Questions and Answers about “the new 7th Edition, Tintinalli Study Guide” with Judith E. Tintinalli, MD, FACEP, editor-in-chief, and ACEP members

Judith E. Tintinalli, MD, MS, FACEP Department of Emergency Medicine University of North Carolina

What is the vision for the new edition? Robert W. Strauss, Jr., MD, FACEP

It’s directed to a global EM audience. More than 400 authors and co-authors from nearly 20 countries. It has a comprehensive view of EM to include the largest variety of conditions seen in the ED we could reasonably put to paper; and also provides information on transition from ED to observation, ambulatory, and inpatient settings. Expanded information on procedures. Selected procedure videos from the ACCESSEmergency Medicine.com video procedure collection.

We have focused on the clinical problems in the boundaries of the Emergency Department itself. We have added one chapter, ‘Legal Issues in Emergency Medicine,’ because a knowledge of those principles is important for clinical practice. We continue to believe the most important element of emergency medical care is good, common-sense clinical practice, and we have tried to provide that information.

And what is ACCESSEmergency Medicine.com? Robert W. Strauss, Jr., MD, FACEP

It’s the McGraw-Hill digital emergency medicine library, which contains the key McGraw-Hill textbooks in digital form on one site – besides Tintinalli's EM, it includes the Reichman procedures text, Goldfrank's toxicology, the Knoop Atlas, Shah-Lucchesi’s Pediatric Atlas, Simon’s orthopedics text, Ma’s Ultrasound text, and others, plus a large collection of procedure videos and animations. A very large collection of ultrasound videos, useful for both teachers and learners. The site also includes article updates, managed by Sandy Werner and Matt Lewin. Future plans include the digital development of the EM Residency Curriculum, managed by Mary Jo Wagner and Kevin Biese, and ACEP-Cat I CME based on the procedure videos.

ACCESSEM also includes a classic drug formulary and search capability.

What percentage of the chapters contain new information? Any new authors? Kevin M. Klauer, DO, FACEP In general a great deal of the material is new and we have also added new information, new chapters, or reorganized chapters to fit the flow of clinical practice. For example, the Cardiovascular Disease section contains chapters on Chest Pain: Cardiac or Not; Acute Coronary Syndrome, Cardiogenic Shock; and Low Probability ACS Syndromes. The Endocrine Emergencies section contains new chapters on Type 1 Diabetes and Type II Diabetes, in keeping with the universal and exponential increase in these diseases. We have more extensive and current references, as well. For example, the last reference I’ve just added (as of this writing, May 31) was published in Academic Emergency Medicine in May 2010. We have tried to make sure that new professional society guidelines have been incorporated into the 7th edition, but that is not always possible due to the inherent time deadlines of publication.

There are well over 400 authors and, regretfully, I can’t keep track of all of them. My co-editors, Steve Stapczynski, John Ma, David Cline, Rita Cydulka

and Garth Meckler have recruited many of the new authors. It is important to have new authors, especially experienced ‘junior’ faculty, because they come with contemporary ideas. And of course as our editors move (Steve has moved from Kentucky to Arizona and John from Kansas to Oregon), or are added to our team (Rita Cydulka at Case Western, Garth Meckler at Oregon) they bring new and valued contributors.

We have greatly expanded the pediatrics section, because pediatric EM care is such an important part of emergency medicine. There are about 35 pediatric chapters, including pediatric procedures, presented with in-depth and contemporary information.

What has changed about how the user interacts with this edition? Kerry B. Broderick, MD, FACEP One thing I always say is – I can’t predict the future. However, I have noted how many of my colleagues still look up information from old editions – using the 4th and 5th editions as a contemporary source of information. It is important for all of us to make sure we keep up with new developments in our specialty, and using the 7th edition is one way to do that—for the present. We will see what innovations users may think of for the web-based edition. We have had some ideas and discussions about that, but no current plans for active ‘interactions’.

How does a printed textbook “fit in” in this electronic information era? Kenneth C. Jackimczyk, MD, FACEP

This is of course the BEST question and has preoccupied me for some time. I believe that certain elements, like the procedure videos, need to be provided as part of hand-held mobile technology – rather than on desk-top technology. Quick drug information is already used by house officers using hand-held technology. Two years ago, I gifted our EM residents with subscriptions to ACCESS EM, and guess what—even the most ardent digital users wanted a real book to hold in their hands—they wanted a real, not virtual, reference source. And then they said – “but Dr T, you can’t sign ACCESS EM for us, we want you to sign our book!”

And I think international users also are, for the moment, more comfortable with the printed textbook.

But all this is in transition and digital use is dependent on issues such as cost, affordability, access, transportability between different user applications, etc.

We tried to decrease the size of the 7th edition (unless you want to use it for weight training) while increasing the volume of material. So references will be provided on a DVD, which will also contain 15 selected video procedures, accompanying the text.

We actually have two 7th edition versions – a web version and a print version. We have edited some material out of the print version for space considerations and also because some material (background, epidemiology, pathophysiology) was not as important for the clinical user—but it is still available on the Web for the ‘scholarly’ user. This illustrates another advantage of the digital version, where in general, length is not as important, and of course, ‘weight’ is not a consideration. Also, some chapters will be available only on the Web.

And of course, digital technology allows for continuous or near real-time updating of key information. We have discussed that implementation but haven’t quite formalized it yet.

Are there any differences between the chapters that are on the DVD and those that are in the text? How were those chosen? Michele Dorfsman, MD, FACEP In order to prioritize clinical information as well as to keep the size of the 7th edition manageable, certain chapters will be available only on the Web version/DVD. These are primarily chapters that provide background information or are focused to specific environments. Examples of such chapters on the Web but not in print include ‘Common Chemotherapeutic Agents,’ ‘Orthopedic Devices & Reconstructions,’ ‘Prison Medicine,’ and ‘Military Medicine.’ And the section ‘Principles of Imaging’ is provided Web-only.

Is ultrasound included in the DVD? Michele Dorfsman, MD, FACEP

We have the ability to provide 15 procedure videos from ACCESS EM on the accompanying DVD. Most/many of them focus on ultrasound. They are very good, and I have learned techniques myself from these videos. The goal of the videos accompanying the 7th edition is the use of real patients or cadavers, to better approximate clinical situations. Most of the US videos were done by Sandy Werner, Don Hagerty, and Jessica Resnick, and the airway/respiratory videos were done by David Cline and Henderson McGinnis.

What new aspects of international medicine are included in the international medicine section? Michele Dorfsman, MD, FACEP Mostly we have tried to accommodate the international practice of EM by recruiting superb international authors. Our international authors have gifted us with great writing skills and a solid knowledge of clinical EM. What I have learned through all my travels is that EM is practiced the same all around the world. There, of course, are accommodations for different cultures and different resources—but EM is really a global specialty now—practices are similar around the world.

What impact do you think the textbook has had on emergency medicine in other countries? Kenneth C. Jackimczyk, MD, FACEP

My international friends have told me it has had very great impact on EM in other countries. They always say ‘I slept with Tintinalli’ when they fell asleep reading the book, the weight crushing their chest! It has been used to define board examination content in other countries. But seriously, in other countries without faculty support or any individuals knowledgeable in EM, my colleagues tell me they had to look up (in the Study Guide) what exactly to do during their ED shifts.

The other way the book has helped is that it defines the scope of practice and the knowledge content of EM. So it convinces Deans, Health Ministers, and

other big shots that EM is true, it is real, and it is a tangible specialty different from any other. I’m proud to say that there are many language translations over the years, Mandarin Chinese, Italian, Spanish, Polish, Turkish, etc.

Does the new Study Guide address more recent additions to residency curricula such as bioterrorism, rural emergency medicine, and ultrasound-guided procedures? Jennifer M. Casaletto, MD We continue to have sections on Prehospital Care and Disaster Preparedness that cover the basics for the general EM resident. Some ‘subspecialties’ that are outside of the boundaries of the Emergency Department itself, like disaster medicine, bioterrorism, and EMS are so large in scope that complete coverage requires separate texts and resources. As far as ‘rural emergency medicine’ goes, we do describe indications for transfer in many chapters, but otherwise the clinical practice is the same. Ultrasound teaching and practice is best provided not as static images but as videos which show how exactly to place the transducer and how things look when you move the transducer or change its orientation. So we continue to add videos on ultrasound-guided procedures. Production of each US video usually takes months and months, and requires a lot of effort by the medical directors to make sure that the steps are clear to both teachers and learners.

But I believe education in procedure performance itself is lacking. I’m sure you are just like me – see one, do one, teach one—or even worse, told how to do it or guess how to do it, and then just do it. We have tried to organize procedure videos step-by-step so that the performance of the procedure is correct, not just the outcome.

What national disasters are covered? Michele Dorfsman, MD, FACEP There is one chapter on Natural Disasters and another on Bomb, Blast, and Crush Injuries. The Natural Disaster Chapter does discuss hurricanes,

earthquakes, and tornadoes. The chapter on Bomb, Blast, and Crush Injuries complements the other chapter.

Judith, with the world of EM and its scope growing, how were you able to still keep this comprehensive review in one volume? Kevin M. Klauer, DO, FACEP We have tried to do very tight editing. I have myself edited about 90% of the entire book and Steve Stapczynski has done the rest. We have similar editing styles. My original idea behind the Web and print versions was to provide a way to keep the book one volume. Chapters are often interrelated so it is easier to keep everything under one cover in print. We have done our best to keep all significant and substantial material in the print book. We have saved a lot of space by putting the references on a separate DVD. It’s not like one can directly go from the print book to PubMed anyway. And one could print out the reference list for key chapters, if one wanted to. But of course using the Web version will allow hyperlinks to references and videos in the collection.

Judith, what excites you most about this edition? Kerry B. Broderick, MD, FACEP Well, mostly it makes me SO proud of Emergency Medicine and my colleagues in the U.S. and around the world who teach and practice our specialty. Because the book reflects what we actually do and what we have to know to practice good Emergency Medicine. It gives me great joy to be part of this worldwide movement.

It (working on this new edition) has been four years of – well – mostly intense interesting work. The book is in color, with an interesting layout. All the work on this edition has been totally digital. And, imagine the fun of corresponding with authors in countries such as Australia, Israel, Malaysia, Saudi Arabia, Italy…

This interview was made in June 2010 by the ACEP Educational Publications Department for their Fall 2010 Catalog featuring the new Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7th Edition. For a copy of the catalog, please contact ACEP at 800-798-1822, ext. 4. (All ACEP members will receive a copy in the mail in early October.)