Should you get Tintinalli, or a traditional paramedic text?
There seems to be three opinions on textbooks:
- Paramedic textbooks are best, because they’re written for prehospital care
- Medical textbooks are best, because they don’t cut content
- No textbook is worth getting
Typically, I fall into the former camp – because generally speaking, it’s true that a medical text doesn’t translate very well to prehospital care. As for the final camp – I know plenty of students who have never opened a book, and none of them were particularly good. I have no doubt someone can get away with it. But I haven’t met one yet.
So, I figured for this paramedic-related article, we’d take a look at the advantages and disadvantages of both types of books. Note this is written from an Australian perspective where we have a comparatively higher standard of tertiary education (especially in anatomy and physiology) than our US counterparts, so as always, your mileage may vary.
Paramedic books (like Paramedic Care: Principles and Practice or Emergency Care in the Streets) are written specifically with prehospital care in mind. They’re pretty massive tomes these days and cover an awful lot of content; they need to cover a bit of A&P, a bit of pathophys, procedures, assessment, and treatment guidelines for a massive array of conditions (and it gets bigger each year). If you go to paramedic school in the US, you’ll end up eating one of these tomes. That said, most of them assume that you’ve been an EMT-B first; something we don’t have in Australia. As a result, sometimes they don’t translate easily (a lot of the basics are glossed over; the Brady books are especially guilty of this, while the AAOS book is better at it).
So, what’s the advantages of a paramedic book? The biggest one is that they’re written for the prehospital environment – an environment where time, resources and diagnostics are limited. Our most exciting investigations typically fall short of a blood glucose level and end-tidal capnography. Spot-check venous blood gases, or even ABGs, are sometimes available – but this is rare, especially in Australia. Out here, the patient history and physical exam, along with an index of suspicion, remains the best tools for patient assessment. The numbers are important; but the numbers are limited, and often not helpful. As a result, a book that focuses purely on our unique environment gives you the best start for learning about assessment and management in the prehospital environment. Everything in it translates to prehospital care, because it was written for prehospital care providers.
Paramedic books also offer a significant amount of background reading. Pathophysiology is clearly defined. Procedures are illustrated. They often include basic 12 lead ECG interpretation guides. Discussions about how and when to give fluids, what IV fluids do to cells, and extra information about physiological processes punctuate the texts. They provide a lot of information. A lot of it is fairly shallow, but for a fundamental understanding, they do a fairly good job (in general). You don’t have to go looking for too much extra information. Want to know how capnography works? It’s covered. Understanding pathophysiology of septic shock? Yep, it’s there. Figuring out MAP = CO x SVR and CO = SV x HR? All covered.
That said, they aren’t without their flaws. Since they have to include so much information, it inflates the size of the book (or books in many cases) and as a result, lots of information gets left out. Sometimes, information is simplified to make it easier to understand (or of reduced length). Many conditions aren’t really discussed in too much depth, and diagnostic approaches for less common (or more minor) conditions are often short, brief, or sometimes ignored entirely. This is a necessary byproduct of having to cram so much information into the text – and focusing on the big-ticket, critical items. A lot of the basic information (some even include anatomy and physiology sections) may be better left to dedicated books (or other resources). But because they seek to be an all-in-one solution, you’re often stuck with the bigger size and accompanying compromises.
Also, these books by necessity will leave out lots of information about many, many different topics. Because they assume you’re already an EMT-B, they frequently skip over fundamental topics – because you know them, right? Well, if you’re an Australian student, sometimes the silly questions are the big questions. Like: When do I ventilate a patient who is still breathing? When do I know that birth is imminent and should stay on scene? When should I apply a splint and a sling? When do I really need my airway adjuncts versus just rolling them on their side? These are basic questions, but they’re questions that our students often don’t have a good grasp on. Paramedic texts usually don’t cover these to a fundamental level (the exception? Emergency Care in the Streets – the most expensive one).
By the same token, they often don’t over a lot of miscellaneous conditions. Patient says “I feel like vomiting.” Okay… cool, what’s the diagnostic approach for “nausea”? There isn’t one in a paramedic text. Lots of apparently minor ailments or conditions are omitted – because there simply isn’t space to cover them. Similarly, sometimes diagnostic approaches are oversimplified. There’s no book that has an approach to “chest pain” – it’s all under Acute Coronary Syndromes, or Pulmonary Embolism, or whatever other cause you can think of. There’s no real guidance for students on how to decide what the chest pain probably is.
So what do we make of that? They’re great resources for prehospital care and set the fundamental standard expected for knowledge, in my opinion. What they lack can often be augmented by buying a medical book, or by utilising online resources. But why not just skip them and go straight to the source…?
Textbooks like Tintinalli (or the Australian equivalent – Textbook of Adult Emergency Medicine) are now becoming recommended texts, often as replacements for paramedic texts. These tend to be the real-deal, aimed either at EM residents/those looking to take exams, or sometimes other ED staff. They don’t cut corners, they have all the information, and they’re fairly comprehensive. Tintinalli in particular covers an obscene amount of content. They’re written for the hospital environment, though – and they assume a good understanding of A&P, and in many cases, pathophysiology.
So what’s good? Something like Tintinalli contains pretty much anything you can think of, in fairly quick formats. Want to know all about the various causes of headache in the emergency setting? It’s here. Want guidance on differential diagnoses of chest pain? It’s here. Need a diagnostic approach for dyspnoea? Yep, covered. Tintinalli also covers a lot of procedures, has a lot of photos, and contains a lot of information for all sorts of things. It even covers off on some paediatric and obstetric elements. There’s an obscene amount of information here – above and beyond what you’d need to know to be a paramedic.
There’s also no corner cutting. Tintinalli assumes you’ve got a good grasp of anatomy and physiology, and frequently provides only brief overviews of pathophysiology. Sometimes it notes information for those elements, but usually it’s very basic and it’s assumed you’ll go elsewhere for information (and there’s a wealth of information online about it these days anyway). Approaches to diagnosis, treatment, and follow up plans are provided in fairly decent detail (although usually the why of treatment isn’t covered very well). It also doesn’t skip out on minor presentations – things like “my eyes hurt” or “I feel nauseous” have sections to help you identify potential causes and management options. It’s all here.
That said, there are issues with this approach. The biggest, by far, is that this is written for hospital use. It assumes you have access to many investigations. For example – the latest edition of Tintinalli basically states that end tidal capnography isn’t accurate, and seems to question why you’d bother when you can just take an ABG anyway. Except… you can’t do that in your ambulance (probably). Many diagnostic or re-assessment approaches will push investigations to arrive at a diagnosis or an end-point. For example, management of shock looks at more invasive monitoring methods (like CVP or UO), which we simply lack in most prehospital environments. Much of it doesn’t translate well to the prehospital environment.
The other issue is that there’s no basics here. It won’t really tell you when to ventilate a patient, how to assess a patient, reference ranges for vital signs, any sort of prehospital scene management, or lots of other information that you would find in a prehospital care book. Some of that could be augmented by your degree, or by having an EMT-B book (if you can find one cheaply)… or you could get a paramedic book and be done with it. When basics are covered, they’re very light on information – because it’s written for physicians. If you read through this and then were sent to a chest pain, you probably wouldn’t have a good approach to the patient. Things like patient assessment approaches aren’t mentioned, because it’s assumed you learned that somewhere else (e.g. in med school). Lots of physiological processes are only mentioned, and not explained – so it’s assumed you already know what they’re talking about.
These problems can be overcome (to an extent, depending on how diligent you are) by listening very closely to lectures, or by getting another book. The problem is that “another book” often ends up being a paramedic text; at which point, you’ve got both books anyway. My alternative? You’ll need an ECG book, and maybe an EMT-B book – because this would cover all of your fundamentals, all of your basics, in a simple, easy to understand manner. But is it worth it?
My take? Get both!
Honestly, I think you need access to a decent paramedic text during your degree, instead of a medical textbook. It will significantly improve your understanding of a lot of topics that lectures often gloss over (due to time constraints). Blindly following the CPM might pass a scenario, but it won’t help as much in the real world when you’re facing undifferentiated chest pain and no idea what protocol to shove it into. The medical book is nice to have, and I’d still recommend students pick one up if the budget stretches, but the utility of a good paramedic book can’t be overstated. You can get older texts for a reasonable amount too – anything within the last few years is fine, because anything that’s outdated will be covered by lectures anyway.
That said, if you insist on picking up Tintinalli instead of a paramedic text, I’d strongly recommend that you pick up an EMT-B book at a minimum (or an older paramedic text). Tintinalli simply won’t cover off on the basics that you need for prehospital care. Your lectures may cover a fair chunk of it, but more often than not they end up leaving gaps because there isn’t enough time to cover things. Thing is, Tintinalli won’t cover those gaps.
At the end of the day, my two favourite, essential texts are:
- Emergency Care in the Streets (AAOS), because it’s strong on its basics while covering a large amount of paramedic stuff
- Tintinalli, because it’s comprehensive to a fault
If you only managed to get hold of an older AAOS book (even the 6th edition is fine!) then you’ve already got a good start on your degree; and yes, it’ll help when you feel a bit lost or confused. Augment that knowledge with a medical book.
Other texts I recommend:
- Textbook of Adult Emergency Medicine, and Textbook of Paedatric Emergency Medicine. Both are Australian-focused, concise, and well written. Not quite as comprehensive as Tintinalli, but easier to read.
- Oxford Handbook of Emergency Medicine, and Handbook of Clinical Medicine. Very handy reference guides for being on road. The prehospital one is crap though.
- Anatomy and Physiology for Emergency Care. Can be found on Amazon Kindle for a ridiculously low price, and covers the most important A&P stuff.