Elsevier

Resuscitation

Volume 60, Issue 2, February 2004, Pages 129-136
Resuscitation

Do textbooks of clinical examination contain information regarding the assessment of critically ill patients?

https://doi.org/10.1016/j.resuscitation.2003.09.009Get rights and content

Abstract

We postulated that some of the reported deficiencies in trainee doctors’ knowledge of acute care might be due to the quantity and quality of available information about the examination and clinical assessment of critically ill patients in commonly used medical textbooks. Using an agreed assessment system, 30 routinely available texts of clinical examination were reviewed. None of these contained a section devoted specifically to “assessing the critically ill patient” and few could be regarded as giving a comprehensive, systematic description of an assessment system suitable for use with the acutely ill. In general, descriptions of how to assess airway patency were rare, with only one describing how to differentiate partial from complete airway obstruction. Only four of the texts mentioned that measuring the respiratory rate would be useful in critically ill patients and the assessment of capillary refill time was poorly covered. Use of the AVPU scale to describe neurological status was found in only 3% of texts, and there was poor description of the clinical significance of hypotension, tachycardia, oliguria, hypothermia and pyrexia. We conclude that the current texts available to medical students and junior doctors do not provide sufficient information regarding the assessment of critically ill patients.

Sumàrio

Admitimos que algumas das deficiências referidas pelos médicos em formação no que se refere ao conhecimento dos cuidados com doentes agudos pode ser devidas à quantidade e qualidade da informação sobre exame e avaliação clı́nica do doente crı́tico nos livros de texto médico uso corrente. Revimos 30 livros de texto de uso corrente, utilizando um sistema de avaliação uniforme. Nenhum continha uma secção dedicada especificamente a “avaliar o doente crı́tico” e poucos tinham descrição aprofundada e sistemática de um sistema de avaliação apropriado para a avaliação do doente gravemente doente. Em geral são raras as descrições de como avaliar a permeabilidade da via aérea e só um refere como diferenciar a obstrução total e parcial. Só quatro textos referem a importância da medição da frequência respiratória, no doente crı́tico e a referência à avaliação do tempo de preenchimento capilar é muito pobre. A utilização da escala AVPU para descrever o estado neurológico foi encontrada em apenas 3% dos textos, e existia uma descrição pobre do significado clı́nico de hipotensão, taquicardia, oligúria, hipotermia e pirexia. Concluı́mos que os livros de texto actualmente disponı́veis para os estudantes de medicina e para os médicos junior não fornece informação suficiente relativamente à avaliação dos doentes crı́ticos.

Resumen

Postulamos que algunas de las deficiencias en el conocimiento de los doctores en entrenamiento acerca de cuidados agudos puede ser debido a la cantidad y calidad de información acerca de el examen y evaluación clı́nica de pacientes crı́ticamente enfermos en los textos usados comúnmente. Se revisaron los 30 textos de examen clı́nico rutinariamente disponibles, usando un sistema acordado de evaluación. Ninguno de estos contenı́a una sección dedicada especı́ficamente a “evaluación del paciente crı́ticamente enfermo” y muy pocos podrı́an considerarse como que entregan una descripción comprensible, sistemática de un sistema de evaluación adecuado para usarlo con pacientes agudamente enfermos. En general, fue infrecuente encontrar las descripciones de cómo evaluar la permeabilidad de la vı́a aérea, con sólo uno de ellos describiendo como diferenciar la obstrucción de vı́a aérea parcial de la total. Solo 4 de los textos mencionaron que podrı́a ser útil medir la frecuencia respiratoria en el paciente crı́ticamente enfermo y la evaluación del tiempo de llenado capilar estaba pobremente cubierto. El uso de la escala de AVPU para describir el estado neurológico fue encontrado solo en el 3% de los textos, y habı́a una pobre descripción del significado clı́nico de la hipotensión, taquicardia, oliguria, hipotermia y pirexia. Concluimos que los textos actualmente disponibles para los estudiantes de medicina y médicos jóvenes no entregan suficiente información acerca de la evaluación de pacientes crı́ticamente enfermos.

Introduction

It is apparent that the management of many critically ill patients can be improved with the result that some cardiac arrests, deaths and unnecessary intensive care admissions might be avoided [1], [2], [3], [4]. Suboptimal care has multifactorial origins, but the education of doctors and their preparation for practice may be particularly important [5], [6], [7]. Recent publications have shown significant deficiencies in the knowledge of junior doctors with respect to the assessment and management of critically ill patients [8], [9], [10], [11], [12]. This may result from lack of appreciation of its importance, inadequate training in acute care at medical school, insufficient clinical experience [5], [6], [13], [14], failure of medical school to prepare trainees for future work [15], the absence of a true apprenticeship or, perhaps, a lack of information about the recognition and assessment of critical illness in textbooks. A recent publication has demonstrated deficiencies in information for medical students on musculoskeletal examination skills in commonly used textbooks of clinical examination [16]. We conducted a similar study to assess the amount and accuracy of information regarding critical illness in textbooks of clinical examination and assessment commonly used by medical students or pre-registration house officers.

Section snippets

Materials and methods

Prior to the commencement of the study, the authors agreed a checklist of clinical signs and measured variables, important in the understanding, detection and investigation of critical illness (Table 1). These followed the standard ABCDE (airway, breathing, circulation, disability, exposure) system of assessment taught on the advanced life support (ALS) [17], advanced trauma life support (ATLS) [18], care of the critically ill surgical patient (CCriSP) [19], immediate life support (ILS) [20]

Results

Thirty books, with publication dates between 1982 and 2002, were studied (see Appendix A). Twenty-two of the 30 texts (73%) studied had been published between 1996 and 2002, with eight (27%) having a publication date since 2000. In four cases, the latest edition of the chosen book was unavailable and, hence, the previous edition was evaluated. The results of comparing the books with the predetermined contents list are summarised in Table 3, Table 4.

Discussion

Irrespective of the diagnosis, clinical deterioration is always accompanied by abnormalities of airway patency, breathing, circulation and consciousness. The ability to prevent deterioration, and subsequent cardiac arrest, requires that these abnormalities be recognised early. Despite the UK General Medical Council’s stipulation that medical graduates must know how to recognise and manage acute illness [23], few UK medical students or trainee doctors have the opportunity to receive formal

Conclusions

Current textbooks of clinical assessment and examination available to medical students and junior doctors do not provide sufficient information regarding the assessment of critically ill patients. We recommend that the authors of these texts consider the inclusion of information regarding the generic signs of acute illness.

Acknowledgements

The authors wish to thank the librarians of the Portsmouth Hospital libraries, the Wessex Region inter-hospital library loan service and the British Medical Association library for their help in locating the texts evaluated in this study.

Conflicts of interest: Gary Smith is a co-designer of the ALERT™ course.

References (27)

  • R Remmen et al.

    Can medical schools rely on clerkship to train students in basic clinical skills?

    Medical Education

    (1999)
  • A Jones et al.

    How well prepared are graduates for the role of preregistration house officer? A comparison of the perceptions of new graduates and educational supervisors

    Med. Educ.

    (2001)
  • G.B Smith et al.

    Knowledge of aspects of acute care in trainee doctors

    Postgrad. Med. J.

    (2002)
  • Cited by (0)

    View full text