Reviews and Notes: Emergency Care of the Compromised Patient

Emergency Care of the Compromised Patient

Robert D. Herr and Rita K. Cydulka; eds. 808 pages. Philadelphia: JB Lippincott; 1994. $98.00.

Early in the 1970s, textbooks for emergency medicine were poorly adapted versions of traditional texts. These were followed by books organized and edited by emergency physicians but written primarily by specialists who had a major interest in emergency medicine or who believed that they understood the emergency department. Subsequently, emergency physicians began to write their own textbooks, in which only a small percentage of the chapters were written by specialists. These books mainly addressed the pathophysiology and clinical components of presenting problems and paid little attention to the underlying social or medical state of the patient or the state of the patient's environment. They did not recognize that patients with chronic disease generate a large portion of emergency department visits or that the emergency care of these patients is different from that of healthy persons.

Emergency Care of the Compromised Patient represents a turning point in the development of textbooks for emergency medicine clinicians. The editors are practicing emergency medicine physicians whose insights, gained from clinical practice, defined the need for this type of book. The text uses a wide definition for the word "compromised" and addresses the situation facing every emergency physician: the isolated evaluation of a person with complex underlying disease or severe social problems that may or may not be related to the presenting problem. Safe and effective care for these patients requires the prompt availability of useful clinical information. Most emergency physicians know the feeling of frustration or even despair that results from unsuccessfully searching texts for useful clinical information about the prisoner with chest pain, the immigrant whose family speaks of a folk illness, the man with an implanted penile device and local pain, or the patient with cancer and human immunodeficiency virus infection who is taking experimental drugs.

Both the comprehensive index and the table of contents describe the division of this book into 14 well-labeled parts, each with its set of chapters. Three appendixes describe the appropriate use of prophylactic antibiotics for preventing endocarditis.

The 83 contributors, of whom about half list "emergency medicine" in their academic titles and hospital appointments, have attempted to follow the requested order in their writings: clinical presentation, emergency evaluation, emergency management, disposition, and summary. Most have achieved this: The emergency physician will find clinically useful information on most topics and will seldom need to look elsewhere. The chronic conditions are well covered and the chapters on homeless people, immigrants, and prisoners are excellent, as is the discussion of compromising chemical dependence. The evaluation of complications for almost all major categories of surgical procedures is nicely summarized. The problems of patients who have had renal and cardiac transplants are also well described. Incidentally, two authors have personal experience as compromised patients, and one of these had her surgeon co-author a chapter.

This text has few shortcomings. The inevitable variations among chapters caused by having multiple authors is present but minor. Significant discussion about the evaluation of patients taking too many medications, or about poisoning, is lacking. A review of the common chronic mental health conditions (including the Munchausen syndrome) and the reasons why patients who have them visit the emergency department would be useful.

A discussion of the value of communication between the emergency medicine physician and the patient's primary or specialty physician would also be useful. Often, this communication can be facilitated by educating the patient about the value of obtaining a current written clinical summary, including a medication list, from his or her primary provider. Finally, a section on how to use community resources would have been valuable. For example, home health services are an essential component of comprehensive emergency care. Some patients with chronic disease also benefit from protocols lodged with the local emergency medical ambulance system to avoid unnecessary hospital use.

Despite its cost, this textbook should be mandatory for every emergency department and urgent care center, and should be encouraged for every primary care setting in which patients with chronic disease may present with a new problem. Physicians in the role of gatekeepers, rediscovered recently as a part of health care reform, need this book to help them manage sicker ambulatory patients and make more judicious use of specialists and hospital facilities. The editors ask that readers send them comments to make the next edition more useful. I anticipate that readers will also tell them how often this excellent book helped them in their "real time" practice.