Book reviews
Can J Rural Med vol 3 (1):41-42
© 1998 Society of Rural Physicians of Canada
History Taking, Examination and Record Keeping in Emergency Medicine. H.R. Guly. 232 pp. Oxford University Press Canada, Don Mills, Ont. 1996. $46.50. ISBN 0-19-262461-X
Emergency medicine is a unique and complex art. Practitioners can never learn enough about how to do it properly. This little book contains wise tips for physicians and nurses who work in emergency departments (EDs). The author clearly has thought long and hard about assessing ED patients. I recognized a physician manager who appears to have investigated many ED cases that had gone wrong.
In Part I (34 pages), the author gives some valuable pointers on what I call "case management" the art of spending 5 minutes with an ED patient and getting it all done, from greeting to record-keeping. He offers suggestions on how to compress notes while documenting vital information ("Poor records = poor medicine. If it's not written down, it wasn't done") and emphasizes principles of continuity of care in ED record-keeping. He discusses the process of making an ED diagnosis and suggests tricks for ensuring follow-up.
Part 2 (22 pages) reviews general principles of assessing joint, bone and skin injuries, and non-traumatic musculoskeletal complaints. The information is vital but very basic, at the level of medical students and first-year residents. Guly emphasizes the need for thoroughness. He gives several examples of how injuries cause occult problems that could be missed in a superficial assessment.
Part 3 (114 pages) covers injuries to body parts, beginning with head injuries and ending with the limping child. Each section provides tips for assessment of a body part. The differential diagnosis of the limping child does not mention viral synovitis, which seems to be relatively common in our practice. Perhaps this oversight is because the book is mainly oriented toward trauma. Nor is child abuse mentioned. Most of the examination essentials are covered. I appreciated the experienced clinician's warning about the knee exam: "trousers must be removed and not just rolled up." The level of detail in Part 3 appears fairly basic.
Part 4 (38 pages) deals with the assessment of burns, vascular injury, nerve injury, major trauma, road accidents and self-harm. Guly offers an approach to the documentation of these problems and emphasizes the need to be precise about nerve anatomy. The section on self-harm takes a narrow approach to management of an injured suicidal patient.
Part 5 (18 pages) comments on issues that the author feels a nurse should consider in recording information on the chart. The relative roles of nurse and physician continue to evolve. The section offers important food for thought to ED management teams.This book is seeded with tips about understanding the patient's agenda while attempting to make an accurate diagnosis. New students will benefit from early exposure to this wisdom, and mature ED physicians will appreciate the reminders.
The book has several limitations. (1) It does not mention the rural context. I am convinced that there are very important differences in the way emergency medicine should be delivered in rural settings. (2) There are very few references to the emergency medicine literature in this book. It is written from the British "A&E" (accident and emergency) perspective, the British term for ED and signifiying a set of traditions quite different from the North American ED. The author seems to triage patients into those who should be seen by the emergency physician and those who should have taken their problem to the general practitioner. North American EDs tend to handle all visitors. (3) The book deals almost exclusively with trauma. Research consistently shows that trauma accounts for only one-third of all rural ED visits in North America. None of these shortcomings limits the usefulness of this book for new and mature students of rural medicine, however. Its lessons easily can be generalized to non-trauma problems.
I recommend this book for medical students and family medicine residents who intend to enter rural practice and for the libraries of rural teaching hospitals. Rural preceptors should take a half hour to skim the book, looking for useful tips to use next time they are on call. Rural ED physician managers should have access to this book until references sensitive to the rural context become available.
Jim Thompson, MD, CCFP(EM), FCFP
Sundre, Alta.
Clinical Associate Professor
Department of Family Medicine
The University of Calgary
Calgary, Alta.
Education for Rural Medical Practice: Goals and Opportunities. An Annotated Bibliography. Edited by James T.B. Rourke. 324 pp. Monash University, Australian Rural Health Research Institute, Moe, Australia. 1996. A$70. ISBN 0-7326-0885-6
Does recruiting rural high school students to medical school increase the retention rate if they become country doctors? Do community-based family medicine training programs do a better job of educating physicians for rural practice? Do return-of-service contracts work as a way of recruiting or retaining physicians for practice in the North?
Dr. James Rourke has produced an annotated bibliography on the literature on rural and remote health in his new book Education for Rural Medical Practice: Goals and Opportunities. His literature review is international in scope and is organized into chapters with commentaries and abstracts on such subjects as practice location after graduation, medical school selection, undergraduate curriculum, postgraduate training for rural general/family practice, residency training for rural specialists and continuing medical education. Each article listed is accompanied by an abstract, sometimes written or amplified by Rourke, as well as key words and comments. The chapter summaries are helpful, quick resources for those looking for a mini-literature review.
This book will be of interest to anyone thinking of practising in rural areas, from current practitioners, to academics and to policy planners, if they are interested in what has been tried around the world to educate doctors for rural practice and if they are interested in a critical review of what works and what doesn't.
This is not a book to sit down and read from start to finish -- rather it is a reference book that can be used to see what strategies have been successful in other jurisdictions. It makes an important contribution to policy development by moving us past anecdote to evidence as to what educational programs and policies best prepare physicians for rural practice.
Plans are under way to have the book released in CD-ROM format, which will be most helpful for searching for information by key word. In the meantime, the author has avoided one of the most common pitfalls of any bibiliography -- that it is not kept up-to-date. Rourke's 1996 supplement to the book has already been released.
It would be good to see an expansion of this project; perhaps the author could turn his attention next to the non-educational determinants of rural practice. What financial incentives work? Which forms of practice organization are conducive to rural practice? Please organize the literature on those subjects for us too, Dr. Rourke!
Ruth Wilson, CCFP, FCFP
Associate Professor and Head
Department of Family Medicine
Queen's University
Kingston, Ont.
