There are new hands at the EMJ tiller this month and the new editors introduce themselves and their first thoughts on change in their first editorial. It seems that evolution rather than revolution is on the cards.

Rachael Clements and our own Rod Mackenzie enter potentially controversial waters this month with their discussion paper on evolving concepts of competence in prehospital care B. They point out that competence can be defined in many ways – with the simplest being "the ability to operate to an adequate, safe standard". At this level it is not really an aspiration but a requirement. The real issue in an evolving specialty is not about whether practitioners should be competent – but is about the definition, measurement and maintenance of it. The authors explore existing frameworks and mechanisms in an attempt to see if any fit well with the specialty. This is a debate to join in with – not to watch and wait.
See page 516

In a short paper Henson and Vickery consider the considerable problem of clinical risk and the self-discharging patient. They present their data on two 3 month periods that straddle an intervention designed to both introduce a capacity assessment and advice sheet in this patient group. They find a surprisingly high triage acuity in this group – with 21% having a presenting complaint of chest pain. Many practitioners in city-centre departments will envy their self-discharge rate of only 0.5% and may question whether this high acuity is reflected in their departments. However, the message is clear – we ignore this group of patients at our peril.
See page 499

Leong and colleagues give us a no frills approach to the management of epistaxis. This very practical, numbered approach is one that may well appeal to readers keen to ensure that they have a clear idea of the skills they need to deal with this common problem. It certainly should strike a chord (not vocal) with those of you who have to take exams soon!
See page 470

In an interesting trial carried out by the Welsh Ambulance Service, Moore and Woollard investigate the effectiveness of 2 different strengths of glucose solution in the management of hypoglycaemia. Their study group is unresponsive adults with low glucose attended by a paramedic emergency service. They find that 10% glucose is not only as effective as 50%, but that it results in lower peak glucose levels. This may be an area where prehospital research is pointing the way for hospitals; we should surely consider whether 10% solution should be used in adults in hospital as well. After all it’s already is the solution of choice in children.
See page 512

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