British Journal of Anaesthesia 88 (3): 460±5 (2002)

Book Reviews

Topics in Neuroanaesthesia and Intensive Care. Georg E. Cold guidance. This fragmented style is clearly suited to the researcher
and Bent L. Dahl (editors). Published by Springer. Price £102.50. who can quickly identify the paragraph(s) relevant to their studies,
ISBN 3-540-41871-7. but not a great help to clinicians trying to put the whole picture
together. Despite such problems, the chapter on head injury is
The 12 topics in this book range from methods for measurement clearly full of useful references and would stimulate an inquiring
of cerebral blood ¯ow to head injury management, aneurysmal mind to try and `®ll the gaps'.
subarachnoid haemorrhage, and the sitting position. In the preface, One major criticism I do have is the very large numbers of
the editors suggest that the book was written not only for those references for each chapter. There are in excess of 1000 references
with an interest in research relating to neuroanaesthesia and for the chapter on ischaemia alone. Of the ®rst 500 references,
neurointensive care, but also to provide useful information for only 16% had been published in the last 5 yr, which increased only
those whose daily practice encompasses such areas. In the ®rst to 57% looking at those from 1990 onward. For a review of
aim they have more than succeeded, but with the latter I tend to current ideas, I would have expected many references before 1990
disagree. to be excluded, as they will have appeared in earlier reviews. Did
As to the quality of the content, there is no doubt. The editors the editors really read all those thousands of references before
have tackled many enormous topics and condensed the important writing the book? I just had to ask myself that question.
®ndings into manageable chapters. The longest chapter has only As a ®nal personal comment, I was greatly looking forward to
47 pages of text and covers head injury from both experimental reading this text and learning from the editors' years of experience
and clinical points of view, including guidelines for management in the care of neurosciences patients. However, my enjoyment
from both sides of the Atlantic. I found many important pieces of rapidly waned as the extremely poor proof reading and editing
information hereÐbut was a little frustrated over the lack of made reading some sentences a real challengeÐeven for a native
discussion, particularly concerning the Lund-management ap- English speaker. Although it is often charming to hear one's
proach as compared with the more widely practised American native tongue spoken with foreign grammatical structure it is a
approach. However, space is always at a premium and I cannot nightmare to try and read not only poor grammar but also poor
truly offer this frustration as a criticism, given the aim of the text. spelling. The whole text suffered badly and the publishing house
Another area I chose to follow-up was the vexed question of should be admonished for failing to get a native English speaker to
barbiturate use in head injury. There was a short section on this correct the excessive number of errors. The title on the cover
topic, but the question I am often asked by trainees `how long suggested that English spelling would be used throughout. This
between bursts is ideal in burst suppression' went unreferenced was not the caseÐeven within a paragraph both English and
and unanswered. American spellings of the same word were used. At a price in
I particularly enjoyed the chapter pulling together all the excess of £100, I would have expected better.
information on aneurysmal subarachnoid haemorrhage. Here the Nevertheless, I was impressed by the thoroughness of approach
organization was good, moving through epidemiology and and will certainly dip again into the chapters on how anaesthetic
experimental models to the effects on intracranial pressure (ICP) agents alter cerebral blood ¯ow, affect the intracranial pressure,
and cerebral haemodynamics, with a long section on vasospasm and in¯uence cerebral metabolism. I now have a source of
and concluding with management principles. The chapters on information on which to modify or continue current practice in our
anaesthetic agents were welcome and con®rmed my preference for neurosciences intensive care unit, and will point any potential
i.v. anaesthesia! It was also useful to have a chapter summarizing researchers in the direction of this book; I am certainly pleased to
the use of vasoactive agents for either raising or lowering arterial have a copy for my unit! For trainees, however, I will suggest
blood pressure, and their effects on ICP and cerebral haemody- some lighter reading before they tackle it.
namics. However, I was a little surprised to ®nd a brief S. Hill
introduction to G-protein coupled receptors (GPCRs) and G- Wessex Neurological Centre
proteins as the introduction to central a2-agonists, giving the false Southampton
impression that this transmembrane signalling system is unique to
this receptor type. Many other GCPRs had been discussed prior to
this point, without any reference to their molecular mechanism of Brain Edema XI. A.D. Mendelow, A. Baethmann, Z. Czernicki, J.
action. T. Hoff, U. Ito, H. E. James, T. Kuroiwa, A. Marmarou, L. F.
I must comment on the organization of the chapters. This was Marshall and H.-J. Reulen (editors). Published by Springer-Verlag
done in such a way that there were several levels of sub-headings, Wein, New York. Pp. 572; indexed; illustrated. Price 167.80
almost every paragraph had a heading. Although this extreme Euros. ISBN 3-211-83561-X.
form of producing `bite-sized' pieces of information seemed
useful for some areas, in others it detracted from an overall view. This book is the proceedings of the 11th International Symposium
The fragmentation often led to apparent contradictions in on Brain Oedema held in Newcastle-upon-Tyne in June 1999. It
sentences from adjacent paragraphs. In some instances, this could consists, therefore, of a collection of papers reporting clinical and
be explained by re-examining the relevant sub-headings so that experimental studies on cerebral oedema. The work reported in
one statement had related, for example, to animal work and the these papers is now more than 2 years old and it is likely that
other to human studies. In several cases though, contradictions much of it has been published in peer-reviewed journals.
were present. One example occurred in the chapter on head injury At the beginning of the book, there is a useful summary of the
on p. 247, `Hypocapnia improves cerebral autoregulation in the proceedings which states that the classi®cation into cytotoxic and
acute phase of head injury'. Yet on the same page, three vasogenic oedema has been shown to stand the test of time and
paragraphs down, we are told `. . . a decrease in PaCO2 does not should continue to be used. There are sections on imaging,
improve CA in patients with HI'. Such contradictory messages do molecular mechanisms, cellular mechanisms, experimental stu-
not help the clinician who reads this book for information and dies/models, experimental ischaemia, pharmacology/therapy,

Ó The Board of Management and Trustees of the British Journal of Anaesthesia 2002
 Book reviews

head injury, head injury monitoring, stroke, subarachnoid not discussed. No mention is made of other monitors of cerebral
haemorrhage and intracerebral haemorrhage, thermal effects, perfusion apart from Transcranial Doppler such as processed
and hydrocephalus. Each section is preceded by a useful summary EEG, near infrared spectroscopy, and somatosensory evoked
of its contents written by the chairs of the sessions. potentials.
The sections on head injury and subarachnoid haemorrhage will I was most alarmed that the lady undergoing awake CEA did
be of interest to neurointensivists and neuroanaesthetists. In not appear to be receiving supplemental oxygen during the caseÐ
particular, the demonstration that prolonged iso¯uorane anaes- the video described how she was sedated with fentanyl and
thesia increases post-traumatic brain injury is of interest and raises midazolam but then showed her with an oxygen saturation of 91%
the question as to whether other volatile anaesthetics have the without a face mask. This was a bad example to set for a teaching
same effect. However, there is very little of interest for video. Furthermore, the regional anaesthetic technique described
anaesthetists and intensivists who are not involved in the (combined super®cial and deep cervical plexus blocks) is perfectly
management of neurotrauma in a neurosurgical unit, and much adequate, but little attention is paid to complications of either
of the work reported is now a little old. The book has a place in the blocks or their prevention. For example, the external jugular vein
libraries of neurosurgical units for reference purposes, but very usually crosses sternocleidomastoid at exactly the point where one
few anaesthetists or intensivists are likely to purchase their own would want to do the super®cial block; it needs to be avoided
copies. when injecting local anaesthetic, which is worth saying.
E.Moss Inadvertent injection of local anaesthetic into the vertebral artery
Leeds or CSF is to be avoided at all costs during deep block (the video
describes these complications as occurring `occasionally').
However, the technique shown for injection of local anaesthetic
Video Review: Anaesthetic proceduresÐCarotid Endarterectomy. does not minimize the chances of this happening. The `immobile
A. R. Bodenham. Published by Media Services, Leeds. Price £35. needle' technique in which one operator steadies the needle and
This video is produced by Leeds General In®rmary to support the syringe against the patient whilst a second operator aspirates and
currently underway GALA trial (General Anaesthesia vs Local then injects, would have been better. No mention is made at all of
Anaesthesia for carotid endarterectomy (CEA)). It would appear transient neurological dysfunction such as Horner's syndrome,
from the title that this would be a detailed discussion of recurrent laryngeal nerve palsy or phrenic nerve palsy which may
anaesthetic techniques for CEA; however, the title `Anaesthetic accompany deep cervical plexus block. Patients with severe
and Surgical Techniques for Carotid Endarterectomy' appears as respiratory impairment may not tolerate the latter, which occurs in
the opening credit. Even this is misleading and could have been two-thirds of recipients of the block, so this group of patients
written the other way around, since over half of the content is should receive super®cial block alone. This is important
devoted to descriptions of two different surgical techniques for information for prospective practitioners of this uncommonly
CEA in suf®cient detail for the surgical Fellowship. performed block. There was no discussion about choice of local
The video starts with an opening preamble about risk factors for anaesthetic or additives, except that the surgeon was given a very
developing carotid stenosis, followed by a passage about reducing large amount of lidocaine (20 ml 1%) to administer periopera-
risk perioperatively. Five factors are named as contributing to risk tively through a relatively large (21G) needle.
reduction during CEA (surgical technique, maintenance of The surgical techniques were very clear and well described,
cerebral perfusion pressure, shunt insertion, patch angioplasty, including detailed descriptions of surgical instruments, choice of
and use of local anaesthesia). No references are provided to shunt and patch, and the relative merits of standard and eversion
support this however, whilst factors for which there appears to be endarterectomy. Once again, the commentary was very didactic
some evidence were omitted (for example, surgeons performing though, with comments like `The carotid sinus nerve is blocked
more than 10 cases per year, preoperative cardiovascular with local anaesthetic', which is controversially bene®cial.
optimization). I understand that this video was produced as a guide to surgeons
The meat of the video is discussion of two separate and anaesthetists who may be randomizing patients to the GALA
operationsÐstandard CEA under general anaesthesia (GA), trial. However, surgical techniques are not being compared in this
followed by eversion CEA under regional anaesthesia. The trial, so why were they given such prominence? After watching
techniques used are perfectly acceptable, if a little didactic. For this video, a surgical trainee would understand many of the pitfalls
example, routine central venous access for CEA under GA to and problems of carotid endarterectomy. The same cannot be said
allow administration of inotropes is hardly widespread practice. for an anaesthetic trainee, who would receive little guidance about
Some people would deliberately avoid it because of the risk of perioperative management or monitoring, together with the
carotid artery damage, but this was got round by the use of occasional `howler' such as the lack of oxygen for the awake,
ultrasonic localization of the internal jugular vein. It would have sedated patient. This video is an interesting introduction to carotid
been good to have seen alternative (and perhaps more modern) surgery, but it falls short of being a de®nitive anaesthetic guide.
anaesthetic techniques discussed. Whilst propofol or thiopental/ Mark Stoneham
fentanyl/vecuronium is traditional, many anaesthetists would Oxford
nowadays use shorter acting drugs such as remifentanil, target- UK
controlled propofol infusion, sevo¯urane or des¯urane together
with a regional block to allow immediate neurological assessment Lung Volume Reduction Surgery. M. Argenianzo and M. E.
postoperatively. Ginsburg (editors). Published by Humana Press, New Jersey. Pp.
It was disappointing that anaesthetic management (as opposed 273; indexed; illustrated. Price US$145. ISBN 0896 03848-3.
to technique) was largely ignored. Monitoring deserves more
attentionÐthis patient population has a high incidence of Lung volume reduction surgery is a fairy story for our time. A
ischaemic heart disease and the use of 5-lead ECG is more likely 1950s idea, it was re-introduced in the last decade of the twentieth
to detect myocardial ischaemia under general anaesthesia than century for the surgery of emphysema as an alternative or,
standard 3-lead. Additionally, blood pressure monitoringÐ possibly, bridge to lung transplantation. Suddenly, here was the
measurement in both arms, selection of allowable `limits' during magic wand for a multitude of distressed and exhausted patients,
the case and selection of appropriate `uppers' and `downers', is dicing with death at the limits of their residual volumes. Greedily,

461
 Book reviews

the wand was waved by surgeons. The resultÐthe resources of lidocaine. We are concerned that while it is not uncommon to use
medical insurance were consumed by their patients, languishing i.v. lidocaine to blunt the hypertensive response to intubation, its
with big air leaks on intensive care units. Answer to this rather suggested use by this route as a method to achieve anaesthesia of
unedifying spectacle? A licensed, randomized, controlled trial of the airway is both potentially dangerous and ineffective. Perhaps
surgical vs medical treatment. representing American practice, novices are encouraged to begin
It is this book's misfortune to have arrived just as the results of learning airway management using awake techniques, particularly
this trial were published (New England Journal of Medicine 2001; focusing on blind nasal intubation. The majority of the chapter is
345: 1075±83). The fable is now for a wider world and bestrides dedicated to the pharmacology of various agents. Interestingly,
the Bristol enquiries in the UK. It, therefore, has to be examined only two paragraphs are given to propofol while three are
by the microscope of the latter to tease out the lessons for the provided for ketamine. Although muscle relaxants are discussed in
future scienti®c evaluation of surgical innovation. It is not my detail, the focus is on the older, longer-acting agents including
intent to digress from the book, but the recent publication is pancuronium and tubocurarine with only a small section on
important. Suf®ce it to state that one of its most telling ®ndings is rocuronium. There are errors, for example in Table 1, where the
that many of those who reluctantly found themselves assigned to indications and contraindications of tracheal intubation are
the medical arm, may owe the randomization process their lives. reversed. Organization of the chapter is poor with aspiration
In the end, the active arm effectively became the test bed for precautions, premedication, cardiovascular sequelae, benzodiaze-
re®ning the criteria for those most likely to bene®t from surgery. pines, narcotics and barbiturates discussed under the heading of
I recall listening to Joel Cooper, the modern wizard of both lung local anaesthetics. The ®nal section covers a series of clinical
transplantation and lung volume reduction. As he told his tale scenarios which does give useful information for the choice of
around the world, he emphasized the importance of the good fairy agents in particular disease states, but is not written for quick
of anesthesiology to surgical innovation. You would not think so reference.
from this book. Interestingly, the speciality is not one of those The second chapter looks at predicting, assessing and managing
mentioned in the preface for whom the book might be of interest. the dif®cult airway. The author covers the range of conditions that
The chapters of interest to anaesthetists are neither practical nor are likely to provide dif®culties but does not offer any
scholarly. A return of self ventilation and early extubation, which classi®cation of these according to the nature of the problems
drive the anaesthetic management and are the key to success, get likely to be encountered. There is a section on the various
little emphasis. Dynamic hyperin¯ation gets scant attention. There predictive tests which is well covered. The remaining section
is little about its science or modus operandi, how to prevent it, covers management strategies. This is effectively a detailed
spot its early signs, or treat it when it develops. description of equipment, in particular the various laryngoscope
So where does this leave this book? Has it been undermined by blades, stylets and airway adjuncts. The limited information about
events and spooked by anesthesiology? No, not completely, it is techniques includes digital guided intubation, nasal intubation,
still a good treatise on the surgery of emphysema, not just lung oesophageal airways, ®breoptic intubation, retrograde intubation,
volume reduction. It contains robust debates about the treatment percutaneous jet ventilation and cricothyroidotomy. Notably, there
options for emphysema which are germane both to thoracic is little on the LMA² or methods of securing the airway via this
disciplines and wider issues of surgical innovation in the twenty- device. The Intubating LMA is not mentioned and the technique
®rst century. But, in particular, it is a tour de force as a record of of awake ®breoptic intubation, probably the mainstay of managing
the intellectual stardust and scholarship that as a consequence has a number of dif®cult airway problems, is given little attention. The
invigorated the science of respiratory physiology. Here, some of book does not provide the reader with the insight to devise a
the old truths, such as hypercarbia and hypoxic drive, are put away strategy for dealing with any particular airway dif®culty that
to bed. However, you do not need to buy a copy just for this, various conditions are likely to present. There is no classi®cation,
oustanding though it is; borrow it. for example, as to which technique is best for managing a problem
I. D. Conacher with soft tissues as opposed to bony abnormalities. The reader is
Newcastle-upon-Tyne not encouraged to have a plan B or C, and is left only with a long
list of alternative laryngoscope blades that are probably not
available in most hospitals.
The best, and probably most useful, chapter of the book is
Airway Management in the Critically Ill. Rade B. Vukmir.
chapter four on laryngotracheal injury from prolonged intubation.
Published by The Parthenon Publishing Group Ltd, Carnforth. Pp.
Perhaps this represents the author's real passion as it reads well
135; indexed; illustrated. Price £42.99. ISBN 1-84-214-046-9.
and offers some real insights into the problems associated with
With increasing numbers of non-anaesthetists taking up training prolonged tracheal intubations, as well as suggestions for
and consultant posts in intensive care, a book that deals principally minimizing these effects.
with all aspects of airway management is certainly welcome. The Generally, we did not ®nd the book easy to read. The numerous
stated aim of this book is to `provide a structured framework to references disrupt the ¯ow of the text and are generally old and
assess properly the needs of the critically ill patient in regards to full of statistics. The author has made no attempt to pull together
emergency airway management'. It attempts to do this by the extensive research that has gone into the book, to offer
covering all aspects of airway management over ®ve chapters. conclusions and summaries that would ful®l the stated aim of
The ®rst deals with tracheal intubation, the second covers dif®cult providing information for generating intervention plans for airway
tracheal intubation, and the remaining chapters are con®rmation of management in the critically ill. It is quite easy to be overwhelmed
tracheal tube placement, laryngotracheal injury from prolonged by the information provided, and to feel confused as to how to
intubation, and surgical airway procedures. speci®cally address a particular problem. The lack of organization
Although chapter one is directed at the novice, it does not within some chapters certainly makes quick reference more
describe the procedure of intubation in any detail and the dif®cult. The photographs within the book are, at times, not
accompanying photographs are of poor quality. The description referenced within the text. They lack adequate explanation and
of anaesthesia is very brief and concentrates on the Guedel levels
of anaesthesia which, with the modern armamentarium of drugs,
has little relevance. The focus then switches to local anaesthesia
of the airway and gives much discussion to the use of i.v. ²LMAq is the property of Intavent Limited.

462
 Book reviews

some have no accompanying key or legend. The area of interest bioethics in the USA since the Second World War, and suggests
has also been cut off in some cases! the need for more empirical research in this area. It is followed by
Effective airway management is about having a primary plan a chapter that looks at the ethical issues surrounding the inherent
and one or more back up plans in case this fails. We feel this book con¯ict between the goals of science and those of medicine, as
does not provide the means by which such plans can be quickly or seen in Phase 1 cancer trials, and emphasizes the importance of
clearly elucidated. Its recommendations regarding procedures that gaining valid consent from patients enrolling in these trials.
are rarely practised in the UK or Europe are misleading and the Finally, with the ®nancial imperative in the USA to cut costs in
lack of organization or any ®rm conclusions leave the reader medical practice, there is a chapter discussing whether such cost-
confused. Flexibility to take in all confounding variables is to be cutting activities fall within the established conditions of research.
encouraged but the author has failed to establish even a broad If they do, this would have implications for the need for informed
framework within which to work. It is therefore dif®cult to consent before such activities are carried out.
recommend buying this book. This book is worth consideration if you have an interest in
K. Hames ethics. It is a book to be dipped into rather than to be read from
M. Popat cover to cover as each chapter deals with a discrete topic and is
Oxford referenced. Its main limitation is that it is heavily based on USA
practice, where medical ethics has a much higher pro®le than at
present within the UK; consequently, guidelines and legal advice
International Anaesthesiology Clinics. Vol. 39: Number 3: 2001: are not always directly relevant to UK practice. It does, however,
Medical Ethics. Edward Lowenstein (editor). Published by stimulate the reader to reconsider certain ethical issues.
Lippincott, Williams and Wilkins, Hagerstown. Pp. 148; indexed. A. Stronach
Price US$74. ISSN 0020-5907. Redditch
The subject of this edition of International Anaesthesiology
Clinics is medical ethics. The aim of the book is to present
material of particular relevance to the anaesthetist, although the The Patient's Internet Handbook. Robert Kiley and Elizabeth
editor also hopes that it will be of interest to any physician. There Graham. Published by Royal Society of Medicine Press Ltd,
are nine chapters in total, each written by a different author from London. Pp. 302; indexed; illustrated. Price £9.95. ISBN 1-85315-
the USA and each covering a separate topic. 489-9.
Four of these chapters deal with life and death issues, and these
will be of value to most anaesthetists with an interest in ethics. This short book aims to introduce patients and the general public
`End of Life Issues in Surgery' is a general chapter written from to health information that is accessible through the Internet. In
the perspective of an anesthesiologist and gives an overview of particular, it seeks to guide patients to information sources that
ethical problems arising in anaesthetic practice. It includes both a will help them to consult, on equal terms, with health
discussion of the ethical issues surrounding a patient's demand for professionals.
speci®c medical interventions, as well as the practice of The book is divided into ®ve sections. Section one consists of a
withholding and withdrawing life support. It contains a set of general introduction to the Internet with basic, practical advice
guidelines for the ethical practice of anesthesiology published by about connecting to it. Whilst this is pertinent for a complete
the American Society of Anesthesiologists (ASA). The with- novice it is unlikely that a reader without any Internet experience
drawal of life-sustaining treatment is dealt with in more detail in a would be drawn to this book. Section two (Searching for
separate chapter, which discusses both the ethical dilemmas and Information) comprehensively describes different techniques used
the practicalities involved with it. Cardiopulomonary resuscitation to search the Internet effectively. Different levels of searching are
(CPR) is the subject of two chapters. The ®rst of these deals with clearly explained including Boolean logic, the interrogation of
`Do not resuscitate' (DNR) orders and suggests a goal-centred databases, and the use of web directories and subject gateways.
approach to making such decisions. It also looks at the question of Throughout this section, full use is made of illustrated examples
what should happen when a patient with a DNR order goes to the including worked examples of search terms; the use of `screen
operating theatre. The second deals with the decision making dumps' is very effective. The ®nal chapter in this section focuses
process in CPR orders, and discusses whether it should be a on discussion lists and newsgroups. Whilst the reader is warned
medical one or a patient/surrogate choice. It also looks at some of that discussion lists and newsgroups `epitomise the best and worst
the issues surrounding autonomous decision-making and consent. aspects of the Internet', and the reader is encouraged to discuss the
Other chapters of interest include one devoted to the subject of ®ndings of their Internet exploration with their doctor, an
non heart-beating organ donation. This is a practice which occurs important piece of advice was omitted. Contributors to a
in very few centres within the UK, partly because of the discussion list frequently remain anonymous and the membership
surrounding ethical controversies. Amongst those discussed are may include individuals with undeclared commercial (or other)
the con¯icts of interest which arise when caring for dying patients interests.
who then become organ donors, and what constitutes an Section three features a selection of health topics: NHS services
appropriate criterion for death determination in such cases. and the Internet are discussed along with drug information,
Finally, there is a chapter examining the problems posed by the complementary and alternative medicine, and pregnancy, child-
uncooperative patient, which looks speci®cally at the ethics of birth and infant care. It is not clear why these subjects were
coercion and constraint relating to patient consent. Using case chosen, other than that they are applicable to a general readership
histories it discusses how to deal with: the uncooperative patient and indeed the information presented is wide ranging. A
in casualty; an elderly confused patient with a fractured neck of considerable proportion of the NHS services chapter is dedicated
femur refusing surgery; and what to do with the uncooperative to hospital performance data, and debate about the paucity of
child presenting for surgery. These are situations in which most information currently provided on the performance of individual
anaesthetists will ®nd themselves at some time during their doctors. Although the limitations of raw data are discussed in this
careers. section, the level of this debate is super®cial. It is unlikely that
This leaves several chapters which are of less direct relevance reading this chapter would enable the lay reader to interpret the
to anaesthesia. The ®rst looks at the continuing evolution of examples given.

463
 Book reviews

Section four, `Keeping Safe', offers valuable guidance regard- of services and to strategic decision making. Compared to
ing the evaluation of information derived from the Internet; medicine, the evidence base in management is relatively weak,
however, despite the section title, only the ®rst chapter but the author makes a strong case for seeking out and using
concentrates on it. This important chapter contains helpful and objective evidence wherever possible. The case made, the focus of
instructive guidance and would perhaps have been better placed the book is on how to reduce obstacles to the practice of evidence-
within Section two. The following chapter focuses clearly and based management.
helpfully on ways in which the reader can use the information Concise and clearly written, each chapter highlights a separate
gleaned from the Internet when consulting their doctor, and the aspect of implementation. These include self-management, the
®nal chapter addresses `The Future'. This short but interesting difference between information and knowledge, monitoring of
section features developments in Internet technology including services, making and implementing decisions, andÐprobably
telemedicine, interactive health care, and the use of the Internet most importantlyÐthe interplay between management styles,
for continuing medical education. local organizational culture, politics, and the interpretation of
The ®nal section of the book is an extensive directory of health evidence. Each topic is illustrated with a health-related vignette
related websites with associated postal and telephone contact outlining an evidence-based management approach to stimulate
information. A brief description is given for each site along with re¯ection, and chapters close with a series of action-points for the
details of any accompanying discussion list or newsgroups. The reader.
only reference within the book to anaesthesia was to the American To manage services effectively, we need to know whether we
Association of Nurse Anesthetists' website for information are doing the right things, and whether we are doing them as well
regarding the options for pain relief during labour; yet a basic as possible. Many managers will have been challenged to produce
search performed through the search engine Google found public their evidence for a particular service change. Many clinicians,
information on web pages from the Royal College of Anaesthetists either moving into management roles or feeling the impact of
and the Association of Anaesthetists of Great Britain and Ireland. changing services, will query the robustness of the underpinning
The book is supported by a website (www.patient-handbook. logic when faced with change. Many, faced with stars (or no
co.uk), and the reader is advised to check this regularly or to stars), traf®c lights, or CHI visits, will want to critically appraise
subscribe to an email alert system for update information. how well their current services are working, and to develop and
However, this is a time-consuming endeavour for all concerned deliver improvements. This thought-provoking book should help
and may prove dif®cult to sustain; several websites that were clinicians and managers to incorporate evidence-based strategies
suggested were not accessible, and this had not been updated on both when assessing whether they are doing the job right and,
the website. even more importantly, whether they are doing the right job.
Overall, this book contained useful, valuable information and Julia Moore
guidance, particularly the section advising patients on preparation Wirral
for a medical consultation, but its purpose remained unclear. The
website directory was potentially useful, but arguably super¯uous
given the detailed chapter on searching for information; likewise, Surgery, Sand and Saigon Tea. An Australian Army Doctor in
for an example, the chapter concerning pregnancy, childbirth and Vietnam. Marshall Barr. Published by Allun and Unwin. Price
infant care seemed unnecessarily long. In my experience, 27.20 Australian dollars. ISBN 1 865 084638.
individuals wishing to obtain health information, particularly It is only fair to point out that reading this book has evoked for me
immediately following diagnosis, will want that information so many memories and re¯ections that, when it comes to drafting
quickly and in a form that is readily understood. They will, a review, it is proving very dif®cult to maintain any semblance of
therefore, turn to the medium with which they are most familiar. objectivity. The reason is quite simply that I followed in Marshall
The scope of this book was too wide and would perhaps have been Barr's footsteps and, for 3 months in 1969, I worked as an
improved by assuming a certain level of Internet competence, and anaesthetist at the same First Australian Field Hospital, Vung Tau,
developing the theme of the `empowered patient'. I would have South Vietnam, as described by the author. Dr Barr describes it
dif®culty recommending the book to any particular readership; exactly as it was, not only how it was at the hospital, the work and
novices are unlikely to use the Internet as their ®rst choice for the play, but also how it was to be in Vietnam at that time. I
information, and regular `surfers' would not require the level of thought I had remembered it well but he has reminded me of so
detail provided in it. much more, the bits and pieces that are seemingly so easily
Helen Casstles forgotten. For me, the book is a postcard from the past, and one
Liverpool that I am delighted to have received and read. I hope I can do it
justice.
Evidence Based ManagementÐa Practical Guide for Health It all happened more than 30 yrs ago. The author is no longer
Professionals. Rosemary Stewart. Published by Radcliffe Medical the young personable anaesthetist who, at something of a loose
Press. Price £18.95. ISBN 1-85775-4581. end in Melbourne and disappointed in love, decided to have a shot
at war. He volunteered for the Citizen Military Forces, and, with
Evidence-based medicine has been de®ned as `the conscientious, the Army eager to recruit specialist medical personnel for service
explicit and judicious use of current best evidence in making with the Australian Taskforce in Vietnam he was, somewhat to his
decisions about the care of individual patients'. The strengthening surprise, eagerly embraced by the Medical Directorate. As he
of evidence-based clinical practice and consequent changes in writes, `their welcome was ¯atteringly warm'. He was on his way,
disease management have led to calls for a similarly rigorous and the rest of the story is his.
approach to the management of health care services and It is a good story, honestly and engagingly told and with enough
development of health policy. detail to satisfy any anaesthetist, young or old, with an interest in
This small book offers health service managers an insight into the `dif®cult situation', particularly one with a military ¯avour.
the techniques of evidence-based medicine. It sets out to show But there is more, a good deal more, than anaesthesia here.
how the principles of ®nding and appraising evidence, developing The book is a sort of diary of perhaps the most interesting and
organizations and individuals to use such evidence, and challenging year of a life and, as it should be with a diary, the year
implementation of research can be applied to the management is recounted with feeling and with candour, the latter not always

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 Book reviews

necessarily to the author's credit. He indeed tells it as it was and, read. I wonder, after so long, how easy and enjoyable it was to
in doing so, spares himself no blushes. I liked him for that. write. I had thought of having a go myself but, with Dr Barr
It is not a book for an anaesthetic department library. I am sure having stolen the march on me, there is some comfort in the
it was never meant to be so. Nor is it a book meant for re¯ection that I no longer need to bother. Instead, I will defer
anaesthetists, for anaesthetists only that is. The author has made a certainly to the better man and probably to the better book.
point throughout of carefully explaining enough about anaesthesia David Gray
and of anaesthetic paraphernalia to inform the lay reader, such that Liverpool
he or she will never feel lost. It is an easy and enjoyable book to UK

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