Pines J, Everett WW

BMJ Books, 2008

296 pages, $79.95

ISBN 978-1-4051-5400-0

Life in the emergency department (ED) is a complicated

game of risk management. From the mundane (eg, ankle

injuries) to the extreme (eg, cardiac arrest resuscitations),

diagnostic measures are fraught with dangerous pitfalls.

Appearances deceive: Patients who seem perfectly safe and stable

occasionally decompensate suddenly, while overtly moribund

patients exhibit uncanny recoveries. In an ideal world physicians

might carry a handheld “diagnosis-prognosis machine” that

instantly determined both the underlying illness and an accurate

short-term prognosis. That machine is not likely to exist for the

foreseeable future. Until then, Evidence-Based Emergency Care:

Diagnostic Testing and Clinical Decision Rules by Jesse Pines and

Worth Everett might be the next best thing to have on hand.

Until now there has been a paucity of truly evidence-based

guidance for diagnostic and clinical decisionmaking in the ED.

Pines and Everett have smartly aggregated a substantial body of

information into a compact textbook format for emergency

practitioners. The text begins with chapters that lay out “the

basics” in simple explanatory language using intuitive ED

examples. These chapters cover diagnostic decisionmaking, the

process of evidence-based appraisal, epidemiology and statistics,

and clinical decision instruments. Subsequent chapters are

universally disease-based, and grouped by section headings

including Traumatic Injuries, Cardiology, Infectious Disease,

Surgical and Abdominal Complaints, Urology, Neurology, and

Miscellaneous.

The authors’ backgrounds and clinical exposure are

emergency medicine-based, and the selection of included topics

makes this apparent. The bulk of chapters cover frequently

encountered and considered ED conditions including acute

knee injuries, acute coronary syndromes, and nontraumatic

abdominal pain. Chapters discussing less common conditions

are wisely chosen, covering diagnosis and detection of diseases

that emergency practitioners are trained to fear and seek most,

including necrotizing fasciitis, testicular torsion, subarachnoid

hemorrhage, and temporal arteritis.

Weaknesses in the book include the surprisingly

unstructured format used for the generation of clinical

questions. Evidence-based medicine formats generally endorse a

fairly standardized “PICO” (patients-intervention-comparisonoutcome)

structure, while Pines and Everett have chosen an

apparently non-standardized, and therefore frequently

imprecise, approach to crafting their questions. This detracts

somewhat from the evidence-based aura of the text, and

occasionally impacts negatively the answers that are generated.

In addition, the cited data are less reliable than a casual reader

might be led to believe. Underlying quality is often mentioned

in passing or even set aside so that a slightly more concrete

conclusion about a diagnostic test’s performance can be asserted.

This has the dual downside of occasionally imbuing the reader

with unearned confidence in the numbers, as well as

diminishing the importance of evidence quality in bedside

decisionmaking.

The book has, however, justly achieved its intended goal of

providing accessible, informative, useful guidance for evidencebased

diagnosis. In my ED I recently discovered a seasoned

academic emergency physician with a copy of the book under

his arm. His curbside review was glowing. A day later a chief

resident wearing a wicked grin pulled the book out of his bag to

challenge my assessment of a culture’s diagnostic utility for a

patient. I admonished him for challenging his elders, and then

checked the book. He was right.

David H. Newman, MD

St. Luke’s/Roosevelt Hospital Center

Department of Emergency Medicine

New York City, NY

doi:10.1016/j.annemergmed.2009.03.020