In this December issue.

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Virtual clinical care is a rapidly developing component of modern health systems. As Andrew Staib and Stephen Gourley say in an editorial, the ability to provide specialist decision making, advice and monitoring where it might otherwise not be available is a major advantage of virtual emergency care. Remote and pre-hospital retrieval environments are areas where the virtual presence of specialist emergency physicians have shown particular benefits. They wisely caution that these new models need robust evaluation when assessing efficacy and cost-effectiveness. Linked to the editorial is a fascinating paper from a large team in Victoria. They conducted a return-on-investment analysis of a virtual ED (VED) program developed in response to local changing healthcare needs, using an economic model based on initial patient outcome data to assess the healthcare costs, potential costs saved and return-on investment from the VED. Every day in EDs, clinicians face situations where they need to decide whether to detain a patient for assessment and treatment. For patients who meet the relevant criteria, provisions of mental health legislation can be used. For other patients, clinicians often rely on so-called ‘duty of care’. In an excellent review, the authors explore this complex area of law, including the relevant legislation, common law principles and grey areas. Highly recommended reading. We publish a survey that sought to identify barriers to recognising and reporting potential child abuse by medical officers and nursing staff in the EDs of three Western Sydney hospitals. The authors conclude that a combination of hospital, departmental and individual staff issues such as time limitations, lack of resources, education and support are barriers to reporting suspected child abuse. In the first large-scale study since the 1980s to explore external causes of unintentional childhood injury presenting to Australian paediatric EDs, six major paediatric hospitals in four Australian states provided data for 2011–2017 on age, gender, attendance time/date, presenting problem, injury diagnosis, triage category and mode of separation. Three hospitals supplied data on external cause and intent of injury. A total of 486 762 ED presentations for unintentional injury in children aged 0–14 were analysed. The results supplement existing knowledge of hospitalised paediatric injury to better understand the causes of childhood injury by age and gender, which require health service utilisation. Opioid-related harm has risen in recent decades, but there is limited research to describe the clinical burden of opioid poisoning to Australian EDs. We publish an observational series of prospectively collected data investigating presentations of opioid poisoning to an ED in Newcastle, NSW (1990–2021). Type of opioid, naloxone administration, intubation, intensive care unit admission, length of stay and death were extracted from the unit's database. Opioid presentations increased in number and severity over three decades as the type of opioid changed. Oxycodone is currently the main opioid of concern. Methadone poisoning was the most severe. Between June 2016 and June 2020, 1548 major trauma patients were admitted to Christchurch Hospital or died in the ED. An analysis of these case concludes that after controlling for age and injury severity, having a lower temperature on arrival in ED was a significant modifiable risk factor for death. Additionally, intubation prior to hospital, increased base deficit, lower initial haemoglobin and lower GCS were risk factors associated with death. The authors suggest that all pre-hospital services should have key performance indicators for temperature measurement and management. A team from Western Australia report the demographic profile of adult patients presenting with constipation and constipation-related issues to an Australian Tertiary Hospital ED, the first study to investigate the management of constipation in adult patients in an Australian ED setting. They conclude that it is important that ED clinicians recognise that functional constipation is a chronic condition and many patients have persistent symptoms. There are opportunities for quality-of-care improvements including diagnostics, treatment, and referral post-discharge to allied health, nursing and medical specialist services. The subject covered in this issue is volunteering, a component of personal and professional life for many clinicians, and one that is rarely discussed openly.