenes he describes frighteningly realistic. Imagine being plonked into a small village in rural Angola with the bare minimum of staff and supplies, and having to treat major trauma, undifferentiated sepsis (in a country with more exotic pathogens than you could dream of, and no lab tests!), paediatric resuscitations, obstetric disasters including a ruptured uterus which you have to perform the laparotomy on (with only ketamine as sedation, no suction and your operating light powered by a car battery), and malnutrition.  Add to this the complexity of navigating the cultural quagmire of a country recently devastated by civil war, the local hospital heirachy and learning a new language (and not an easy one like French or Spanish, Damien had to learn medical & social Portugese!), and it makes for compelling reading.

In Australian hospitals, junior doctors wouldn’t be allowed near a lot of these patients, but as an aid-worker, it’s you or no-one, so one gets to practice in the true sense of the word.  Flying by the seat of your pants is the norm, and I have no doubt that doctors who do this sort of work develop skills, confidence, and perspective that  most of us can only dream of. The risks of aid-work are also covered, and there are some harrowing reminders of the dangers involved, not only in the field, but also on return to “civilisation” and the difficulties some face trying to re-integrate back home.

A level-headed, non-judgemental but stark comparison is made to the extreme affulence of our health system, when he starts back at work in an Australian tertiary ICU.  Whilst making no judgements, the book serves as an unsettling reminder of how cheap life is in some places, and how totally over-valued it in wealthy countries like ours, and how much we (and the general public here) take for granted. His description of the resource-intense management required for a drunk violent patient in ED – something we deal with every other day – again highlights this divide, and the fact that a lot of what we do at work is a serious waste of our skills.

I may be biased having met Damien and hearing the background to this book first hand, but overall I found Band-Aid for A Broken Leg a “can’t put down” read.  If you are feeling disillusioned with the drudgery of ED training, studying for the exam or the pressures of the public hospital system here, I’d strongly recommend you read this book, both as a reminder of just how good we’ve actually got it, and as an insight into a way you can actually make a powerful difference into the lives of strangers, should you choose to one day sign up and do some aid work.

For those who prefer Kindle, you can get it here.

For those who like paperback – it seems to be selling out – so try ordering it from your LBS or at the time of writing you could still get it at the ABC shop online.

(Please note – these are not affiliate links – I get no commision – I just reckon it’s a great book that you should buy!)

EDExam Book Rating: 5 Stars!

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Textbook Review: Toxicology Handbook (Murray, Daly, Little, Cadogan)

The Toxicology Handbook: Murray, Daly, Little & Cadogen is a “must-read” for the exam, and a “must have a copy on-hand at work”, locally written, up to date, concise, easy to read, chock-full of practical evidence based advice on Emergency Department toxicology. Phew! Can I say anyting else good about it?

Written by some of the leaders in the Australian toxicology and medical education scene, this small but detailed book contains just about everything you’ll need to know to pass the ACEM Fellowship exam tox questions, as well as manage a broad spectrum of toxicological emergencies in the ED.  For some topics (for example – Paracetamol Overdose) you may want to look up an encyclopedia of toxicology like Goldfrank’s Toxicologic Emergencies just to get that little bit of extra detail, but given the sheer volume of what you need to read for the exam, it’s nice to have a succinct but detailed reference like TOXICOLOGY on hand.

Each section is written in the same format, making it easy to skim through and find what you’re looking for, there’s sections on Approach to the Poisoned Patient, Specific Considerations (for a range of toxicological situations), Specific Toxins (in alphabetic order), Antidotes, (again, in alphabetic order), Envenomation, Antivenoms, as well as some useful appendices (containing things like the TCA overdose ECG and more!).

All up I’d give Toxicology Handbook: Murray, Daly, Little & Cadogen a 10/10. I would not have passed the Fellowship exam without it, and I’d strongly recommend you get yourself a copy, you will use it again, and again, and again.

NB: Kindle version now available if you want to read it on your iphone/ipad/e-book reader.
Click on the link below for the Kindle version:
Toxicology Handbook – Kindle Edition

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Checklist Manifesto – Book Review: Works for surgeons, can it help Emergency Physicians?

I saw  The Checklist Manifesto: How to Get Things Right on a “what I’m reading” spot on Amit Maini’s EDTCC Blog recently, and thought it looked interesting, so bought myself the Kindle version, and read it a couple of days on my iphone.

The author (Atul Gawande), an American surgeon, delves into the story behind his recruitment into a project to develop surgical checklists.  He was directly involved in the development of a checklist, which was distributed internationally by WHO and was shown to drastically improve patient safety and reduce morbidity and mortality.

His research covered areas as diverse as business, skyscraper building, fast-food, disaster management, aviation and of course, medicine.  The book contains a fascinating plethora of anecdotes showing how checklists are used in all of these industries (and many more) to improve outcomes.

The underlying theme is about simplifying processes that we as modern professionals, in industries where the volume and complexity of information we are expected to know has outstripped our ability to retain and execute all of the tasks and procedures we’re expected to deal with.

How does this apply to Emergency Medicine?  Firstly, in exam preparation: I used checklists (2 years before I read this book) to keep track of topics I was studying for the Fellowship exam.  I didn’t just use the syllabus as the checklist (a sure fire path to insanity), instead I looked through the syllabus and picked out the expert level knowledge topics, and made one checklist of those, as they were the “must know” topics.  I also used them to plan my study for the week, putting short lists of topics I had to get through for each day up on post it notes.  Once I got better at writing checklists, I started writing some topic summaries as checklists.  The most obvious topics these could be used for are the resuscitation topics, as these require factual knowledge and procedural skills to be combined, and are often done incorrectly or out of sequence.  Checklists are different to most lists you learn for the exam, and from protocols (which are voluminous and tiresome to follow).  They are succinct, practical lists of things to check & do in defined situations, and by definition should improve your practice, not hinder you by being an obstruction to proceding with whatever task you’re applying it to.

I also think that given the complexity of what Emergency Medicine entails, there are numerous potential applications for checklists that could be formally used in our day to day work.  While experienced ED docs subconsciously use them, they would be great teaching aids, and would surely improve the performance of just about everything we do, from resuscitation, to procedures, to referrals, admissions and patient discharge. 

Here’s a couple of examples:

Pre Intubation Checklist:
Check BSL – don’t intubate hypoglycemia
Check K+ on VBG – no sux if K+ high – femoral stab if no IV access
Check Laryngoscope handle/light
Check backup handle/light
Check & size ETT/cuff
Check Bougie
Check & size LMA
Check Suction
Check BVM/O2 supply
Check ventilator
Check patient position – ear to sternal notch
Check Vital signs – normalise as able
Check drugs & doses
Check & allocate staff roles before commencing
Check difficult airway trolley – cric kit at bedside
Communicate failed intubation plan to team

You can see how having a nurse standing next to you reading these items out while holding a red pen and a clipboard would minimise the chance of a bad intubation attmept!

Pre Lumbar Puncture:
Check for raised ICP – Clinically
CT If indicated
Check Platelets +/- coags – reconsider need if Plts < 50
Check for petechial rash (contra-indication in some jurisdictions)
Check for local skin infection
Check for previous back surgery
Check ability to maintain patient position
Check nurse assistant available for whole procedure
Check that lab able to process samples (BEFORE procedure commences)
Explanation & Consent verbal/written

I just made these up off the top of my head, but you can see, in our job, with the constant interruption to our thought processes, where it’s quite easy to forget or be distracted from one or two items on a checklist, how these sorts of lists could help avoid complications, and even potential disasters.

While the information you need to know to write these lists is all in the books, combining this with practical experience and sequencing of tasks is what helps create checklists, and like all dynamic tools, they need to be frequently revised before the optimal checklist is created.  The practical application of this knowledge is also what turns it from a “list” (that you need to know for an exam) to a “checklist” that you can actually use in your day-to-day work.

I’d thoroughly recommend The Checklist Manifesto: How to Get Things Right to anyone studying for ACEM Primary or Fellowship Exams, and any experienced Emergency Physicians who want to improve their practice and teaching.

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