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It has been an opportune time to look critically at how things are done at Emergency Medicine Australasia (EMA) and 2012 might well go down as heralding the ‘year of change’ for EMA. Thus, although it is clear that changing how clinicians practise remains a challenge,1 changing how the journal delivers content and interacts with the emergency medicine community is eminently achievable. A Strategic Planning Day, held in early September 2012, enabled robust discussion between representatives of the journal, the Australasian College for Emergency Medicine (ACEM) and our publisher around the findings from a survey sent to the EMA Section Editors, Editorial Board, authors and ACEM/Australasian Society for Emergency Medicine (ASEM) members and readers. The response rate for this voluntary anonymous survey was considerably better than the previous EMA Readership Survey conducted in early 2010 that attracted only 61 respondents. This time, a total of 601 participants (20 of 34 Section Editors [59%]; 8 of 21 Editorial Board members [28%]; 83 authors of papers accepted since 2010; and 470 ACEM/ASEM members and readers) provided extensive feedback, including many invaluable comments.2 These survey findings indicated that EMA is generally regarded as being relevant to Australasian emergency medicine research and clinical practice, with a range of helpful suggestions and comments received regarding opportunities for improving and enhancing the journal. Nine strategic goals were identified to guide future development of EMA with a recurring theme of better engagement with the Australasian emergency medicine community who value the journal, and to increase ACEM members' involvement in journal production and content. Also highlighted was the need to seek a balance between research and educational content within the journal that still remains free from drug company advertising,3 and to build on the already rapid editorial response time (median of 21 days) to submitted papers to ensure that authors see EMA as a journal of choice in terms of publishing quality and service. EMA looks forward to continuing to promote the best Australasian emergency medicine research, safe in the knowledge that the journal competes strongly in the international arena, and more importantly, reaches a large, like-minded and energetic readership. Those of you interested in the Impact Factor (IF) will know that our latest IF, released in mid-June, which had risen to 1.089 from 0.901 last year, dropped back to 0.979. However, EMA retained its ranking at 13th with the total number of journals in the ISI Journal Citation Reports®: Emergency Medicine Category rising from 23 to 24. Much more surprising was that, with one exception, every single journal above EMA also had a decrease in IF value and seven of 12 dropped a place or more in the rankings.4 This suggests that in 2011, across almost all the emergency journals, either the number of citations to articles published in 2009 and 2010 fell, and/or more articles were published in total or were included in the denominator. Although 2011 was a disappointing year in IF terms for many, EMA included, this should not detract from recognising the quality and relevance of papers being published in our journal, including, for example, articles on access block and ED overcrowding,5 the 4 h target (National Emergency Access Target – NEAT),6 prehospital fluid management in traumatic brain injury,7 the emerging role of intravenous lipid emulsion8 and the challenge of increases in intern numbers.9, 10 Looking ahead to next year and beyond, a number of improvements to journal format and delivery are planned. New graphics for EMA with a more modern font and a fresher layout are being developed. In addition, readers who want to cease receiving a hard copy will be able to ‘opt-out’, once the business model is finalised. Meanwhile, a new app released by Wiley-Blackwell will be made available to EMA readers during 2013, which will significantly improve access to journal content on mobile devices.11 Promoting the symbiosis and interactivity between the journal and other online content was also identified as a strategic goal. This builds on recent dialogue within EMA on the role of social media,12, 13 which is challenging the passive model of publishing papers: initially online with a doi number followed by an increasingly long delay to publication in a hard copy issue. This model is now at risk of rapidly becoming obsolete, being replaced by far more responsive and interactive online publishing models with supplemental content ‘print short – online long’, open access, podcasts, blogs, real-time comments allowing immediate feedback, Continuing Professional Development quizzes and polls, all with rapid information sharing on social media platforms, such as TwitterTM (San Francisco, CA, USA) and FacebookTM (Menlo Park, CA, USA). At EMA, we will definitely be adopting a more progressive attitude to research, education and publishing.14 Other journals have also recognised the role of social media,15 and many, including EMA, are now developing electronic content for mobile device use and interactive multimedia capability. Initial forays by the EMA editorial team, including brief editorial summaries highlighting key articles and free online content, were introduced in 2012. This content was specifically produced for social media and is currently published on the LifeintheFastLane medical education blog, linked to online publication of the current issue of the journal.16 EMA also has an active Twitter account (@EMAJournal) with a dedicated interactive website http://emajournal.org/ under development. These initiatives, which leverage off the academic standing and peer-review capabilities of the journal, will enable access to multidimensional content that is relevant to the Australasian emergency medicine community. Our specialty stands at the vanguard of acute healthcare and is growing and evolving rapidly. As Sklar et al. envisage when predicting how emergency medicine might progress, EDs of the future will learn more about and research into time-sensitive conditions, develop standardised disease management protocols and guidelines, and will make greater use of technology for information management as well as diagnosis.17 It is indeed a good time to recognise that change is an opportunity to progress, not a hurdle to be met. We hope EMA will maximise the benefits it can offer, to our local as well as our expanding international readership, as we showcase and now debate real-time the best Australasian emergency medicine research and clinical developments. AFTB is Editor-in-Chief of Emergency Medicine Australasia, and AG is Journal Manager of Emergency Medicine Australasia.

Access for clinicians to medical information has never been easier or faster, with the specialty of emergency medicine leading the world in the online dissemination of information to its practitioners. This has allowed those training in and practising emergency medicine to stay abreast of their field with relatively little effort. Australasian emergency physicians are among those pioneering online medical education and the use of social media. Three years ago in this journal Cadogan provided an in-depth synopsis of many of the available Web 2.0 resources that could be of use to medical professionals, and their potential utility and popularity within the rapidly growing Australasian and international emergency medicine community. Unfortunately, it appears that his call to ‘get with the times’ has fallen on deaf ears in the medical journal publishing world.1 Medical journals in general have been slow to adapt to the online paradigm, with few really using the vast array of social media and Web 2.0 tools for distributing journal content. Modern online business and marketing models are also scarce within the journal publishing world. Although some emergency medicine journals have adopted a range of Web 2.0 tools, such as supplemental content in online articles, real-time comments and forums, social media plug-ins, videos, podcasts and more (e.g. Annals of Emergency Medicine, Academic Emergency Medicine and the Emergency Medicine Journal), others (such as Resuscitation, the American Journal of Emergency Medicine, Canadian Journal of Emergency Medicine and this journal Emergency Medicine Australasia) have shown no signs of modernising their content. The latter journals, for instance, simply provide digitised versions of their print articles, and charge significant fees for non-subscribers to purchase individual items. Meanwhile, there is discussion around the utility of social media for scientists and researchers, as many are interested in Web 2.0 tools that will help them ‘do science’ rather than ‘talk about science’. Some feel that journals should be helping develop these tools, for example data gathering and analysis, rather than simply promoting published material.2 Several issues have arisen as a result of the way in which modern medical information is created and the speed at which it can be accessed and distributed, particularly in the field of emergency medicine. These have direct implications for the particular niche of medical journal publishing and social media, and are discussed below. A major challenge related to social media and medical journals is the conflict between the widespread and growing support for free access to medical information by clinicians, against the need for publishers of medical journals to maintain an effective business model and maintain a profit. On the whole, medical journals seem slow to adopt the contemporary culture and methods of online distribution of information, and few, if any, are adapting to modern online business or marketing models. These might include the ‘freemium’ model (majority of content provided for free, premium content available at a price), alternative revenue streams (database mining, iPhoneTM[Apple, Cupertino, CA, USA] applications, advertising, niche marketing) and novel information distribution (videos, podcasts, iPadTM[Apple] or other e-book reader functionality, forums, blogs, social media applications). There are currently numerous competing free, and several paid online educational resources for emergency physicians, which leave medical journals in a precarious position. Failure to adapt to the modern information paradigm might relegate them to a redundant position, especially given the additional growing popularity of open-access journals which have adopted the ‘author pays’ rather than ‘user pays’ paradigm to make content universally available at no cost. One of the key tenets of social media is the engagement of consumers, and catering to the wants and needs of the various communities that use a particular product. Without addressing this free versus paid issue, as well as coming up with novel ways to provide consumers with useful content while maintaining an effective business model, there is little value in medical journals, including Emergency Medicine Australasia, pursuing a social media presence. What is clear is that the current production mode of medical journals, with slow approval and publishing times, infrequent distribution of hard copies to subscribers, negligible engagement with consumers, no functional online presence and no clear brand presence needs to change to meet the expectations of current and future generations of clinicians. Progress for medical journals will necessitate ‘loosening the grip’ on journal information, as well as introducing new methods of distributing information as a trade-off for gaining more users and increasing engagement. Given how few journals are pursuing this type of model, there is certainly scope for Emergency Medicine Australasia to participate in this evolution of the online delivery of medical journal content. Medical staff now have too much information made available to them yet cannot find the information they need when they want it – the so-called ‘information paradox’.3 Information overload is experienced by many in the emergency medicine arena. With so many free online resources now available, I frequently hear colleagues at all levels say they are overwhelmed by choice, and find it hard to know which sources they should use and can trust. Clinicians also prefer information sources that ‘add value’. This means summaries that provide synthesis and interpretation of literature findings. When faced with a need to know a certain medical fact, clinicians want relevant, concise, authoritative, searchable information from a credible source. Currently, the Australasian College for Emergency Medicine (ACEM) provides no online learning material designed specifically for trainees, and still recommends hard copy textbooks as references for the Primary and Fellowship exams. This places trainees and educators in a conundrum as to where they should source information. It is likely that blogs, podcasts and textbooks alike are all now the commonest sources of information for emergency medicine practitioners, with Emergency Medicine Australasia and other similar journals being a source of relatively little directly useful exam or clinical practice information. Yet, Emergency Medicine Australasia is in a unique position to take advantage of this conundrum. As a ‘College endorsed’ source, there is an opportunity to engage users, especially trainees, as a credible, authoritative resource, while being careful to not add to the information overload. However, simply placing more journal content online, or even increasing the amount of journal content full-text ‘freeview’ without social media interactivity or a clear ‘value-add’ with more summaries, expert comments or analysis, would be futile. Scientific papers are increasingly being critiqued publicly in blogs, TwitterTM (Twitter, San Francisco, CA, USA) and other social media outlets within hours of their publication. Although this might have the potential benefit of rapidly weeding out poor-quality research, it is proving a daunting area for researchers whose work is in the firing line. This is particularly so when unchecked and often unqualified criticism brings their work into potentially unjustified disrepute. Some journals struggle with anonymous and vexatious online comments, and need to carefully oversee and edit their discussion areas. Some solutions to this are coming from the general science community with resources, such as the Faculty of 1000 (F1000), which is a peer-nominated faculty of reviewers who identify and evaluate the most important articles in biology and medical research publications (see http://f1000.com/), and The Third Reviewer, an online journal club that provides a forum for scientists to share opinions about recently published research (see http://thirdreviewer.com/). These centralised, independent, collaborative projects help to moderate the online discussion of scientific papers, and remove much of the onus of policing comments from the journals. Other online reference managers and academic social networks, including Mendeley (http://www.mendeley.com/), CiteULike (http://www.citeulike.org/) and Zotero (http://www.zotero.org/), are aimed at helping users gather and share scientific literature. In the future new ways of assessing an article's impact are likely, with the development of metrics programs that analyse all of the online activity generated by individual articles, as well as the more traditional academic scrutiny simply based on journal article citations. Richard Smith, the Editor of the British Medical Journal from 1991 to 2004, commented on the future of medical journals in an online presentation, and suggested that although no one can predict the future, that medical journals will become paper and electronic, they will be multimedia and will include raw data and the software used to interpret them, will be ‘live documents’, and act as forums for debate, and will need to concentrate on meeting the needs of their readers as a community rather than authors, as well as maintaining the usual features, such as education, debate, reviews and news.4 The format of articles and how they are written also needs to change to meet the demands of the Generation Y (Millennials) and Generation Z (Internet Generation) users, who purport to have short attention spans, learn more from audio/visual content than print, and prefer poignant summaries over long-winded articles. It is not only these generations that have low tolerance for digitally inept content. Studies into the future of libraries show that those research behaviour traits that are commonly associated with younger users – impatience in search and navigation and zero tolerance for any delay in satisfying their information needs – are now becoming the norm for all age groups, from younger pupils and undergraduates to professors.5 Social media is an ideal avenue to fulfil the information needs of the various groups that use medical journal content, and so journals need to start adapting to this new information age. Given the low level of social media presence, universities, academics, researchers and medical specialty colleges, including ACEM, need to address this desire for increased medical journal social media content. However, for current and future ACEM trainees and Fellows (FACEMs), this might be overshadowed by the diverse overall range of interest, input and capability of the various related players (see Fig. 1). The social media paradigm. ACEM, Australasian College for Emergency Medicine; EMA, Emergency Medicine Australasia; FACEMs, Fellows of the Australasian College for Emergency Medicine; SM, social media. Credit should be given to ACEM for taking the first tentative steps into embracing TwitterTM and FacebookTM (Facebook, Menlo Park, CA, USA). However, the content must be engaging and serve some greater educational purpose (rather than, for example, posting of random links with no description on TwitterTM, and simple photos of College meetings on FacebookTM). No doubt, this will be improved by a more focused approach by ACEM, who this year are undertaking a major IT restructure involving a number of the College's systems and processes that include a new website and the migration to the SharePointTM 2010 platform (MicrosoftTM, Redmond, WA, USA).6 One must question the rationale for medical journals failing to adapt to the online market, when the benefits of social media are so clear and while the appetite for information from the medical community is so high. Some would argue that in the business world companies do not so much have a choice whether or not they use social media, but rather the choice is now how well they do it. Rather than being afraid of failure, modern companies need to ‘fail fast, fail better and fail forward’, as not taking any action in this arena relegates a company, especially one with information as its main commodity, to a non-competitive position.7 The potential benefits to educational institutions, such as ACEM, or a journal, such as Emergency Medicine Australasia, of establishing well designed social media practices that are targeted and responsive to the needs of their users are enormous, and if done well, will likely create significant positive outcomes not just to the aforementioned organisations, but more importantly to their members and readers, and most of all to their patients. However, belatedly, ACEM and Emergency Medicine Australasia need to climb on board the Web 2.0 roller coaster and indeed take the ride that Cadogan foreshadowed.1 AB is the administrator of http://www.edexam.com.au, a free website that supplies information and resources for the ACEM Fellowship Exam. He posts regularly on Twitter: @edexam.

Emergency medicine (EM) is spreading globally, starting as a recognized need in new territories and progressing to an official specialty.1–7 A growing number of emergency physicians (EPs) trained in mature systems are supporting the international development of EM.8–18 In the USA and Australia with their mature EM systems, international EM (IEM) is expanding as a defined area of interest, as individuals aspire to assist others.8–10,15,19 In Australia over the last 5 years, the number of emergency doctors involved in IEM, and the frequency and duration of their engagements have increased.5–7,16–19 Expansion of interest and opportunities has led to the building of structured EM programmes in some neighbouring countries,2,3 and have generated publications.4,5,7,19 Since its inaugural meeting in 2004, the International Emergency Medicine Special Interest Group (IEMSIG) of the Australasian College for Emergency Medicine (ACEM) has become a source of information-sharing for EPs and EM trainees engaged or wanting to engage in IEM activities.19 Whereas some IEM participation is in international disaster response,11–13 most is now aimed at increasing the capacity of the local facility or region to provide effective emergency care in a context of relative political stability.2–7,17,18 Such EM capacity-building is a form of development, and its purpose is to create a positive impact across the whole socioeconomic and political spectrum in the host country. There have been two significant recent developments in response to the increasing involvement of EPs in IEM. First, since April 2010 ACEM has created an IEM Secretariat capacity, with dedicated IEM office staff. Second, this journal Emergency Medicine Australasia (EMA) has undertaken to support IEM information-sharing by actively encouraging the publication of IEM manuscripts. To this end, Emergency Medicine Australasia will now carry special Instructions for Authors for IEM manuscripts with recommendations for submission of this particular type of paper. These recommendations are found online on the EMA homepage.20 The newly appointed ACEM International Programs Secretariat will facilitate the combined objectives of ACEM and IEMSIG.19 It is intended that the Secretariat will (see Table 1): Support informal IEM linkages and information-sharing between ACEM Fellows, trainees and non-ACEM doctors, bodies and representatives. Act as a point of enquiry for individuals, governments, fund holders and professional bodies seeking IEM expertise. Enhance the ability of IEMSIG to promulgate its activities, newsletters, reports, guidelines and calls for expressions of interest through the ACEM website. It is important that advocates and providers share their experiences by publications with a relevant readership, such as the IEMSIG Newsletter and EMA, in order to progress the development of IEM, and to avoid repeating previous mistakes. Effective reporting will improve future undertakings and achieve better health outcomes. The new author submission guidelines on the Emergency Medicine Australasia website will facilitate the optimal dissemination of learning from IEM publications. Whereas all IEM programmes have some generic features, different types of service and skills delivery benefit from different reporting structures. These types of delivery include: Disaster response Emergency care delivery Emergency care capacity assessment (local, regional, national) Emergency care capacity-building (local, regional, national) Disaster response is addressed in an accompanying editorial.21 The others are commonly linked, as for instance, it would be unusual for an EP providing a service to not be able to contribute to capacity-building. Capacity-building may be provided at various levels from a brief promotion of EM as a specialty, to consultations with key stakeholders, to the provision of medium to long-term EM programme development and/or training. Table 2 contains specific guidelines for reporting the different types and formats of IEM manuscripts. In general, a ‘case series’ describing cases that are largely novel to the expected readership will be enhanced if combined with an ‘assessment’ of the local, regional and even national emergency care capacity. This approach acknowledges the maxim that emergency care cannot be provided in isolation, separate from a system. Similarly, the value of a case series is enhanced when combined with a discussion of lessons learnt by the presentation and/or management of the cases. This elevates the impact of the manuscript by providing an element of ‘capacity-building’. Tools for reporting the ‘assessment’ of a system of care are already accessible from a number of sources.22–25 A reasonable approach is to commence with the wide lens (geography, population, demographics, epidemiology, health indicators) and narrow the field progressively from national to local, and from health system to emergency service. The guideline for a manuscript on ‘capacity-building’ is to provide a broad framework similar to, for instance, an observational study or trial. Key headings should include: background (including the headings of a health system assessment); programme development and delivery; programme evaluation; discussion of facilitators and challenges, including lessons learnt; and a conclusion. Tools for reporting an emergency care capacity-building programme are also accessible from a number of sources.26–31 More general recommendations for reporting an IEM manuscript are listed in Table 3. The planned structure adopted for delivery of a programme will provide a solid basis upon which to evaluate and report it. Local participation in programme delivery and reporting will add value, and including local stakeholders in the publication process is a component of capacity-building. Acknowledging a team approach should include any non-medical contributors such as nursing staff and donors. Finally, some form of evaluation, preferably mixed method, adds to the usefulness. As IEM grows, so does the need to disseminate the lessons from personal experiences and programmes. The two developments described here – the inauguration of a dedicated ACEM International Programs Secretariat and the promulgation of IEM recommendations in EMA to facilitate and improve manuscript submission – will support the increasing range of initiatives being undertaken by Australasian EPs and EM trainees. Hopefully, an enhanced capacity to share information will contribute to delivering improvements in emergency care globally. IEM Secretariat: Hydie Pallier and Dee Reynolds. ACEM CEO: Jenny Freeman. Georgina Phillips: Assistance with proposal to ACEM Council for IEM Secretariat. Both authors have contributed to each of the criteria below: Substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data Drafting the article or revising it critically for important intellectual content; and Final approval of the version to be published Chris Curry is Section Editor, International Emergency Medicine, Emergency Medicine Australasia.

The day-to-day running of Emergency Medicine Australasia (EMA) has been transformed by adopting the web-based peer review and online manuscript submission process Manuscript Central. This system by ScholarOne (Charlottesville, VA, USA) is now available in version 4.0 which has been upgraded to include Manuscript Central Optima, an integration with Thomson Scientific's Web of Science and EndNote, as well as eForms and eCommerce to create an easier and more streamlined process. The Thomson Corporation acquired ScholarOne in August 2006 through Thomson Scientific, and a ‘European User Conference’ in November 2006, and a ‘USA User Conference’ in January 2007 paved the way for the final genesis of version 4.0 of Manuscript Central. Manuscript Central v4.0 enables users to submit, review, annotate and format technical manuscripts online in innovative ways, giving authors and publishers alike access to additional expertise in information and tools that span the entire research process. At the click of a button as the Editor-in-Chief (EIC), it was possible recently to rapidly check the total number of manuscripts submitted to EMA in the last year. The result yielded 154 papers, of which 51 have been rejected, 43 accepted and 60 are still ‘in progress’. The breakdown of the types of paper submitted revealed 82 original research papers, 16 review papers, 36 case reports, 9 Editorials, 8 Letters to the Editor and 3 Perspectives. Forty-eight papers were submitted from outside of Australasia (31%), and of those accepted for publication, their countries of origin included the UK, the USA, Switzerland, Hong Kong, India, Japan, United Arab Emirates, Pakistan and Nigeria among others. These statistics tell nothing of the publication process itself, but again it was easy to discover further core data through the EIC Centre. Papers submitted to EMA have somewhat disappointingly been taking an average time of 38 days (around 6–7 weeks) from first submission to reaching a first decision (to reject outright, or to proceed to minor revision or to a major revision). This key performance indicator clearly leaves room for improvement, with the aim now being to reduce this to closer to 20 days or 4 weeks maximum for this critical initial decision time. Once the EMA editorial process including peer review fully engages into action, the average number of days from submission of a revision to final decision is then 130 days. Much of this time is out of our hands, as it in part depends on the time the authors take to respond, and how many revisions are needed. After a paper is finally accepted by EMA, the average number of days to then be published in print is 139. Much more important though, is that for original research and review papers, it is now only 30 working days to the release of a citable electronic publication on OnlineEarly, each with a unique Medline searchable .doi number. This electronic version involves the paper being formatted into journal style, proof read by the author, permissions sought and the paper being signed off prior to release online. These latter publication times are well within similar biomedical journals' benchmarks, and are a credit to everyone involved. Aspiring authors who are wondering just who reads the contents of EMA should know that currently, there are some 2802 print copies of the journal published that go to all members of the Australasian College for Emergency Medicine and the Australasian Society for Emergency Medicine, to some private subscriptions and to libraries in Australasia, Europe and the USA. Even more impressive are the figures for journal usage in the last year on the Web through Blackwell Synergy, the online journal service from Blackwell Publishing (now part of Wiley). Over two and a half thousand Table of Contents for EMA are accessed on Blackwell Synergy each month, with between 7000 and 23 000 abstracts downloaded each month, and between 3000 and 8000 full text papers (either hypertext markup language [HTML] enabled, or as .pdf files) downloaded every month. The download trend has increased steadily throughout the last year, with a total now of 109 671 full text papers downloaded since January 2006. This is an exhilarating and challenging time for the readers and editors alike of EMA. Exhilarating because the international reach of EMA is undeniable; challenging because the journal must strive to improve and maintain excellence in the quality, relevance and readability of the papers it publishes. More challenging still is to look to the future as readers become increasingly familiar with what is on offer on Web 2.0. The concept of Web 2.0 was articulated in 2004, and within a year and a half, Google had no less than 9 500 000 citations to this new platform.1 Seven core principles or core competencies for Web 2.0 were espoused by one pioneer Tim O'Reilly. These included services, not-packaged software, with cost-effective scalability; control over unique, hard-to-recreate data sources that get richer as more people use them; trusting users as codevelopers; harnessing collective intelligence; leveraging the long tail through customer self-service; software above the level of a single device and finally lightweight user interfaces, development models and business models.1 These concepts of open, online social networking on Web 2.0 are embodied in the rapid rise of phenomena such as blogs, wikis, podcasts and vodcasts utilizing Really Simple Syndication feeds, easily accessed by website tagging and organizing tools, with authors bypassing the need to use the more complex Web 1.0 HTML.2 Medical educators and clinicians alike will undoubtedly be drawn to this new collaborative interactive medium where clinical thoughts, images and videos can be shared real-time.3 Will EMA still be with us? Absolutely, just as the popularity of small or large printed medical textbooks alike has been untouched by the appearance of online or CD-ROM productions. However, Web 2.0 will behove all of us at EMA to maintain the best quality possible by excellent peer review, timely paper turnaround and publication times, and most importantly, relevant content that our readers want. What is lost in interactivity will be compensated for by the avoidance of an initial flood of unreviewed, unexpurgated, largely unreferenced and potentially uncontrollable medical content online, as Web 2.0 explodes on the scene. A similar danger to the printed word journal was successfully brought under control in the best biomedical journals by a vigorous editing process, competitive referencing system, and by the readers' understanding of the fundamental importance of the evidence-base of the data cited on the scientific rigour of the conclusions drawn.4 Clearly the journal process at EMA does not happen by itself, with many individuals working on the journal of their own free will, in their own ‘spare’ time. This includes the Editorial Executive, the respective Section Editors and the many peer reviewers, to whom I owe a debt of gratitude and admiration for their dedication, enthusiasm and energy shown, in spite of the avalanche of commitments at work, as well as at home. Finally, Alison Hughes, the Editorial Assistant at Blackwell Publishing, has been outstanding, offering the highest levels of professional assistance, reliability and focus any Editor-in-Chief could hope for, ably assisted by Blackwell Publishing Production Editor Charlotte Bolcskey and overseen by our invariably supportive Journal Publishing Manager Alma Ross. Thank you to you all for your expertise and encouragement as the journal moves forwards in a positive fashion. Ultimately, EMA is about what you, the readers, make of it; what you enjoy, how you contribute, what you cite, and above all, what you learn that changes your clinical practice, or at least regularly makes you question your knowledge base and challenge your established care processes. That will be our success. Web 2.0 or no Web 2.0, we will be there. Associate Professor Anthony FT Brown is the Editor-in-Chief of Emergency Medicine Australasia.

This 25th anniversary issue of Emergency Medicine Australasia (EMA) contains a truly outstanding collection of articles set around emergency medicine research, Australasian and international emergency medicine status, the role of journals and journal publishing, and the pedagogy of emergency medicine with the emerging role of Free Open Access Medical education (FOAM) contrasted with the traditional textbook, all set against a historical background describing the evolution of EMA from its inception as a broadsheet in 1989. The authors are internationally renowned and recognised leaders in their fields – a veritable ‘who's who’ of contemporary emergency medicine. If anaphylaxis is a quintessential emergency medicine presentation,1 then this issue is the quintessence of just what journals, such as EMA, and their content can offer the practice of our specialty. It is clear that we are all in the midst of a revolution in how we access, store and review information, which is now delivered instantly online to the bedside, ED desk or our home. This has driven dramatic changes in how journals reproduce research and other articles, as some publishers struggle to maintain their very existence in the field of knowledge translation. It is now de rigueur to follow a favourite opinion leader and instantly exchange information via avenues such as Twitter®, but how this does or even should change how we practise is unclear. Traditionally, changing physician practice has proven extremely difficult and generally requires comprehensive approaches at different levels (doctor, team practice, hospital, wider environment), tailored to specific settings and target groups.2 Suddenly we are faced by the opposite possibility – that doctors might jump to the latest fad popularised by Social Media interconnectivity. This enthusiasm is then hostage to the common challenge of medical reversal whereby a new superior trial contradicts current clinical practice. Two dramatic recent examples include the failure of targeted therapeutic hypothermia in unconscious survivors of out-of-hospital cardiac arrest of presumed cardiac cause, and the lack of benefit on mortality of intra-aortic balloon pumps in patients undergoing early revascularisation for MI complicated by cardiogenic shock.3, 4 Also, there is still a myth perpetuated that textbooks are 5–10 years out of date when published, which ignores the fact that there has been a rapid evolution in book publishing, too, with utilisation of electronic manuscript submission systems that dramatically cut down the process time, as pointed out by Tintinalli in this issue.5 Indeed, the upcoming 4th edition of Cameron's Textbook of Adult Emergency Medicine, due out in the middle of this year, includes references from as recent as November 2013. As I look back at my 20 years with EMA where I progressed from copy-editor, when paper versions of articles covered in red biro corrections were posted off to the College, via various section editor roles to Editor and then finally Editor-in-Chief, I seek to understand in particular just why papers were rejected by the Journal. In 2001 Taylor found that deficiencies in manuscript preparation were more frequent than mistakes in study design and execution in those manuscripts rejected.6 This is still largely true today, particularly when statistical significance does not equate with clinical significance or medical relevance, and where an article ultimately does not further our knowledge, and fails the Gestalt ‘so what?’ test. Throughout my time at EMA, it has been an honour and privilege to have worked with so many dedicated individuals who so generously gave up their time to serve the Journal. As pointed out by Cone in this issue, most small and mid-size journals are still produced nearly entirely through volunteer labour, on the assumption that this work is part of their academic duties.7 I am indebted to the effort and skill of those of you who have contributed over the years – despite the naysayers of its true worth, I am convinced that our peer-review process did in fact create many a silk purse from a sow's ear precursor! The legacy for the next Editor-in-Chief is hopefully an enduring, robust journal that continues to mature and grow over the next 25 years. If I am allowed some final reflections: funniest article – Greenberg et al.'s spoof Letter to the Editor ‘Thinking outside the box’, that even now still brings a smile to my face.8 My proudest achievement – our stand against drug company advertising.9 The next proudest achievement – I hope – will turn out to be this issue, that I trust every reader will keep for posterity, rather than file in the bin as with other paper issues of EMA. Considering just 18 months ago we were belatedly recognising the need for EMA to climb on board the Web 2.0 roller coaster, I think that we can now be counted among the vanguard of those who are discussing this particular media revolution.10 I wish you all, both readers and journal staff alike, a long and positive continuing relationship with EMA. AFTB is Editor-in-Chief of Emergency Medicine Australasia. He has received part-funding from Astra Zeneca, Boehringer Ingelheim, Sanofi-Aventis, Shire and Roche to attend educational meetings, and honoraria from Boehringer Ingelheim and Roche for educational materials. He is on the Board of the Queensland Emergency Medicine Research Foundation and has received funding from this body as a co-investigator. He has acted as an Expert Medical Witness for the Queensland, Victorian, South Australian and NT Coroner, and on behalf of the Court in negligence (tort) cases.

BACKGROUND: Medical specialization is a key feature of biomedicine, and is a growing, but weakly understood aspect of health systems in many low- and middle-income countries (LMICs), including India. Emergency medicine is an example of a medical specialty that has been promoted in India by several high-income country stakeholders, including the Indian diaspora, through transnational and institutional partnerships. Despite the rapid evolution of emergency medicine in comparison to other specialties, this specialty has seen fragmentation in the stakeholder network and divergent training and policy objectives. Few empirical studies have examined the influence of stakeholders from high-income countries broadly, or of diasporas specifically, in transferring knowledge of medical specialization to LMICs. Using the concepts of socialization and legitimation, our goal is to examine the transfer of medical knowledge from high-income countries to LMICs through domestic, diasporic and foreign stakeholders, and the perceived impact of this knowledge on shaping health priorities in India. METHODS: This analysis was conducted as part of a broader study on the development of emergency medicine in India. We designed a qualitative case study focused on the early 1990s until 2015, analyzing data from in-depth interviewing (n = 87), document review (n = 248), and non-participant observation of conferences and meetings (n = 6). RESULTS: From the early 1990s, domestic stakeholders with exposure to emergency medicine in high-income countries began to establish Emergency Departments and initiate specialist training in the field. Their efforts were amplified by the active legitimation of emergency medicine by diasporic and foreign stakeholders, who formed transnational partnerships with domestic stakeholders and organized conferences, training programs and other activities to promote the field in India. However, despite a broad commitment to expanding specialist training, the network of domestic, diasporic and foreign stakeholders was highly fragmented, resulting in myriad unstandardized postgraduate training programs and duplicative policy agendas. Further, the focus in this time period was largely on training specialists, resulting in more emphasis on a medicalized, tertiary-level form of care. CONCLUSIONS: This analysis reveals the complexities of the roles and dynamics of domestic, diasporic and foreign stakeholders in the evolution of emergency medicine in India. More research and critical analyses are required to explore the transfer of medical knowledge, such as other medical specialties, models of clinical care, and medical technologies, from high-income countries to India.

INTRODUCTION: The quality of reporting of abstracts of randomised controlled trials (RCTs) in major general medical journals and in some category-specific journals was shown to be poor before the publication of the ConsolidatedStandards of ReportingTrials (CONSORT) extension for abstracts in 2008, and an improvement in the quality of reporting of abstracts was observed after its publication. The effect of the publication of the CONSORT extension for abstracts on the quality of reporting of RCTs in emergency medicine journals has not been studied. In this paper, we present the protocol of a systematic survey of the literature, aimed at assessing the quality of reporting in abstracts of RCTs published in emergency medicine journals and at evaluating the effect of the publication of the CONSORT extension for abstracts on the quality of reporting. METHODS AND ANALYSIS: The Medline database will be searched for RCTs published in the years 2005-2007 and 2014-2015 in the top 10 emergency medicine journals, according to their impact factor. Candidate studies will be screened for inclusion in the review. Exclusion criteria will be the following: the abstract is not available, they are published only as abstracts, still recruiting, or duplicate publications. The study outcomes will be the overall quality of reporting (number of items reported) according to the CONSORT extension and the compliance with its individual items. Two independent reviewers will screen each article for inclusion and will extract data on the CONSORT items and on other variables, which can possibly affect the quality of reporting. ETHICS AND DISSEMINATION: This is a library-based study and therefore exempt from research ethics board review. The review results will be disseminated through abstract submission to conferences and publication in a peer-reviewed biomedical journal.

BACKGROUND: Large, multicentre studies are required in emergency medicine to advance clinical care and improve patient outcomes. The Australasian College for Emergency Medicine clinical trials network is available to researchers to assist with facilitating large, multicentre research. However, there is no current information about the research capacity of emergency departments (EDs) in Australia and New Zealand. METHODS: All EDs accredited for emergency medicine training in Australia and New Zealand were eligible to participate. Research leads or ED directors were invited via email and telephone to complete a survey. Data were collected regarding the presence of a research lead; their research experience; available research resources including colleagues, funding, departmental paid research time; publications; and research culture. RESULTS: One hundred and twelve responses were received on behalf of 122 (84%) sites (10 satellite plus main) from a possible 143 sites with all types of hospitals and regions represented. Research leads were identified at 66 (59%) sites; 32 (29%) had a director of emergency medicine research. A wide range of research was underway. Ninety-six sites (66%) contributed data to multicentre projects. Twenty-one centres (17%) were highly productive with multiple resources (skilled colleagues, funding, staffing), a positive research culture and high-volume output. Sixty to seventy centres (50-58%) had limited resources, experienced an unsupportive research culture and authored manuscripts infrequently. Paid time for research directors was associated with increased research outputs. DISCUSSION: ACEM sites have the capacity to undertake large multicentre studies with a varied network of sites and researchers. While some sites are well equipped for research, the majority of EDs had minimal research output.

This article provides background information about the emerging field of international emergency medicine (IEM) and how emergency physicians in Australasia can participate in its practice and development. It reviews the seven key areas of knowledge and skills involved in the practice of IEM as put forward by US fellowship programmes: (i) Emergency Medicine Systems Development; (ii) Humanitarian Relief; (iii) Disaster Management; (iv) Public Health; (v) Travel and Field Medicine; (vi) Programme Administration; and (vii) Academic Skills. Current obstacles to the development of similar programmes in Australasia are explored and identified as primarily financial. Means by which individuals can fund and engage in IEM activities are proposed. This article provides a reference of domestic and international IEM training resources that can be obtained by Australasian emergency physicians and trainees today.

BACKGROUND: The literature on scientific publication errors in medical research is limited, and no studies on emergency medicine publications have been conducted yet. This study aimed to investigate the characteristics of the publication errors in emergency medicine literature. METHODS: This bibliometric study reviewed intervened publication errors in the manuscripts of seven high-impact emergency medicine journals from 2000 to 2020, covering twenty years, and evaluated the corrections in the forms of an erratum, corrigendum, addendum, and retracted papers. The detected publication error rate and the trend, error severity, and error types were calculated. RESULTS: We detected 257 intervened scientific papers consisting of 251 corrections due to one or more publication errors and six retractions. Authors were the primary source of the errors (93.2%). Most of the errors were in the author attribution section (40.5%). The published errors of 7.2% had an impact on the paper's conclusion. Simple typographic errors were the most common error type (62.5%). The corrected publication error rate was 1.3%, with a steady trend over the twenty years. CONCLUSIONS: Publications errors are inevitable, but it is possible to minimize them. The number of corrections in emergency medicine literature is at a low rate and show many similarities with the previous literature.

Emergency airway management is a complex task for emergency physicians. This viewpoint by the EUSEM states the most important aspects and discusses the recently published practice guidelines for emergency airway management of the Society of Critical Care Medicine.

BACKGROUND: Patients with acute conditions often lack the capacity to provide informed consent, and narrow therapeutic windows mean there is no time to seek consent from surrogates prior to treatment being commenced. One method to enable the inclusion of this study population in emergency research is through recruitment without prior consent, often known as 'deferred consent'. However, empirical studies have shown a large disparity in stakeholders' opinions regarding this enrolment method. This systematic review aimed to understand different stakeholder groups' attitudes to deferred consent, particularly in relation to the context in which deferred consent might occur. METHODS: Databases including MEDLINE, EMCare, PsychINFO, Scopus, and HMIC were searched from 1996 to January 2021. Eligible studies focussed on deferred consent processes for adults only, in the English language, and reported empirical primary research. Studies of all designs were included. Relevant data were extracted and thematically coded using a narrative approach to 'tell a story' of the findings. RESULTS: Twenty-seven studies were included in the narrative synthesis. The majority examined patient views (n = 19). Data from the members of the public (n = 5) and health care professionals (n =5) were also reported. Four overarching themes were identified: level of acceptability of deferred consent, research-related factors influencing acceptability, personal characteristics influencing views on deferred consent, and data use after refusal of consent or participant death. CONCLUSIONS: This review indicates that the use of deferred consent would be most acceptable to stakeholders during low-risk emergency research with a narrow therapeutic window and where there is potential for patients to benefit from their inclusion. While the use of narrative synthesis allowed assessment of the included studies, heterogeneous outcome measures meant that variations in study results could not be reliably attributed to the different trial characteristics. Future research should aim to develop guidance for research ethics committees when reviewing trials using deferred consent in emergency research and investigate more fully the views of healthcare professionals which to date have been explored less than patients and members of the public. Trial registration PROSPERO CRD42020223623.

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OBJECTIVES: To explore the magnitude and determinants of burnout among emergency physicians and nurses working at emergency departments of hospitals in Abha and Khamis Mushait cities. SUBJECTS AND METHODS: A cross-sectional hospital-based study was conducted in emergency departments of hospitals in Abha and Khamis Mushait cities belonging to Ministry of Health. All physicians (n=95) and nurses (n=187) currently working at these sites were invited to participate in the study by filling a validated self-administered questionnaire including two main sections: personal and professional characteristics of physicians and nurses as well as Maslach burnout inventory (MBI) to assess the three components of the burnout syndrome: emotional exhaustion, depersonalization, and reduced personal accomplishment. RESULTS: The study included 282 physicians and nurses. The age of more than half of them (54.3%) ranged between 31 and 35 years. Most of them (70.9%) were females. About two-thirds of the respondents (66.3%) were nurses while the remaining 33.7% were physicians. Majority of the emergency healthcare professionals (88.7%) had high emotional exhaustion. The prevalence of high depersonalization (cynicism) was 20.6% whereas that of low personal accomplishment was 41.1% among emergency healthcare professionals. The overall prevalence of burnout among healthcare professionals was 16.3%. Multivariate logistic regression analysis revealed that male healthcare professionals were at almost higher three-folded risk for developing burnout compared to females (aOR=2.76; 95% confidence interval (CI): 1.21-6.28, p=0.017)). Smokers were at higher significant risk for burnout compared to nonsmokers (aOR=15.37; 95% CI: 7.06-33.45, p<0.001). Healthcare professionals who reported a history of taking medications for sleep disorders expressed higher risk for burnout opposed to those with no history of sleep disorder medication (aOR=6.59; 95% CI: 2.08-20.81, p=0.001). CONCLUSION: A considerable proportion of physicians and nurses working at emergency departments of hospitals in Abha and Khamis Mushait cities had burnout syndrome, particularly high emotional exhaustion and low personal accomplishment.

BACKGROUND: Emergency department-based palliative care services are increasing, but research to develop these services rarely includes input from emergency clinicians, jeopardizing the effectiveness of subsequent palliative care interventions. AIM: To collaboratively identify with emergency clinicians' improvement priorities for emergency department-based palliative care for older people. DESIGN: This was one component of an experience-based co-design project, conducted using semi-structured interviews and feedback sessions. SETTING/PARTICIPANTS: In-depth interviews with 15 emergency clinicians (nurses and doctors) at a large teaching hospital emergency department in the United Kingdom exploring experiences of palliative care delivery for older people. A thematic analysis identified core challenges that were presented to 64 clinicians over five feedback sessions, validating interview findings, and identifying shared priorities for improving palliative care delivery. RESULTS: Eight challenges emerged: patient age; access to information; communication with patients, family members, and clinicians; understanding of palliative care; role uncertainty; complex systems and processes; time constraints; and limited training and education. Through feedback sessions, clinicians selected four challenges as improvement priorities: time constraints; communication and information; systems and processes; and understanding of palliative care. As resulting improvement plans evolved, "training and education" replaced "time constraints" as a priority. CONCLUSION: Clinician priorities for improving emergency department-based palliative care were identified through collaborative, iterative processes. Though generally aware of older palliative patients' needs, clinicians struggled to provide high-quality care due to a range of complex factors. Further research should identify whether priorities are shared across other emergency departments, and develop, implement, and evaluate strategies developed by clinicians.

BACKGROUND: The number of Global Emergency Medicine (GEM) Fellowship training programs are increasing worldwide. Despite the increasing number of GEM fellowships, there is not an agreed upon approach for assessment of GEM trainees. MAIN BODY: In order to study the lack of standardized assessment in GEM fellowship training, a working group was established between the International EM Fellowship Consortium (IEMFC) and the International Federation for Emergency Medicine (IFEM). A needs assessment survey of IEMFC members and a review were undertaken to identify assessment tools currently in use by GEM fellowship programs; what relevant frameworks exist; and common elements used by programs with a wide diversity of emphases. A consensus framework was developed through iterative working group discussions. Thirty-two of 40 GEM fellowships responded (80% response). There is variability in the use and format of formal assessment between programs. Thirty programs reported training GEM fellows in the last 3 years (94%). Eighteen (56%) reported only informal assessments of trainees. Twenty-seven (84%) reported regular meetings for assessment of trainees. Eleven (34%) reported use of a structured assessment of any sort for GEM fellows and, of these, only 2 (18%) used validated instruments modified from general EM residency assessment tools. Only 3 (27%) programs reported incorporation of formal written feedback from partners in other countries. Using these results along with a review of the available assessment tools in GEM the working group developed a set of principles to guide GEM fellowship assessments along with a sample assessment for use by GEM fellowship programs seeking to create their own customized assessments. CONCLUSION: There are currently no widely used assessment frameworks for GEM fellowship training. The working group made recommendations for developing standardized assessments aligned with competencies defined by the programs, that characterize goals and objectives of training, and document progress of trainees towards achieving those goals. Frameworks used should include perspectives of multiple stakeholders including partners in other countries where trainees conduct field work. Future work may evaluate the usability, validity and reliability of assessment frameworks in GEM fellowship training.

BACKGROUND: The increasing burdens of trauma and time sensitive non-communicable disease in Addis Ababa necessitate a robust emergency medical care system. The objectives of this study were to assess the proportion of patients who used emergency medical services (EMS) and to quantitatively and qualitatively assess barriers to EMS utilization in Addis Ababa. METHODS: A cross-sectional quantitative and qualitative study was conducted on patients who visited five selected public hospitals in Addis Ababa with specific emergency conditions. Data were collected by trained nurses using a standardized questionnaire. Descriptive statistics and logistic regression was done on cleaned and coded quantitative data using SPSS version 20. Thematic analysis was performed on the qualitative data. Ethical approval was obtained prior to the study. RESULTS: A total of 429 participants completed the survey with a non-response rate of 5.1%. The most common emergency scene was the home (n = 222, 51.8%) followed by road side (n = 159, 37.1%). Only 87(20.3%) patients arrived by ambulance, though a majority (53.4%) of participants recalled at least one access number for an ambulance service and 96.3% stated that ambulances were an important part of the continuum of care for their emergency condition. A higher proportion of participants believed that ambulance transportation is generally safer (n = 341, 78.5%) and faster (n = 298, 69.5%) than emergency transport by taxi or private car. Patients who were non-Amharic speaking had a negative association with arriving by ambulance (P = 0.001, OR 0.47; C.I, 0.31, 0.71). The median acceptable time to get the ambulance (according to respondent's perception) was 16 min but actually perceived ambulance waiting time was 40 min. CONCLUSION: EMS utilization in Addis Ababa is relatively low and emergency patients are instead being transported by taxi or private car. Perceived longer ambulance waiting time and language barriers may have contributed for low utilization. Findings of this study suggest an action to improve access by improving ambulance availability while simultaneously enhancing the public's knowledge and perception of EMS in Addis Ababa.

INTRODUCTION: Health systems offer access to unscheduled care through numerous routes; however, it is typically provided by general practitioners (GPs), by emergency medicine doctors in in emergency departments (EDs) and by GPs in out-of-hours GP services such as practitioner cooperatives. Unscheduled healthcare constitutes a substantial portion of healthcare delivery. A systematic review was conducted to establish the factors that influence parents' decision making when seeking unscheduled healthcare for their children. The systematic review question was "What are the factors that influence the decision making of parents and families seeking unscheduled paediatric healthcare?" METHOD: Five databases (CINAHL, PubMed, SCOPUS, PsycInfo, EconLit) and four grey literature databases (Proquest, Lenus, OpenGrey, Google Scholar) were searched. The titles and abstracts of 3746 articles were screened and full-text screening was performed on 177 of these articles. Fifty-six papers were selected for inclusion in the review. Data relating to different types of unscheduled health services (namely primary care, the emergency department and out-of-hours services) were extracted from these articles. A narrative approach was used to synthesise the extracted data. RESULTS: Several factors were identified as influencing parental preferences and decision making when seeking unscheduled healthcare for their children. A number of the included studies identified pre-disposing factors such as race, ethnicity and socioeconomic status (SES) as impacting the healthcare-seeking behaviour of parents. Unscheduled healthcare use was often initiated by the parent's perception that the child's condition was urgent and their need for reassurance. The choice of unscheduled service was influenced by a myriad of factors such as: waiting times, availability of GP appointments, location of the ED, and the relationship that the parent or caregiver had with their GP. CONCLUSION: Policy and planning initiatives do not always reflect how patients negotiate the health system as a single entity with numerous entry points. Altering patients' behaviour through public health initiatives that seek to improve, for instance, health literacy or reducing emergency hospital admissions through preventative primary care requires an understanding of the relative importance of factors that influence behaviour and decision making, and the interactions between these factors.

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