The Accident and Emergency Department at St Luke's Hospital is a highly sensitive department through which all medical and surgical emergencies are admitted.

It has a patient turnover of over 100,000 per year - more than a quarter of the Maltese population each year. Staff at A&E manage all acutely and critically ill patients, ranging from multiple trauma to serious medical conditions. This means caring for those grievously injured in assaults, road accidents, falls, occupational injuries, as well as those threatened by myocardial infarctions, cardiac arrests, strokes, respiratory failure and the like.

This span of life-threatening conditions makes it crucially important that all doctors working in A&E are sufficiently knowledgeable, experienced and confident in dealing with all these various emergencies as they arise.

A&E is not the place for junior or inexperienced doctors, because this imperils patient care, quite apart from contributing to delays in the department and risk stressing other physicians.

A rather unfortunate approach to allocating doctors to the accident and emergency service has been increasingly adopted in the recent past, especially in recent months.

There has been repeated and frequent turnover of doctors assigned to work in the A&E Department, often at short notice. This makes it very difficult to adequately train these colleagues to face their difficult responsibilities.

Every few months, a significant number of experienced doctors from A&E are deployed to work with other specialities. These colleagues, who have been trained or were in the process of being trained up to the competence required to safely operate in A&E, are then replaced by doctors with little or no experience in dealing with emergency conditions.

Inevitably, this challenge could lead to unsafe work practices, because only very junior and inexperienced medical staff are available to deal with the bulk of patients.

Surprisingly, these transfers and replacements often occur without the prior knowledge or consent of the consultant in charge of the A&E Department. It is imperative that an adequate number of senior house officers be permanently assigned to A&E and for these to be supplemented by other doctors contracted to work in the A&E department for an adequate, minimum period, say one year. This would not only ensure better patient care but also that junior and inexperienced doctors are not traumatised and burnt out.

These major problems were magnified further some two weeks ago when the number of doctors working the morning shifts in A&E were reduced, following directives by the Medical Associ-ation of Malta aimed for senior house officers working in A&E. This depletion of medical staff inevitably results in prolonged waiting times for the patients and increases the stress of all the staff in the department.

The A&E Department is currently under the responsibility of only one consultant, who is expected to, single-handedly, provide training for new doctors, devise work policies, arrange rosters and leave, and handle all the administrative work that his job description entails. The appointment of more consultants in A&E is urgently required to address this volume of work.

Doctors working in the A&E Department receive a relatively much poorer remuneration than colleagues of comparable grade. This because of the very nature of the work, which is intense, non-stop and particularly stressful.

Consequently, it is impossible for A&E doctors to work overtime in the A&E Department, as this would lead to rapid burnout. In addition, soctors wishing to specialise in emergency medicine are required to undergo a training programme which includes secondments to other specialities.

To add insult to injury, because of the chronic shortage of experienced medical staff in A&E, it is very difficult to release these doctors from their duties in A&E so that they can hone their expertise during these secondments. This is causing them further frustration.

It is a great pity, and to the long-term detriment of the provision of good A&E service, that these factors 'disincentivise' most doctors from remaining in the A&E Department long-term, with many moving on to other specialities or overseas, where working conditions and salaries are better.