Books, Multimedia, and Meeting Reviews: Book Review
This handbook is ideal for any anesthesiologist or emergency medicine physician working on the frontlines of prehospital care or as a classroom reference for training advanced medics and nurses. While the medical concepts are generally simple and straightforward, the pragmatic focus on clinical application and the inclusion of frequent clinical pearls make this a useful reference for both basic training and polishing up existing skills.
This second-edition handbook comes from the nonprofit Great North Air Ambulance Service course in Pre-Hospital Anaesthesia, a 2-day training program for emergency response medical personnel in Great Britain. More than 20 air ambulance companies are now in operation there, drawing on a pool of 700 emergency medicine and anesthesia physicians for prehospital care. Like the European emergency medical systems in Austria, Germany, and France, the British system is evolving to provide more hands-on physician care at the scene of major traumas; unlike in older “stay and play” trauma systems, however, modern practitioners have learned important lessons from battlefield medicine in Iraq and Afghanistan. Most notably, when prehospital procedures are strongly indicated (eg, tourniquets, airway management in patients with severe traumatic brain injury, tube thoracostomy to relieve tension pneumothorax) and when speed-to-hospital is the greater priority (eg, exsanguinating internal hemorrhage).
The handbook is sharply focused on the key anesthesia issue in prehospital care: indications for rapid sequence intubation (RSI) and the safe conduct of the procedure. Harking back to my own decade-long experience as medical director of a busy Trauma Resuscitation Unit, the key points emphasized by the authors are exactly the ones I would make to my trainees: in particular, the risks and benefits of RSI in different populations; the idea that RSI in a trauma patient is a 1-way process (waking the patient up if the intubation is going badly is seldom an option); the difficulties presented by an austere environment and awkward patient positioning; the importance of preoxygenation; the relative merits of succinylcholine versus rocuronium; and medication and dose choice of induction agents. Even the recommendation to abandon manual inline stabilization in favor of securing the difficult airway or the note to check breath sounds before boarding the helicopter represents hard-won, real-world experience.
One appealing feature is a nuanced review of outcomes research in prehospital airway management. Two important and controversial topics are addressed: (1) whether endotracheal intubation in the field improves survival, and (2) whether anesthesia or emergency medicine specialists achieve better results. The authors do a nice job of summarizing existing knowledge without any discernible bias as to the results. In the more practical chapters that follow, the authors provide a detailed and accurate description of how to assess an emergency patient and get them intubated. They include some novel ideas: universal use of a bougie during field intubations, the potential benefit of a supraglottic airway—with placement facilitated by intravenous sedation—and a strict limitation to 2 attempts at intubation before changing strategies. The handbook includes numerous checklists and color illustrations, which will make it attractive and useful to novice prehospital practitioners. Also included is a chapter on crew resource management that frames the importance of teamwork during prehospital airway management, transport, and handoff to the hospital.
Outside of RSI, the handbook is less specific about other potential elements of prehospital anesthesia. Instructions on how to place a chest tube or perform a surgical airway are potentially useful but would need backup with hands-on training to really “stick.” Written instructions on how to perform a resuscitative thoracotomy are almost certainly misplaced in this book, both because they are too complex to be useful without actual experience and because the need for this procedure is a near certain marker for futility of resuscitation, even when performed in an emergency department. The chapter on postintubation management, however, is quite useful and makes a number of good points—often in checklist form—for what happens after the endotracheal tube position is confirmed. The only fact I looked for but did not see was a warning against hyperventilating patients after intubation—easy to inadvertently do when catecholamines are running high in the providers! This can be detrimental for both patients in hemorrhagic shock and those with serious traumatic brain injury. However, this is a small quibble.
All in all, this is an excellent reference for those venturing into the world of prehospital medicine. Although this is less common for anesthesiologists in the United States, in other parts of the world this is a common and important role. This handbook will be a useful guide to read and carry.
Richard P. Dutton, MD, MBA
US Anesthesia Partners