The Emperor of All Maladies

Siddartha Mukherjee

ISBN 978-1439-107959

Published by Scribner in 2010

In short: An incredibly well done "biography" of a disease that impacts us all uniquely. Mukherjee covers an astonishing breadth of subject matter from Egyptian Imhotep's teachings of 2625 BC indicating, "Therapy: There is none." to the latest advances and theory on cancer. This is the story of ambitious experiment and discovery that is the story of cancer research. And gratitude is paid to the many patients whose lives and deaths added to our current knowledge of this disease.

Cancer has had a profound impact on my life mainly due to significant family history and loss of loved ones to terminal cases. My direct exposure to cancer was well before I had completed any formal training in EMS. My role then was as the son of a victim; a contributor of hope, unskilled care and comfort. Memories of this time burn in my heart with incredible distraction and will be forever unresolved. The wasting of a human being as a result of this disease is something that no one should have to endure or observe. I suppose that is why I approached The Emperor of All Maladies with both trepidation and intense interest.

Mukherjee is a rare author. Many have taken a biography and made a page turner of it. To do so with a popular personality is routine; take a black glossy dust jacket, add a portrait of the subject, splash the title on with gold lettering, and, finally, fill the pages with reflection and anecdote. But in The Emperor of All Maladies, Mukherjee has done it with a disease that can't speak, has countless occurences of the same story, and takes a very poor picture. His subject also benefits from no sympathy or endearment. This is, however, a remarkable story.

Based on the publisher's interview with the author and the introduction of the book, the motivation for it was his own patients. One of them asked him "Where are we in the war on cancer?" Humbled by his lack of a ready answer, he began researching the book. In another interview with the author he notes that he started the work as a history, but realized that it really was a biography: a biography of a disease and the multitudes that have been afflicted by it and worked against it.

There is a constant undercurrent in the book that stresses the importance of cancer patients in our attempts to understand the disease. Even when that patient is an ancient Peruvian mummy showing signs of malignant cancer in her bones the reverence paid is clear. The history of cancer researchers such as Sidney Farber is retold without apology for generally toxic treatment strategies more focused on cure than understanding the disease. In fact, this imbalance between trial and error and intentional design is another common theme on these pages. The other is the dichotomy among surgeons and chemotherapists who often worked insularly without considering the benefit of potential combined treatment which is so commonplace today. Palliative care is given as much credence in this work as surgical, pharmacological and radiological care. Finally, after the long historical road has been traveled, prevention is presented as the best cure.

Of all the patients we encounter in EMS, I find cancer patients some of the most challenging. These are full-time patients; they have seen it all and felt pain way beyond "severe." I find them generally eerily comfortable with mortality and stoic in their needs. I feel inadequate since resolution of their complaints are limited generally to basic palliative care.

The description of various types of cancers and mechanisms of migration found in the book are helpful for visualizing what patients are confronted with. The in-depth coverage of the diverse approaches to cancer research over history is instructive on several counts. Despite a heavy focus on data-driven care and quality improvement, sometimes there simply is no data or no known solution given the data. Trial and error will be required. Sometimes solutions come from completely unexpected sources; like early chemotherapy being derived from an errant mustard gas deployment during WWII.

Coverage of the political and social aspects of cancer research over time are incredibly interesting and instructive. The roles of certain non-medical participants in the nascent field instill faith in humanity and the revolutionary power embodied in one person. The leverage of the burgeoning entertainment industry by the early Jimmy Fund demonstrates that not all big ships turn slowly.

I have high standards for historical writing, and consider Mukherjee a master of this genre. it may be that the subject is close to home, but I suspect it will be close to home for any reader. If you are going to read a book about an awful subject, it better be well written, informative and engaging. And this is.

A Final Arc of Sky: A Memoir of Critical Care

Jennifer Culkin

ISBN 978-0-8070-7329-2

Published by Beacon in 2009

In Short: A glimpse into the life of a critical care and flight nurse. If you're looking for gory details of hairy trauma calls requiring air transport, look elsewhere. These are personal reflections from an EMS worker who has seen and felt a great deal and communicates it well. If you need a reminder that there remains a human side to this vocation, this is the book for you.

Culkin has woven an embracing tale that keeps the reader turning the pages quickly, but thoughtfully. This is personal writing, as if you have received a letter from the author. Whether the topic is a cardiac transport that ends poorly, the awkwardness of being a healthcare professional in the room with a loved one at the hospital, or the grief of losing co-workers in a less than notoriously dangerous field, she offers sound reflection and anecdote that is worthy of attention. Culkin strikes a balance that seems elusive in memoirs between detail (3" tape on her thigh for note taking, loose helicopter door handles and near misses, what music was left on in her deceased co-worker's car) and restrospective knowledge that comes from a career in an intense field.

Landmark: The Inside Story of America's New Health-Care Law and What it Means for Us All

The Staff of the Washington Post

ISBN 978-1-58648-934-2
Published by Perseus:Public Affairs in 2010

In Short: A clear and concise introduction to the Patient Protection and Affordable Care Act of 2010.

The staff at the Washington Post who have been involved in covering the health care reform in the Unite States have compiled this succinct report on how the 2010 health-care reform bill came about and was passed and what is known about what the reform means.

In my opinion, if you are interested in learning what these changes are all about you are left with three options; 1) read the 906 page bill, 2) read / view / hear the collective reporting in mass media or 3) leaf through the 277 pages of this book. I've started #1, have grown incredibly fatigued from #2, and was delighted with the overview provided in Landmark.

I would encourage potential readers to also watch the PBS Frontline episodes "Sick Around America" and "Sick All Over the World" which review the health care systems (good and bad) in several countries. Perhaps not so surprisingly, it appears the reform bill mainly represents political hijacking and was minimally informed by lessons learned in other countries if at all. As the first chapters of Landmark clearly demonstrate as they bring the reader along on the lobbying and vote gathering escapades of congressional leaders, reform and compromise in this case are mutually exclusive. As, e.g., Taiwan, Switzerland, Germany and Japan have demonstrated significant systematic progress in health care will require some near term social and political pain.

By the way if you are hoping to read anything of direct substance about EMS in either the full bill or in this book, you'll be disappointed. As with many things, the devil will be in the details and the details have been deferred. You can rest assured, however, that as reported by JEMS the National EMS Advisory Council (NEMSAC) has provided a position statement on the role of EMS in health care reform.

The Poisoner's Handbook

Blum, Deborah
ISBN 978-1-59420-243-8
Published by The Penguin Press in 2010

In Short: A well written history of forensic medicine in the early 20th century that includes enough anatomy, physiology, pharmacology, and data-driven research to keep this EMT interested.

Deborah Blum has done a tremendous job exploring a significant period of medical history and presenting it in an entertaining and informative manner. It is 1917, in New York City, with Tammany Hall politicians in charge and no one seems to really care why or how people are dying. Charles Norris is appointed as Medical Examiner in 1918 and this book is about how he and his team bring discipline to forensic science (then known as "medical jurisprudence"). Norris is aided in his work by toxicologist Alexander Gettler. Together the two form one of the most obsessive teams in history. Norris and Alexander are classic examples of determination and commitment to data-driven research in the interest of advancing the medical field and preventing illness and disease.

Blum brings the reader along as she follows Norris and the nascent field of forensics in this biologically challenging and often politically frustrating journey to learn more about toxicity within human anatomy. A key player in this story is prohibition, during which the government actually increased the toxicity of alcohol in an effort to scare citizens from drinking.

Some of the toxins explored in this book include:

- Chloroform (ChCl3)
- Wood Alcohol / Methyl Alcohol / Methanol (CH3OH)
- Cyanides (HCN, KCN, NaCN)
- Arsenic (As)
- Mercury (Hg)
- Carbon Monoxide (CO)
- Radium (Ra)
- Ethyl Alcohol / Ethanol (C2H5OH)
- Thallium (Tl)

There may be little of direct relevance to 21st century EMS, but the principles of Norris' research remain as valid today as they did in his time. The review of how different toxins act on human tissue and organs was also fascinating and useful. It is also important to remember that sometimes (contrary to medical training) when you hear hooves they may, indeed, belong to zebras not horses.

Resuscitate

Eisenberg, Mickey S.

ISBN 978-0-295-9889-4
Published by University of Washington Press in 2009

In Short: "How Your Community Can Improve Survival from Sudden Cardiac Arrest" and how your EMS system can use sudden cardiac arrest survival performance as a metric for quality improvement.

Should victims of sudden cardiac arrest expect reasonably similar chances of survival (mentally intact discharge from the hospital) regardless of where they arrest? Does an EMS system's performance measured in terms of treatment of sudden cardiac arrest provide a means of measuring overall system efficacy?

Dr. Eisenberg knows a thing or two about survival following suddent cardiac arrest and the findings from his practice as medical director in King County and Seattle and his research nationwide is startling. Furthermore, he lays the story down in a very readable (and guided) fashion that fits equally well in the hands of doctors, EMT's, dispatchers, public safety administrators and politicians.

Survival from witnessed V-fib arrests in King County, Seattle and Rochester, MN approach 50% whereas the national average is somewhere near 10% (with some areas below 1%). Why the disparity? Many factors are involved and they don't all involve EMS in the field. Rethinking the scope of EMS (e.g. to more closely integrate dispatch, medical control, patients, bystanders and preventative care) is a start. Redefining "success" is a another. Both would be well served by a foundation of data collection and review.

Still not conviced you should read this book? Check out the podcast with the author.

Josie's Story

King, Sorrel

ISBN 978-0-8021-1920-9
Published by Atlantic Monthly Press in 2009

In Short: I believe this is quality improvement (QI) in its most heart wrenching, systematic, civilian, and effective form. A must read for anyone who lays hands on another human being.

Josie King was an 18 month old who died due to a medication error while hospitalized for burns. The story (and error) did not involve EMT's or out of hospital care, but the story is one we should all read and the resulting initiative is one we should all embrace.

Josie's Mother, Sorrel, has made it her life's work to not let her daughter's death be for naught. She founded the Josie King Foundation with the mission "to prevent others from dying or being harmed by medical errors. by uniting healthcare providers and consumes, and funding innovative safety programs, we hope to create a culture of patient safety, together."

One example of an initiative stemming from the foundation is the "Condition H" call at University of Pittsburgh Medical Center. "H" stands for help. Described as a "family life line" this program allows patients and their families to signal a need for a rapid response team at their bedside to review the plan of care or any other issue that they feel has not been adequately addressed.

Pain: The Science of Suffering

Wall, Patrick
ISBN 978-0-231-12006-0
Published by Columbia University Press in 2000

In Short: A great additional read for anyone who just didn't get enough out of your certification courses or continuing medical education regarding the mechanics of pain and current practices.

Wall provides a thorough and well-paced review of the anatomy and physiology of pain before continuing into current philosophy and treatment. Weighing in at a mere 175 pages, this book is densely packed with information and even some practically useful knowledge.

Think you have it covered on quality and severity assessment using dull / sharp and 1-10? Ever have a patient describe pain as "bright?" Wall provides an illustrative matrix of about 60 pain descriptors plotted against a severity scale based on research findings.

This book is chock full of case studies and anecdote along with reviews of research and summaries of specific disease related pain mechanisms. Wall also explores pain in patients without any obvious source.

In one of the later chapters, Wall emphasizes the need for action when another human being is in pain. "It is a mystery to me why first aid is not taught to everyone in school. Biology is taught and children end up able to name dinosaurs and identify pistils, stamens, and anthers on a flower, but they cannot tell you what blood is for and why we pee. The aim would not be to produce a gang of overconfident doctors: we have enough of those. It would be sufficient if we grew up with an intrigued awareness of our own bodies in health and an unflinching willingness to offer a hand to others in trouble."

My Stroke of Insight

Taylor, Jill Bolte

ISBN 978-0-670-02074-4

Published by Viking in 2008

In Short: A neuroscientist brings the reader along on a memoir of her own stroke and recovery.

In some ways, patients with suspected strokes are incredibly challenging to me. This is particularly true when communication is difficult. Jill Bolte Taylor takes time in this recounting of her own stroke to emphasize the comfort provided by an EMT that spoke softly, confidently, and continuously without any feedback from her. She heard every word, but was unable to respond and needed the input from this EMT to help her confused and oxygen starved brain make sense of what was happening.

As a neuroscientist, Taylor is able to tell her story in a unique and detailed manner. She also tells the story as if she is writing a journal about a recent trip abroad. Its eerie, but fascinating. A combination of prescient knowledge, coincident observation and retrospective reflection is woven into a story that gets to the heart of the patient experience.

Remember, you are heard sometimes when it doesn't seem you are. Remember that the little things matter. A hand on a shoulder, a reassuring voice, eye contact. It matters.

Medicine for the Outdoors

Auerbach, Paul S.

ISBN 978-0-323-06813-0

Published by Mosby Elsevier in 2009 (5th edition)

In short: Principles over practice. Adaptive EMS at its best.

A must have for anyone practicing in a rural area, or anyone who spends time away from the conveniences of ambulances, ER's and on-line medical control. Auerbach has compiled an impressively comprehensive tome of outdoor medical knowledge, skills, and practice.

Among the more extreme skills, there are also a number more immediately applicable skills. The book includes section about how to:

* control the airway by attaching the tongue to the mouth with safety pins,

* fashion an improvised CPR mouth to mouth barrier from a surgical glove,

* improvise C-spine stabilization with common materials,

* provide "sutures" with hair and string,

* splint and sling anything with anything (yes, more safety pins),

* provide prolonged traction as needed without a traction splint,

* close wounds,
* apply advanced bandaging (many examples with illustrations),
* identify potentially harmful insect and reptile bites using a variety of techniques,

While this book can be read cover to cover with interest, its value is likely to be as a reference. This is the book to pick up before that group hike or other outdoor adventure in which you're sure to be the only one with EMS training. If you pack light enough, you might even want to bring it along.

Cheating Death

Gupta, Sanjay

ISBN 978-0-446-50887-2

Published by Wellness Central in 2009

In Short: Some things hitting protocols now, some things 20 years out, some things that remain unexplained.

Yes, this is by "the" Dr. Sanjay Gupta. This is an easy read providing a lay overview of relatively current findings related to theraputic hypothermia, compression only CPR, suspended animation via hydrogen sulfide exposure, near death experience, spontaneous recovery from "brain death", fetal heart surgery, and miracles.