In this April issue

In 2023, the Australasian College for Emergency Medicine (ACEM) reached the ripe old age of forty. The practice of emergency medicine today is significantly different from 1983. Questions to consider about current clinical practice include how is the scope of the specialty and the role of emergency physicians changing, what are the skills and training necessary to deliver effective and compassionate emergency care in increasingly complex healthcare contexts and what is needed to create sustainable and satisfying careers in emergency medicine? In August 2023, ACEM hosted the Emergency Medicine – Building our Future Summit in Melbourne to begin this conversation. Clare Skinner, Immediate Past President of the College, summarises the outcomes from the summit and indicates how the College will absorb them into planning for the next forty years.

Centralisation of trauma services in western countries has led to improved patient outcomes. In a first-rate review, clinical guidelines from all ten Emergency Medical Services (EMS) in Australia and Aotearoa New Zealand were compared. There were several inconsistencies between them. The lack of consensus, especially in trauma triage, makes benchmarking and comparison of trauma systems difficult. The conclusions are important and are probably of no surprise to most readers. They can almost certainly be applied to clinical guidelines in other areas of practice, both prehospital and hospital.

Emergency clinicians appear to be generally optimistic about the use of AI in emergency medicine, so long as it is used as a decision support tool and they maintain the ability to override its recommendations.

An advance care directive is a legal document outlining the wishes made by a person about treatment options. A study from South Australia concludes that directives are beneficial when patients, families, and emergency department staff agree with the decisions made. Advance care directives are useful to start conversations around goals of care and end of life care relevant to patient's current situation as well as when the directives were first written. Please also read the papers published under the Trainee Focus section.

Emergency medicine is a discipline with complex leadership demands, which are experienced by junior and senior emergency physicians alike. In this environment, emergency physicians can struggle to work out what it means to be a leader and develop professional identities as leaders, necessitating a leader identity workspace. A team from Swinburne University of Technology conclude that neither emergency departments nor hospitals more generally exhibit the properties of, or are experienced by emergency physicians, as leader identity workspaces.

Patients with severe traumatic brain injuries need urgent medical attention at a hospital. A review from Auckland evaluates whether transporting adult patients with a severe traumatic brain injury directly to a neuroscience centre is associated with reduced mortality. None of the studies reviewed demonstrated statistically significant findings indicating that direct transportation to such a centre increased survivability for patients with severe traumatic brain injuries. Subsequent transfers from a non-neuroscience centre to one reduced mortality rates at 24 h and 30 days.

An interesting retrospective study from Dunedin concludes that musculoskeletal chest pain is common in emergency care, providing a basis and justification for further research to improve management and outcomes for people with musculoskeletal chest pain.

EDs are an essential service, and higher rates of presentations per population are seen in regional and remote areas compared to major cities. Australian-wide differences in utilisation and performance remain largely unknown. A significant study that looks at this issue highlights ED usage, casemix and performance by location. The authors conclude with a powerful statement that it is imperative regional and remote EDs are appropriately resourced to support the communities they serve.

The focus in this issue is on death and dying in the ED. Please also read the paper in this issue on advanced care directives and end of life care.

In the last issue (February 2024), this introductory page mentioned a paper called ‘Abdominal pain in older patients’ suggesting it had a single author. We apologise for this typo.