Nancy Caroline’s Emergency Care in the Streets 8th Ed Review

Does it hurt when I do this?

Nancy Caroline is a big name in paramedic education – after all, she practically invented it. Her book, Emergency Care in the Streets, was really the first textbook for paramedics. It took some of the important parts of emergency medicine (in a time when emergency medicine wasn’t much of a discipline) and taught it to people from straight off the street. Since then, we’ve had 7 more books in the series, each one adding to the content of the previous one. Dr Caroline herself died between the release of the 5th and 6th edition, and the books have taken on a decidedly different tone since then. Caroline’s first books were fairly conversational and basic in nature; after all, these were people with experience as EMTs and little else. But as education standards have changed (particularly outside of the US, where degrees in paramedicine are more common) the series has often felt dated. Caroline’s “Sidney Sinus” cast of characters might’ve been a good way of explaining heart blocks back in the 80s and 90s, but we’ve moved on from those days. In keeping true to her legacy, has the series been left behind?

The Caroline books have often been held up as the standard for paramedic education; and with good reason. They’re fairly comprehensive, easy to read, and straightforward. But we’ve got other entries these days – Mosby’s Paramedic Textbook and the wonderful Dr Bledsoe’s Paramedic Care series (also called the Brady Books) are in direct competition. The traditional thinking went like this:

  • Caroline: Basic but easy to understand
  • Mosby: Happy middle ground
  • Bledsoe: Highly clinical and harder to read

I’d tend to agree here, except that as a degree-educated paramedic I didn’t find Bledsoe hard to read for its language, but because it’s just a slog through loads of information to get to the good stuff. The last Caroline edition I really looked at was the 6th edition – and it was pretty good, but very dated. How does the 8th edition improve on it? Is it worth owning?

What’s good?

Firstly, there’s overall just more depth to the book this time around. I’ve flipped through the 7th edition and found it largely the same as the 6th edition with a few concessions. The 8th edition is more like a rewrite than the 7th edition. Every section seems to just have more depth to it, mostly in explaining physiology or pathophysiology. There’s too much to really list for changes, but here are the big things I’ve noticed:

  • There’s finally an expanded section on capnography for patient assessment. I think it’s still a little too shallow, especially compared with Bledsoe’s explanation, but the basics are in place. It’s much better than the previous editions where it was essentially only used to confirm tube placement.
  • General airway management advice is expanded. There’s more discussion on identifying difficult airways (e.g. LEMON and the 3-3-2 rule), basic ways to manage difficult airways (like ‘ramping’ the obese patient), and stuff like that.
  • They’ve finally stopped pushing the “everybody gets oxygen and it never causes harm” myth.
  • The Patient Assessment section is simplified; instead of the branching tree in the previous editions, it’s now a straight line with the provision of being able to deviate as dictated by the patient presentation. This is a much better way to promote patient assessment as opposed to “Assess major trauma like this, and a medical patient like this…”
  • There’s more stuff in the cardiology section; it’s now a decent introduction to reading 12 lead ECGs. They finally cover bundle branch blocks, fascicular blocks, and a few other important patterns like benign early repolarisation. There’s not too much discussion of them (or their clinical significance) but it’s not bad.
  • Some of the old, outdated photos have since been removed and replaced with better ones.
  • There are new sections on managing cardiac arrests and the unstable critical care patient; these are great resources for new students and focus on the fundamentals of crew resource management, what’s important in an arrest, and how to properly care for critical patients.
  • There’s a much better Anatomy and Physiology section; although I can’t help but feel scrapping it and getting people to buy a dedicated A&P book is a better idea.
  • It retains a lot of the basics of prehospital care; which is why I really like it. For Australian students who come fresh off the street (with no EMT-B training), this book offers a good perspective on the fundamentals of care plus the advanced aspects. This is why I prefer it over Bledsoe’s book; Bledsoe’s book has more detail overall, but it’s better to read an EMT-B book before running into his (to get some fundamental facts down).

What’s bad?

No book is perfect. The same is true of this book. There are some complaints that I have – although they’re mostly minor in nature.

  • It’s still way too bloody expensive, especially if you want ebook access (and who doesn’t?). The books are over $380 AUD – granted, you can only buy them new right now because it’s just released – and that won’t even get you ebook access. Hypothetically, this could be your only book for the program – but it’s still way too expensive. The books are big, so an ebook would be great; but that costs extra (by a few hundred dollars!). It’s hard to recommend it over something like Bledsoe’s books, which are much cheaper and have an ebook available.
  • Some sections still lack a bit of depth. For example, bundle branch blocks are discussed, but their clinical significance is largely ignored. Same with axis deviations. It’s one thing to recognise a problem – it’s another entirely to understand why it’s a problem.
  • I think there’s a bit too much  in these books these days – the fact that it has to be split over 2 volumes suggests we’re slowly creeping towards the need to stop trying the “all in one” approach to paramedic textbooks.
  • There’s a load of ‘fluff’ chapters, like career development or documentation, that are probably becoming increasingly irrelevant and should be scrapped to cut down on the size of the book. Or alternatively, scrap them and put something better in their place.
  • Online materials aren’t great; their slideshows are fairly basic and have very little information, and their lecture outlines aren’t great either. There’s an audiobook with the basic online access key, but so what? This is a visual book. eBook access is prohibitively expensive.

Overall? Recommended – I guess.

This is probably one of the best paramedic textbooks out there today. It has great content, it’s very easy to read and understand, and overall it’s a good resource for anyone new to paramedicine. It’s more academic than the previous editions, but it still has lots of great little maxims and advice to help novice providers. It’s a great set of books. There’s a lot of information here, all presented in a fairly good way.

But damn, it’s expensive – and it’s very much US-centric. I don’t know if it’s cost-effective for Australian students. Unfortunately, we still lack a decent paramedic textbook; the best attempt (Paramedic Principles and Practice ANZ) is incomplete, and the worst attempt (Emergency and Trauma Care for Nurses and Paramedics) is particularly bad. The latest Caroline book represents an excellent hybrid between the EMT-B and EMT-P books that Australian students could benefit so much from… and yet it’s way too expensive for many to ever get it. The lack of a proper ebook is particularly disheartening, especially when Bledsoe’s books are available.

The cost is by far the biggest issue – for the same price, a student could get Prehospital Emergency Care and Paramedic Care together – which would answer all of their basic prehospital care questions, plus provide much of the same detail as Caroline’s tome – all in ebook format. On top of that, there are further educational expectations for Australian students, usually fulfilled by a medical textbook.

So do I recommend it? Yes. It’s probably the best paramedic textbook around today – especially for Australian students. But it’s ridiculously expensive. Once second hand copies start to become available, it’ll be better priced.


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