Primary survey Highlights from the January 2015 issue. Mary Dawood, Editor


A mask tells us more than a face (Editor’s choice)
As ED clinicians we often pride ourselves on recognising the sickest patients by how they look, this skill is tacit and one that is the result of experience and longevity in emergency care. Our psychiatric colleagues have long accumulated significant research into disturbances in affect recognition in patients with mental illness, so I was intrigued to read in this issue a study by Kline and colleagues from the US which explored the variability of facial expression in patients with serious cardio pulmonary disease in emergency care settings. They found that patients with serious cardio pulmonary disease lacked facial expression variability and surprise affect. They suggest that stimulus evoked facial expressions in ED patients with cardiopulmonary symptoms may be a useful component of gestalt pre-test probability assessment. So, there may be some substance in one of the many satirical remarks made by Oscar Wilde that “A mask tells us more than a face” though I doubt his context was clinical.

It’s not the age that matters
Accurately measuring weight in children presenting to the ED is essential and particularly crucial in resuscitation situations where interventions and drug dosages are calculated by weight. The APLS formula, 2× (age+4) has been widely used in western ED’s, but as obesity in our young people is becoming more common and children are taller than previous generations , this formula may fall short in terms of accuracy and patient safety. An alternative formula (3×age)+7 by Luscombe and Owens (LO) has been suggested as more accurate than the APLS formula. Skrobo and Kelleher in Cork University Hospital Ireland undertook a retrospective study of 3155 children aged 1–15 years comparing both formulas to identify which one best approximates weight in Irish children presenting to the ED. They conclude that the LO is a safe and more accurate age based estimation over a large age range. Maybe it’s time to review our practice but do read this paper and weigh up your own thoughts, no pun intended!

Not all suffering is pain
Pain is the commonest reason patients attend the ED. Our sometimes lack of appreciation and subsequent under-treatment of pain is often a source of distress and dissatisfaction which can result in uncharacteristic behaviour. However not all suffering is pain and we may find ourselves wanting when the cause of distress is emotional rather than physical. This issue features a prospective cohort study by Body and colleagues in Oxford which sought to describe the burden of suffering in the ED. Of the 125 patients included in the study many reported emotional distress particularly anxiety as well as physical symptoms. Indeed only 37 patients reported that pain was causing their suffering. It should not come as any surprise that being seen, information, reassurance, explanation, care by friendly staff and closure were the key themes reported as relieving suffering. This approach just represents best practice but in the mounting pressures of ED’s worldwide it is all too easy to lose sight of the person and their need for compassion and understanding. Dismissing emotional suffering as perhaps someone else’s problem is detrimental to our patients and ultimately ourselves. Do read this paper; it is a timely and salutary reminder of what we should be about, why we do the job we do and what patients expect of us. There is also a podcast with the Editor in Chief and the author. Find this online alongside this issue.

Best evidence or clinical acumen (Readers’choice)
As demands for emergency care and acuity of patients presenting continues to rise globally, ED clinicians are increasingly faced with making decisions to discharge patients from high acuity areas of the ED. Patient safety and well being should govern any decision to discharge a patient but many cases are complex and weigh heavily on clinicians making such decisions. Calder and colleagues in Canada conducted a real time survey of experienced ED physicians to determine how they perceive their discharge decisions and the impact on adverse events. The authors concluded that ED physicians in their study most often relied on clinical acumen rather than evidence based guidelines and that neither approach was associated with adverse events. They recommend further research which focuses on decision support solutions and feedback interventions.

The greater good
Pulmonary embolism (PE) is a leading cause of death in pregnancy and the post partum period and a devastating event for mother and baby. When accurately diagnosed and treated the risk of an adverse outcome is low. In this paper Goodacre and colleagues explore the options for imaging and discuss the evidence for using clinical features and biomarkers for the selection of women for imaging. Their review of the literature suggests that the harm of investigation with diagnostic imaging may outweigh the benefits but that clinical predictors could be used to identify women at higher risk who could be appropriate for imaging. They also state the need for further research around clinical predictors and particularly the use of D-dimer at a pregnancy—specific threshold.

Pearls of wisdom
There is little doubt that the emergency department is a quite unique environment that offers abundant opportunities for learning. Seizing and exploiting these opportunities is not always as straightforward as we would like it to be. The constant pressure to manage multiple patients and make decisions to refer, admit or discharge against the backdrop of a ticking clock often mitigates against the teachable moment however genuine our desire or commitment to teaching is. It’s easy to feel impatient and exasperated by the seemingly slow pace of some learners when you are trying to maintain safety in a crowded department. On the plus side, however, learning in such an environment can instill a sense of urgency, something that cannot be learnt from a textbook. Nonetheless teaching and learning is integral to all our roles and so it was refreshing to read in this issue “Top 10 ideas to improve bedside teaching in a busy emergency department” by Green & Chen from California. We have probably all used some or all of these methods to teach in different circumstances but the authors imaginative use of a framework, of ‘mnemonics’ and easy to remember names such as “Aunt Minnie” and “Snapps” is amusing and lighthearted. In reading this paper, you may just find that pearl of wisdom for the next teachable moment.


Mary Dawood

The view from the F2…..

The view from the F2

As an aspiring emergency physician I have been keeping a close eye on the latest media frenzy regarding the NHS crisis. My own feeling is that from working in the NHS over the Christmas and New Year period is that the hospitals are considerably busier than this time last year.

Headlines such as ”hospital declares ‘major incident’ in NHS A&E crisis”1 have become common place and mutterings from GPs, consultants and juniors alike are saying the NHS is at breaking point.

Is it clear that the A&E departments across the country are facing an unprecedented number of admissions than ever. It is worrying that the strains demonstrated by hospitals declaring themselves as ‘major incidents’ could indicate the demise of the NHS , unable to cope with the extra demand.

Why is this? I wish to explore this topic and discuss some of what I believe to be the most crucial contributing factors to this NHS crisis.

I have asked myself, my colleagues and scoured the reports on this ‘ NHS crisis’. Why has there been such a high demand on the NHS this winter? What can I or my colleagues do to alleviate this?

The following are some of contributing factors which I believe have placed the NHS under more strain than ever. I have also discussed action plans that we as physicians could implement to try to alleviate some of these pressures.


  1. Ageing population: Medical advances have allowed an extended life expectancy for our population. 30 years ago a myocardial infarction carried a mortality rate of over 40%, now with advances such as PCI, time limits of 60mins from onset of chest pain to catheter table , cardiac rehabilitation & medications the mortality rates have significantly improved. This has consequences for the health service in other ways – people are living longer in the community with now more chronic illness. Our population is also living for longer , there are over ten million adults aged over 65 years living in the UK currently and this is projected to increase by an additional 5.5 million in twenty years time.2 We are now experiencing the conse of this situation with more patients with chronic illnesses unable to cope in the community and requiring hospital admission.
  2. Four hour target in the A&E department – The government and media have publicised the 4 hour target in the Emergency department. This is a potentially lucrative enticement to a patient who cannot get an immediate appointment from their GP in that they can be seen / investigate / treated / admitted or discharged within 4 hours from the emergency department. Should this target be abolished? – there does not appear to be much evidence that it improves healthcare and it seems that it in fact has created additional waiting / clinical assessment unit type wards in the hospital. If the targets were dropped and patients were seen purely on clinical need, perhaps not so urgent / acutely unwell patients would attend and instead try and attend their GP.
  3. GP out of hour’s service access – Since the GP contract changed in 2004, it has placed an extra strain on access of healthcare ‘out of hours’. Patients often think that after 6pm there are no GP services available and therefore present directly to the emergency department as they know its open 24/7. Some patients are unaware that a GP out of hour’s services exist. Is there an opportunity to educate patients in the community about accessing healthcare out-of-hours?
  4. NHS budget – in the financial climate, austere measures have been placed upon all public services. The NHS has also been affected by this. The NHS budget has been frozen for around 5 years, more productivity has been demanded from it and as the population has risen demand upon it has increased. The NHS is paid for by the taxpayer, and it is difficult to ask more from the taxpayer to contribute to the NHS. This calls into question privatisation of the NHS (I do apologise if this word causes offence to anyone reading). Should some fees be introduced to the NHS? e.g. fines for those who continually fail to attend appointments , recurrent drunks in the ED , a small fee for calling upon ambulance services and attending the ED?? Imposing fees could have major consequences. It is known that those who are in the lowest socio economic state have the poorest health. If fees were placed would we be neglecting those who could not afford a small payment towards their health? What do we do if patients refuse to pay? Do we set litigation against them? Would fee for service environment result in a more litigious society?
  5. Societal attitudes to illness and health – With the advent of social media , constant and instant information is available from Twitter , Facebook and Google. Society has become more risk averse. People are generally unwilling to accept any health risks (and why should they accept risk?). Therefore attending the hospital /emergency department whereby health can be assessed quickly with bloods & imaging and quick decisions can be made is now an expectation. It is not uncommon to hear colleagues complain that more patients are attending the emergency department for non emergency ailments such as simple coughs and sore throats. I don’t think there is any solution to this rather than acceptance of society’s shift in their health beliefs and health seeking behaviours. Perhaps its time we roll with this change and consider making healthcare more accessible to people’s lifestyles e.g. running more evening clinics in general practice when people can attend after work.


Rant over, I feel like a weight has been lifted off me however the gravidity of this situation is bearing down on the NHS and it appears to be unravelling before our eyes (maybe I am being a tad dramatic here but it is a pressing issue all the same).

I realise that this is a complex issue that will require time, money and patient education. What can we do as physicians? What can I do as a budding emergency medicine doctor? I suppose for now its patient education. Information empowers our patients and perhaps the next time we encounter a patient in the emergency room who you felt may have benefited from a visit to their general practitioner rather than the emergency room, inform them of this. There is no need to chastise patients but pointing out the resources available such as walk-in centres and out of hours GP services towards the end of the consultation may be worthwhile.

So from a foundation doctors perspective the above factor are what I belief are contributing to the current crisis however , what do you think? Are there other factors I have not considered? Does anyone have any remedies for this NHS ailment?

Yours comments and opinions are greatly appreciated.

Thanks for reading.

Aine Keating



  1. BBC news article Nick Triggle (06/01/2015). A&E waiting is worst for a decade. UK
  2. Government document. (2007). Ageing population. Available: Last accessed 06/01/15.




Clinician Abuse: Electronic Health Records

This month, the print version of the Emergency Medicine Journal features an article from a group including Jeffrey Perry and Ian Stiell on a topic near and dear to our hearts – Electronic Health Records. While the next generation of physicians will never remember a time of charting on paper, the majority of practicing physicians recall such times – and many office-based practices may yet still use paper.

In the Emergency Department, however, one of our most valuable assets is time – and all such times are increasingly measured and under greater scrutiny as quality and efficiency metrics. With an eye towards this, Perry et al performed an observational, before-and-after, study comparing time spent in documentation on non-traumatic chest pain between paper charting and electronic charting. Paper charting required a mean of 6.1 minutes per patient, while electronic charting required 9.6 minutes. If one assumes this charting differential is generalizable to other complaints, and multiply such by a very reasonable 2 patients per-hour on an 8- or 9- hour shift – suddenly you’re looking at an additional hour of documentation time. Unsurprisingly, qualitative survey of clinicians found universal disfavor of electronic charting.

I shine a light on this article in the context of the ongoing American Medical Informatics Association Annual Meeting in Washington, DC (#AMIA14). If you spend any time perusing the social media or press releases from the meeting, all the hype is about “Big Data”, FHIR, and hackathons – advanced applications of clinical informatics, essentially, assuming an integrated Electronic Health Record infrastructure. What’s been utterly lost in the rush to the future are the basic considerations clinicians struggle with on a daily basis – carving out enough face-time with patients to deliver the best possible care. With initiatives such as “Meaningful Use” in the United States providing mandates for EHRs, the emphasis has clearly been on checking boxes for federal reimbursement – and hardly responsive to clinician concerns.

Patient satisfaction” is an overwhelming industry mandate – what happened to clinician satisfaction?

Reference: “Assessment of the impact on time to complete medical record using an electronic medical record versus a paper record on emergency department patients: a study

Highlights from the December edition: EMJ

Paul Middleton: Associate Editor EME

Editor’s Choice: ED and GP patients

Causes of Emergency department crowding are complex, but the proportion of ‘inappropriate GP patients’ has often dominated the debate. Recent Australian research suggested that ∼10% of patients could be classified as appropriate for general practice, whilst demonstrating that the preferred government methodology doubled these figures.

In this issue, Harris and McDonald investigate the case-mix of patients attending ED, GPs, a walk-in clinic (WIC) and an out-of-hours (OOH) telephone service. There was a similar case-mix of presentations to the WIC, OOH and GP, with the only difference being respiratory illness presented more frequently to GPs. Injuries were 12 times as likely to be seen in ED, whereas non-traumatic musculoskeletal conditions were twice as likely to be seen in GP practice. Patients were also 4 times more likely to present to ED with chest pain suggestive of myocardial ischaemia as compared with non-ED sites.

These findings, although based on a small sample of a highly diverse population, demonstrate that patients are making relatively sophisticated choices. This paper highlights that, rather than concentrating on the blunt tools of “reducing ‘inappropriate’ attendances”, governments need to take note of Gerry Fitzgerald’s comment that there are “…not general practice patients or ED patients; there are just patients, who need medical care”, and our job is “…to understand those needs and to provide accessible, affordable and quality services that meet those needs. Patients should not be blamed for our failure to do so.”

Sepsis survey

Almost 13 years ago, Manny Rivers changed the paradigm for the sepsis syndrome with the outcomes of Early Goal Directed Therapy (EGDT). Since then, studies from PROCESS to ARISE have suggested that EGDT is not in itself more successful in preventing sepsis mortality, but that a high-quality, process-of-care approach results in the best outcomes. Jiwaji et al surveyed ED and ICU consultants across Scotland, with a 2/3 response rate, and compared approaches to sepsis resuscitation. Almost 90% of ED consultants used normal saline to resuscitate, compared to only a quarter of ICU consultants; many of the ICU group preferred Hartmann’s, but 63% used gelofusine, despite little evidence for its benefit. Half as many again ICU consultants initiated central venous and intra-arterial monitoring in the ED compared with ED consultants, and similar proportions used specific transfusion triggers. This variability suggests the need for harmonisation of approach with the patient remaining the central concern, whoever is providing care. In a time-critical environment, recognition of which is an undoubted result of Rivers’ work, ED and ICU need to work towards common skill sets and protocols to ensure that early recognition, source control, antimicrobial therapy, fluid resuscitation and escalation remain the fundamental goals of sepsis treatment.

Basic Life Support

Exponentially growing levels of evidence supports the primacy of early recognition of cardiac arrest, immediate instigation of high-quality CPR and urgent defibrillation. In the last 20 years, ubiquitous courses in BLS train essential psychomotor skills, but these skills deteriorate in weeks or months. Video-based Practice While Watching (PWW) programs, with participants observing a standardised video with an instructor, have been successful in initial skill teaching and maintenance, but Na and colleagues investigated a novel small group discussion and debriefing (SGD) program, allowing participants to watch themselves and discuss with an instructor. 2000 people were studied. Healthcare professionals’ (HCPs) performance of compression skills was better using SGD compared to PWW methods, but showed no difference in non-compression skills (ventilation, AED use etc). In non-HCPs there was a significant improvement in both sets of skills using the SGD method. This interesting study points the way to possible mass-instructional methods that could be highly useful in community and HCP education in order to improve the often dire outcomes of cardiac arrest.

Capillary refill

Although normal finger capillary refill time (CRT) is considered to be less than 2 seconds, upper limits of 4 seconds may be seen at the chest or foot, and in the upper CRT limit in neonates may be up to 5–7 seconds. Longer times are seen in lower extremities and lower skin temperatures. Schriger and Baraff also showed that CRT varied with age and gender, with approximately 2 seconds for children and men, and longer times for women and the elderly.

We know that turning a continuous variable into an ordinal or categorical variable loses both information and precision, but clinical practice often demands these simplifications. Mrgan and colleagues assessed the relationship between CRT and with mortality as both categorical and continuous variable in 3000 patients. Although based on limited data, multivariate analyses showed no relationship between CRT and either 1 or 7 day mortality when used as a categorical variable, as in the Trauma Score, but when used according to the Schriger and Baraff definitions, CRT was associated with odds ratios of mortality of 5.8 and 4.2, with, however, very wide limits of agreement. The authors concluded that CRT should really be used as a continuous variable, but implementation of this statistically sound approach will be challenging without substantial further research.

Light rather than heat in stroke?

Stroke treatment over recent years has generated a lot more heat than light, but no one can disagree that stroke evolution is time-dependent. The PIL-FAST study casts an intriguing light on the challenges of research into a time-dependent pathology, seeing the patient journey as an emergency care continuum and implementing pre-hospital interventions.

This pilot study by Shaw et al investigates the ability of an ambulance service to implement a randomised controlled trial (RCT) in the prehospital phase of stroke care, treating hypertension using lisinopril or placebo The truly illuminating aspects of this study are the difficulties encountered, and the subsequent limitations imposed on this research. Of 1463 suspected stroke admissions only 40 fulfilled inclusion criteria, and of these only 14 were recruited; some missing enrolments were caused by the attendance of a PIL-FAST trained paramedic to only one third of cases, with only 58% of those patients being enrolled. 76 from an eligible 200 paramedics volunteered to be trained in the research protocol. Paramedic concerns about longer scene times among those recruited did not materialize. A new paramedic record system was introduced during the study, preventing the investigators to review the entire trial period. Most worrying, these groups identified concerns relating to ‘professional boundaries’ despite apparent ‘enthusiasm for research’.



Paul Middleton

EMJ Associate Editor

Highlights from November edition: EMJ

Triage category and prediction of longer-term outcomes

Triage identifies patients who require the most urgent attention, and allows stratification of scarce resources. Many emergency presentations conceal a multitude of sins, with few as all-encompassing as syncope. The broad range of conditions that provoke, mimic or originate as syncope means that predicting those most risk in this broad group relies on exhaustive and penetrating questioning and examination.

Bonzi’s retrospective study on 678 syncope patients found that the triage process was poorly predictive of adverse events at 10 days. They also examined an OESIL score, and found that previous cardiac history and abnormal ECG were predictive of later disasters. This paper highlights that triage, for all its uses in managing flow in an ED, is no substitute for early, informed, careful risk-stratification, and that it will not perform well in an area for which it was never designed.

Traumatic head injury triage

A cohort study by Fuller et al from TARN investigated the classification of adult head injury patients by the London Ambulance Service (LAS) and the Head Injury Transportation Straight to Neurosurgery (HITS-NS) criteria.

Bypass of major trauma patients to definitive care is a common theme in many trauma systems, and one challenge is to manage intracranial injuries needing urgent neurosurgical intervention, in the context of physiological instability from multisystem injury. Head injured patients are particularly vulnerable to hypoxia and hypotension, so to accurately balance the risk between these competing priorities a triage tool which accurately predicts the presence of intracranial injury is necessary.

In 6559 patients, Fuller found that the both tools showed poor sensitivity for a significant traumatic brain injury, when compared to a reference standard, of 44.5% and 32.6% respectively. Adding bleeding disorders, vehicle entrapment and age ≥55 to the LAS rule increased sensitivity to 74%.

The investigators showed under-triage rates for significant TBI of 67.4% and 55.5% for HITS-NS and LAS, with false negative cases often comprising older patients with less severe injuries and low falls. The poor performance of these triage rules underlines difficulties in patient disposition, even within a mature trauma system. This paper adds to the debate about which strategy is superior, however without clear evidence that outcomes in head injured patients stabilised at a trauma centre and then transferred for neurosurgical intervention are worse than those for patients taken directly to a specialist centre with possible under-resuscitation, the emphasis on initial trauma centre management will remain.

High sensitivity cardiac troponin T in infection—more outcome prediction

De Groot points out that 13% of patients who meet criteria for early goal directed therapy go to a normal ward, when disposition is guided by either Mortality in ED Sepsis (MEDS) or Predisposition, Infection, Response and Organ-Failure (PIRO) score, and suggests that this could be improved by the addition of a biomarker reflecting myocardial damage from hypoperfusion, highly sensitive cardiac troponin T (hs-cTnT).

They found increased odds of hospital death by 2.2 with hs-cTnT in the third quartile compared with the second, and 5.8 if it was elevated to the fourth quartile. hs-cTnT also showed good discrimination measured by the area under the (AU) ROC curve, and was an independent and more powerful predictor than the MEDS or PIRO scores alone. However, like many sophisticated (and expensive) biomarkers, hs-cTnT correlation with other reliable predictors of outcomes may not help to guide us practically in our choice of intervention, however may assist us in our efforts to engage the arbiters of higher levels of care. But the greatest usefulness of this study may be in the finding that hs-cTnT in the lowest quartile predicted a zero risk of death.


The way we think about our patients, the processes of diagnosis, and the intrinsic organisation in the way physicians integrate information are topics of huge interest for many. Gestalt derives from a German school of psychology and suggests that we can discern a whole concept or image in parallel with perceiving the fragmented pieces of information that form the whole; the “the whole is other than the sum of its parts”. This ability is likely to be intrinsic to the effective practice of emergency medicine, and is likely to involve subtle cues such as lack of facial expression, recently shown to be associated with the presence of cardiovascular disease.

Body studied the use of gestalt in the diagnosis of chest pain by inducing emergency physicians to make a graded estimate of the likelihood of an ACS. Treating physicians were blinded to initial troponin level and the outcome, although they had access to the ECG and other information.

In 451 patients with chest pain, of whom 81 had an AMI, unstructured clinical judgment had moderate overall diagnostic accuracy, with an AUROC curve of 0.76, but was insufficient to rule in or rule out ACS in the ED. However, a normal ECG and initial troponin added to physician gestalt would enable 25% of patients to be safely discharged, and using high-sensitivity troponin would increase this figure to 40%.

Procedural sedation for cardioversion

Propofol, methohexital, thiopentone and etomidate were identified in an EMJ review as good choices for procedural sedation in cardioversion, largely due to their short onset, duration and recovery time, and propofol has been described as the closest to an ideal agent for cardioversion.

Kaye and Govier collected data from a case series of 100 patients given propofol for ED cardioversion of both atrial and ventricular tachycardias, and demonstrated minimal complications and no sentinel adverse events. They concluded that propofol 1 mg/kg was safe in patients undergoing ED cardioversion, with a similar level of safety using a 0.5 mg/kg dose in patients with haemodynamic compromise.

What do you believe? with Iain Beardsell.

SONY DSCA change is as good as a rest, or so the saying goes. Working in Emergency Departments we are constantly changing. Many of these changes are directed at the processes within the ED, continually striving to find the “golden bullet” solution to the “four hour question”.

Over the first six years of my consultant career the department I work in, like many others across the UK I’m sure, has been subject to constant change . These have come in different guises: “Lean”; Service Improvement; Perfect Week; the list goes on. Many of these are run by external agencies, at huge cost, all hoping to solve the dominant question in Emergency Medicine – How do we achieve the four hour target

Like, I suspect, many Emergency Physicians I have a very short attention span. This was part of the reason I chose the specialty that I love. Not unlike Martin Sheen’s President Bartlett of West Wing fame, the question on my lips most often is “What’s next?”. This serves me well when seeing patients, but not when I require the sustained interest required for successful change. We throw ourselves into projects, but over time this quickly wanes and the much vaunted developments are cast aside for the next new thing. The last few years in our ED are strewn with unsustained changes and I’d estimate that no more than one in ten ideas, no matter how promising or useful, have continued beyond six months after their inception.

Why is this? It can’t simply be that we lose interest. I recently watched a “TED” presentation that struck a chord.

In his talk Simon Sinek, an author best known for popularizing the concept of “the golden circle” describes a simple but powerful model for inspirational leadership all starting with the simple question “Why?”. As I watched, I realised that many of these changes over the years I had been happy to participate in, but I just didn’t believe in them. Apart from the temporal reasons with which we are obsessed I didn’t know why we were changing. We have keep doing new things, yet our “performance” hasn’t improved, in fact it has got worse.

As doctors and nurses in Emergency Departments we chose our career paths, I hope, because we believed in the best care for all, especially those with life threatening illness, at any time of day or night. This is our fundamental belief. Why is it, then, that we struggle to to adopt and maintain these changes that may help us towards that goal?

As Sinek discusses in his talk, it isn’t necessarily that the ideas we try to implement are bad, but because the premises on which they are based do not address our beliefs. There is a fundamental disconnect between the four hour target and what we think is best for our patients. Of course this is untrue – a faster, more efficient process for seeing people must be better for many, but with years of government scrutiny and management interference we have simply refuse to believe this anymore. We are, in general, a stubborn bunch and will not have others force their beliefs on us without the appropriate analysis

Change goes on apace in my department, as I am sure it does in yours, but it is my belief that it is time for us to pause and rethink what and why we are changing. Constant, rushed implementation of quick fixes that the clinical team do not believe in, but merely participate in, simply will not work. It is time for us to reappraise what we, as doctors and nurses, believe and then to proclaim these beliefs to others.

So I ask you all – what do you believe in? What does your department stand for? What is your vision? I asked this question of colleagues recently and was met with blank, rather guilty stares. We simply did not know. I’m sure you could come up with a few without any thought: to provide evidence based compassionate care to all, whenever they need it; to educate and encourage all staff so that work is not just a job, but a vocation; that no patient should be in pain; that we should aggressively resuscitate all those who require and desire it and tenderly and gently care for those who life is at its end. Articulating these visions and beliefs is easy – the real challenge is making them a part of your ED’s philosophy and daily life.

Of course, the irony is that none of these beliefs in anyway contradict the aims of the four hour standard. In fact they compliment it – evidence based care is efficient and limits unnecesssary testing and giving appropriate pain relief early facilitates discharge. And a happy clinical team, who work together will always, always be more effective and efficient.

We need a rest from the change. We need to look within ourselves and find what it is we believe in and then work towards these visions with passion and enduring commitment. We need to ask others, managerial and political, to trust us, to help us work towards achieving what we believe in and to join us on the journey. Given this opportunity we will provide the best emergency care we possibly can (including achieving government set targets). And that is my fundamental, unshakable belief.