Book Review

Acute Care Surgery: Principles and Practice

N Engl J Med 2007; 357:1454-1455October 4, 2007

Article

Acute Care Surgery: Principles and Practice
Edited by L.D. Britt, Donald D. Trunkey, and David V. Feliciano. 832 pp., illustrated. New York, Springer, 2007. $169. ISBN: 978-0-387-34470-6

This book had its genesis in the emergence of a newly defined discipline within general surgery. Acute care surgery integrates the long-established field of trauma surgery with the management of general surgical emergencies. Traditionally, management of nontraumatic emergency conditions requiring surgery has been entrusted to both general surgeons and surgical subspecialists, depending on the supply and availability of these surgeons in each hospital. As surgical subspecialties have multiplied and matured, there has been a peculiar decline in the availability of surgeons who will provide emergency care, particularly during off hours. This phenomenon seems to be related to the reluctance of some surgeons to provide elective or emergency care to patients whose diseases have become the province of subspecialists.

To address this important gap in the delivery of care, the editors of Acute Care Surgery — all of whom are experienced and highly respected trauma surgeons — have assembled more than 100 authors to write a book that addresses “the full-spectrum of surgical emergencies.” The first section, “General Principles,” provides a sound foundation for general surgeons who are in practice or in training. The chapters on initial assessment and resuscitation, operative approaches, and perioperative care are comprehensive and well organized. Particularly valuable are the tables that highlight important technical steps and possible decisions in various situations. The chapters devoted to thermal injuries, management of mass casualties, and care provided before the patient arrives at the hospital are somewhat typical of books on trauma care. The challenging problems of caring for elderly patients and delivering emergency care in rural settings are particularly pertinent to the theme of the book.

The second section addresses problems through a series of chapters focused on specific areas of the body. Unfortunately, some chapters are not consistent with the theme of the book and gravitate to comprehensive discussions of nonemergency conditions. Others seem to reflect the interests of their authors and underemphasize important nontraumatic emergencies. For example, vital topics such as the challenging intubation of an airway and the management of pancreatic necrosis are not sufficiently addressed. The difficult task of finding the appropriate blend of information about scientific principles, diagnosis, and treatment for emergency surgical problems is accomplished much better in this book for topics that are related to trauma.

Each chapter in the first two sections begins with a case scenario and a multiple-choice question related to the case. The answer is provided at the end of the chapter. Although this is meant to stimulate the reader, a single scenario does not do justice to the breadth of conditions that are covered in each chapter. Once again, questions related to trauma dominate.

Issues of informed consent, advanced directives, organ procurement, ethics, and the implications of the Emergency Medical Treatment and Active Labor Act are important areas of concern in all aspects of surgical care. Here the book excels not just by including these topics but also by making clear their relevance to the subject matter. In contrast, the chapters that present perspectives on emergency surgical care in the United Kingdom, Australia, and Japan do not offer much new information. The inclusion of a Scandinavian country or a developing nation might have generated more interest.

The book recommends the development of an emergency surgical care system based on the existing trauma system in the United States. This may be a sound model, but the critical issues of resources and support — the linchpins for the development and sustainability of such a system — are not addressed.

Acute Care Surgery is aligned with the recent series of reports by the Institute of Medicine on the crisis in emergency care. The field of acute care surgery is in its infancy, and this is reflected in some of my criticisms of the book. But these shortcomings are offset by a number of outstanding contributions as well as by the overall value of this book for those who are interested in the emerging field of acute care surgery.

Mark A. Malangoni, M.D.
Case Western Reserve University, Cleveland, OH 44109