Abstract
Reviewed by: Charlotte Houltram, ST4 Anaesthesia & ICM East Lancashire Health Trust, Blackburn, UK
This book is somewhat different to others I have come across in this area. The authors have structured it into 10 sections each focusing on a “pitfall” in ICU. They often begin each chapter with a vague case history, although these cases are not the main focus of the remaining text. The pitfalls themselves are issues which most doctors who have spent time on ICU will be familiar with. They range from delay in definitive treatment to lack of appropriate end of life care planning.
For me the real value of this book lies not in the pitfalls, which in some instances are fairly obvious (e.g. lack of adequate staffing, poor communication or lax infection control practices) and are far too complex to be easily remedied, but more in the evidence the authors present around the issues.
The book covers a good number of the large, good quality trials which provide the current evidence base for ICM practice. This will be invaluable to trainees starting out in ICM who may know what treatments patients are offered but not necessarily why they are offered them. Trials such as BASICS, FEAST, PROSEVA, SEPSISPAM, CRASH, CORTICUS and many more are covered in a good amount of detail, with the original data often being reproduced in the text. This allows the trainee to gain a broad understanding of the rationale for ICU practice without having the necessity of searching out all the source papers themselves. The book outlines trial methodology and outcomes in summary. Having said this, all the material is fully referenced so the original papers will be easily located by anyone wishing to do some further reading. Along with the inclusion of positive trials which inform our current practice, there is also a review of practice which was previously widespread and has subsequently been abandoned due to negative trial evidence. It is a good lesson in how a treatment appearing logical, plausible or intuitive may not actually be useful, and on occasion may even be harmful. The flaws in evidence-based medicine (EBM) are also covered to give balance and context to the subject.
An additional bonus with this book is to be found in the appendix, where there is a section named “A practical approach to EBM” that outlines how to critically appraise an RCT or meta-analysis. This is extremely useful to those not familiar with statistical analysis and data interpretation as the finer points of relative and absolute risk reduction, confidence intervals, the number needed to treat and odds ratio are also explained succinctly with examples.
I also very much liked the selection of quotes and pictures in the book as well as the historical information included. There are some apt stories about puerperal fever, the work of Florence Nightingale, Lister and the 1950s polio epidemic as well as lines from everyone from Levi Strauss and Leonardo De Vinci to Sheldon Cooper. This made the book a more engaging and easy to read publication and broke up what could have been a rather dry (although very useful) foray through EBM.
At times, I did find there was a tendency for the prose to border on a lecture. I am not sure the sections around documentation or inadequate rehabilitation contributed much. And at times the focus was not on UK practice, particularly in the area of law and ethics. Having said this, the negative points were largely outweighed by some of the thought provoking insights raised, such as “Evidence vs. Eminence” and “Is less more?” I especially thought the “Choosing the wrong target” section was helpful in demonstrating how chasing the numbers, i.e. giving weight to surrogate outcomes, does not necessarily translate into an improved endpoint for the patient.
Although the target readership is not explicitly stated, I feel this book is appropriate for trainees in ICM, particularly those preparing for their speciality exams. I will be using it as a reference when studying for my FICM and recommend it for this purpose, as well as for those at earlier stages of their training looking to get a grounding in why ICM is where it is today. The book does assume some prior knowledge though and would be of less benefit to those entirely unfamiliar with ICM practice. The sections on statistics and critical appraisal would be very useful for those reviewing/presenting a paper, say, for a journal club or similar. Of course, with all printed texts nowadays there is the likelihood of new information rapidly making the publication obsolete, but with this book, there would still be value in knowing the path that ICM has taken in its development, to help better understand the issues the speciality faces going forward.