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I was very keen to read this book—mainly because I have heard one of the authors state publicly that stroke patients are being transported by air ambulance to emergency rooms in parts of California and I was wondering whether he would advocate this in print. Sadly the nearest he got was “The message to the public is simple: the goal is to take the patient to the emergency room as fast as possible using emergency medical transportation and transfer the patient to a hospital that has brain imaging tests available on a 24 hour a day 7 day a week basis.” Not quite, but the tenor of the book is described —controversial, not overtly dangerous but rather premature, and, for most parts of the United Kingdom, a work of fiction (at least for the moment).
It is one of those slimline varieties meant for the white coat pocket and is obviously aimed at the emergency room doctor eagerly awaiting an acute stroke patient to be flown in, scanner and thrombolytic infusion ready to go. The relevant chapter is right in the middle of the book and for anyone involved in the day to day care of stroke patients it is fantastic, just like the famous “brain attack!’ episode of the television series “ER”. There are tables describing how to monitor patients, how to administer TPA and how to set up labetalol or sodium nitroprusside infusions for hypertension poststroke. Sandwiched between are rather more ordinary notes on prevention, stroke units (one page), transient ischaemic attacks, and diagnosis of the stroke syndromes plus the basic management of subarachnoid haemorrhage and intracranial haemorrhage (with a rather worrying table on the acute management of haemorrhage post-thrombolysis !).
Perhaps the most practical chapter is on the diagnosis and evaluation of patients with stroke which is full of helpful tables but again basically designed as a screening tool for patients suitable for thrombolysis. The text is full of “Americanisms” such as “bronchopulmonary toilet” which I found very amusing and kept me reading in places rather like a Bill Bryson.
The worst chapter is on the imaging of the brain and blood vessels and here the book could have been much better. Most of the CT brain images are overexposed and on black and white paper. Although there are arrows indicating to the reader where to look, most of the scans are uninterpretable. Obviously this is a key area in making treatment decisions with thrombolytic drugs and I was disappointed that this was not done better.
Unfortunately the last few chapters are brief add-ons and could have been left out—a rather impractical section on neuroprotection and a miserly three pages covering rehabilitation and discharge planning.
This book rides on the edge of the evidence and is certainly the “Californian way”. The authors are to be congratulated for their campaigning zeal for the emergency management of stroke which some of us hope will become more widespread. However, it could be argued that at the present time a more useful practical stroke guide would cover how to set up a neurovascular clinic and stroke unit, how to overcome resistance to change, how to participate in or set up large multicentre trials etc. Whether you read this book will largely depend on your point of view.
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