Book review

Acute Resuscitation and Crisis Management: Acute Critical Events Simulation (ACES). Edited by David T. Neilipovitz. Ottawa: University of Ottawa Press, 2005. ISBN 0776605976. Paperback, 292 pages. $35.

This book is the companion text to the ACES (Acute Critical Events Simulation) Resuscitation course, offered through the Canadian Resuscitation Institute (CRI). The CRI is a “non-profit corporation created to facilitate the development of peer-reviewed educational initiatives for health care professionals who practise acute care medicine in a wide variety of clinical settings.” This text, and presumably the ACES course, would be of interest to those providing adult acute care medicine, such as hospitalists, internists, clinical assists in monitored and intensive care units, emergency physicians, intensivists, and their corresponding learners.

It took me about five sittings over a 10-day period to make my way through the text but the effort was definitely worth it. I was rewarded with a review and overview of the essential principles of management of critically ill patients, with a focus on the initial hour or so of resuscitation. Subsequent chapters detailed some of the important issues in the ongoing care of the critical patient in an appropriate monitored setting.

The book is organized into five sensible sections: Introduction to ACES, Airway, Breathing, Circulation, and Sepsis.

The introductory section provides an overview of the team approach to a critically ill patient and builds an argument for a simulation-based course like ACES. It includes a chapter on crisis resource management and a general overview of medical errors. Of particular interest to medical educators is a chapter on the use of simulation in other industries (airlines, nuclear plants) and an argument for its incorporation into medical education, justifying the creation of the authors’ ACES course.

Sections 2, 3, and 4 represent the “A, B, and C” of early resuscitation, respectively. The Airway section includes five chapters on basic and advanced airway management, medications for airway management and rapid sequence intubation, and dealing with the difficult and failed airway. Section 3, Breathing, dedicates five chapters to the important issues in the management of patients in respiratory failure, including the physiology of gas exchange, respiratory mechanics, early management of respiratory failure, and practical approaches to mechanical ventilation. Section 4, Circulation, has five chapters addressing shock, fluid resuscitation, evidence-based use of blood products, vasoactive medications, and hemodynamic monitoring.

The final section is dedicated en tirely to the issues surrounding sepsis, with a focus on early goal-directed therapy and supporting literature. It is a practical approach to the management of patients in sepsis and approaching fever in the critical care population. This section also includes a chapter on a practical approach to antimicrobial therapy.

The authors’ writing is accessible and provides an excellent review of concepts that we all should remember from our training but probably need to polish up on from time to time. The ACES course is an excellent enrichment of, though not a replacement for, the standard ACLS training for those who find themselves providing acute care without a training base with which they are comfortable.

Each chapter begins with a case scenario which, in some chapters, is referred back to later in the text. However, more case examples spread throughout the chapters would im prove readability and assist the reader in applying the principles discussed.

The ACES course—which I have not taken—and supporting text appear to have been written with a strong inpatient bias. While this likely suits the authors’ target audience, as an emergency physician, I found that some of the clinical scenarios, population, and approaches referenced were not as relevant to my experiences. The text was particularly conservative in its review and warnings against rapid sequence intubation, save for exceptional circumstances; this is not the current message in academic emergency medicine circles. Additionally, the text did not deal with trauma, neurosurgical catastrophes, burns, the multiply injured patient, etc. Perhaps some of these issues are addressed during the full ACES course.

Finally, the diagrams, figures, and pictures were quite simple and somewhat sparse. Future editions would benefit from increased graphics support to help break up the text and reinforce some of the ideas presented.

Despite these criticisms, I would recommend this text to learners and acute care providers who are interested in developing a practical approach to the early management of the critically ill patient. The authors have made an important contribution to Canadian critical care literature.

—Adam Lund, MD, FRCPC
Emergency Physician, Royal Columbian, Eagle Ridge, and BC Children’s Hospitals

Hepatitis awareness dangerously low

Over 500 000 Canadians have chronic hepatitis B and C. This is approximately 10 times the number of people in Canada living with HIV infection. Yet, according to a recent national survey commissioned by the Canadian Liver Foundation, more than 50% of the population don’t even know what hepatitis is. When asked to define hepatitis, fewer than half were aware that it is a form of liver disease and 7% could not define hepatitis at all. More than half mistakenly believe they are at low risk (54%) or have no risk at all (25%) of contracting hepatitis, 31% believe it is a blood-borne infection, 10% think it is a sexually transmitted disease, and 4% believe it is a form of food poisoning. British Columbians are the least likely in the country to be worried about getting hepatitis (61%).

The 2006 survey also revealed that young men (aged 18 to 34 years) are most likely (61%) to think they are at low risk of getting hepatitis and 18% believe they are at no risk at all. Risky behavior in general, often characteristic of this age group, may actually put them at further risk of contracting hepatitis. In contrast, young women (aged 18 to 34 years) are most likely to think they are at risk of contracting hepatitis, with 24% believing that risk is moderately high.

The Canadian Liver Foundation reports that there is a general lack of understanding about the risks associated with contracting hepatitis. Many people are not even aware that they have a form of hepatitis until serious liver damage has occurred. It is clear that more education is required to ensure Canadians have a better understanding of the seriousness of hepatitis, the risks associated with it, and how to reduce their chances of contracting it through simple measures such as not sharing needles, razor blades, and toothbrushes, the washing of hands after using the washroom, the use of sterile tattooing and piercing equipment, and practising safe sex.

For more information, visit www.liver.ca or call 1 800 563-5483.

New BCMA Core-Plus insurance program

Commencing 1 July 2006, the BCMA will offer new expanded and tax-effective health care and dental benefits to members and their employees.

The new Core-Plus program provides a base level of insurance coverage (the Core Plan, similar to that currently offered through the existing Medical Office Benefit Plan) but adds a tax-effective and flexible self-insured component (the Plus Plan). As the new plan satisfies the Income Tax Act’s requirements for a private health services plan, the Core-Plus premiums and self-insured expenses may be claimed as income tax deductions, resulting in additional savings for medical and dental expenses.

The plan will have two components:

1. The Core Plan, underwritten by Sun Life, will provide you and your employees with basic extended health care and dental benefits at competitive premium rates.

2. The Plus Plan will allow you to provide coverage at a predetermined level for eligible health expenses that are not covered by the Core Plan. The level of self-insured benefit is established by each BCMA member, based on applicable CRA guidelines.

BCMA staff will be holding information sessions throughout the pro vince in May and June to explain the new Core-Plus program. Be sure to attend the session nearest to you to get the details of this new opportunity. Information packages will be mailed to all eligible members following the sessions, so if you are unable to attend in person, watch the mail for your package.

—Sandie Braid, CEBS
Assistant Director,
BCMA Benefits

Critical illness insurance

Critical illness (CI) insurance was first developed in South Africa about 20 years ago by Dr Marius Bernard, brother of the famed surgeon who performed the world’s first heart transplant. CI insurance is an accident and sickness type of coverage that pays a one-time benefit in the event that the insured suffers from and survives one of the covered illnesses or impairments. Insurers provide coverage for a number of impairments. All else being equal, the more impairments that are covered, the higher the premium will be. The survival period varies by illness but is generally 30 days for most impairments. However, for the cancer impairment, there is a 90-day moratorium (waiting period) before that coverage becomes effective.

Once a CI benefit is paid, the coverage ends. The protection provided by CI insurance doesn’t overlap with the protection of life insurance or disability insurance. Life insurance pays a benefit only on death, whereas CI insurance pays it on diagnosis and survival. Disability insurance typically pays a monthly benefit when a loss of income is incurred, while CI insurance pays a lump-sum benefit regardless of any loss of income.

At the core of a CI policy are the “big three” impairments: heart attack, stroke, and cancer. Other impairments that can be covered include coronary artery bypass surgery, kidney failure, paralysis, major organ transplant, multiple sclerosis, blindness, deafness, Alzheimer disease, Parkinson disease, brain tumor, coma, loss of speech, major burns, and other diseases. As with life insurance, CI policies provide benefit amounts ranging from modest sums, such as $10 000, up to millions of dollars.

CI insurance is a unique product that is largely defined by technical details that describe the covered impairments in precise contract terms. This is mutually beneficial and necessary to ensure that the insured is an informed customer and that the insurer will only pay a benefit for the covered critical illnesses. Failure to provide a clear description of the product’s coverage, limitations, and exclusions would create confusion. For example, the definition of a heart attack is (a) a new episode of chest pain, (b) an electro cardiograph (ECG) indicating an acute heart attack, and (c) the presence of cardiac enzymes and/or troponin. This means that episodes of angina would not constitute a heart attack and, therefore, would not be covered.

Due to the nature of CI insurance, the underwriting of these policies is more stringent and is dependent on family history. As a result, CI plans can have a higher decline rate than that of life insurance plans. For instance, an applicant may be approved for life insurance but declined for CI insurance if more than one immediate family member has suffered from cancer before age 60.

Another important aspect of CI policies is the limitation on coverage and benefit payouts. For example, if an insured is diagnosed with cancer within 90 days of the policy issue date, coverage will be rescinded and premiums will be returned to the insured. These types of restrictions are necessary to prevent those who already have an illness from reaping a windfall benefit, which would increase the cost for others who have a legitimate insurance need.

The BCMA’s 18-impairment CI plan is underwritten by Sun Life Assurance Company of Canada, a member of the Sun Life Financial group of companies. Coverage is available in units of $10 000, from a minimum of $50 000 to a maximum of $500 000.

For further information on this plan, please contact Karen Paul at 604 638-2836 or e-mail kpaul@bcma.bc.ca.

—Sandie Braid, CEBS
Assistant Director, BCMA Benefits

Medical writing prize: $1000 for best student article

The J.H. MacDermot Prize for Excellence in Medical Journalism comes with a cash award of $1000 for the best article on any medicine-related topic submitted to the BC Medical Journal by a medical student in British Columbia.

The British Columbia Medical Association awards the annual prize to the finest medical student manuscript received by the BC Medical Journal that year. The prize honors Dr John Henry MacDermot (1883–1969), who became the editor of the Vancouver Medical Bulletin at its formation in 1924, remaining at the helm until 1959, when it became the BC Medical Journal. He was editor of the BCMJ until he retired in 1967. Dr MacDermot was also past president of both the VMA and the BCMA.

Adam Lund, MD, MEd, Sandie Braid, CEBS. Pulsimeter. BCMJ, Vol. 48, No. 4, May, 2006, Page(s) 185-187 - News.

Above is the information needed to cite this article in your paper or presentation. The International Committee of Medical Journal Editors (ICMJE) recommends the following citation style, which is the now nearly universally accepted citation style for scientific papers:
Halpern SD, Ubel PA, Caplan AL, Marion DW, Palmer AM, Schiding JK, et al. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002;347:284-7.

About the ICMJE and citation styles

The ICMJE is small group of editors of general medical journals who first met informally in Vancouver, British Columbia, in 1978 to establish guidelines for the format of manuscripts submitted to their journals. The group became known as the Vancouver Group. Its requirements for manuscripts, including formats for bibliographic references developed by the U.S. National Library of Medicine (NLM), were first published in 1979. The Vancouver Group expanded and evolved into the International Committee of Medical Journal Editors (ICMJE), which meets annually. The ICMJE created the Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals to help authors and editors create and distribute accurate, clear, easily accessible reports of biomedical studies.

An alternate version of ICMJE style is to additionally list the month an issue number, but since most journals use continuous pagination, the shorter form provides sufficient information to locate the reference. The NLM now lists all authors.

BCMJ standard citation style is a slight modification of the ICMJE/NLM style, as follows:

  • Only the first three authors are listed, followed by "et al."
  • There is no period after the journal name.
  • Page numbers are not abbreviated.

For more information on the ICMJE Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals, visit www.icmje.org

BCMJ Guidelines for Authors

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