The ‘art’ of anaesthesia has some truly archaic heritage, with the use of narcotics to stem pain from surgery or illness being recorded from thousands of years ago. However, the origins of modern inhalation anaesthetics lie in the nineteenth century when, with the demonstration in the mid-1800s of ether being administered to a patient by a dedicated physician to allow dental extraction, the anaesthetist was born. Since that time, there have been great advances in anaesthetic agents and techniques, but no evolution has been greater than that of the anaesthetists themselves. Modern anaesthetists possess key skills and knowledge that are vital to the stabilisation and initial management of myriad conditions. As a result of these attributes, we have evolved to be integral (although often unsung) in a broad and diverse number of specialist areas both within and outside hospitals. Such diversification has naturally led to increased specialisation; and so it should be, given the increasing evidence that specialisation and centralisation of care can improve outcome for uncommon conditions.
The dependence on our skills in such varied clinical situations raises the question of whether emergency care could become compromised if we continue down the road of subspecialisation. Indeed, we are increasingly seeing a new role for emergency, trauma and pre-hospital anaesthetists; so even emergency management itself is now being recognised as requiring specialist training and knowledge. Even in specialist centres, anaesthetists and intensivists will be required to deal with emergencies outside of their normal professional comfort zone. Likewise, it is not uncommon for the ‘generalist’ to be confronted with a ‘specialist’ emergency. A classic example of such a dilemma is the adult anaesthetist presented with a child requiring immediate emergency care. With the anaesthetist ‘on the scene’ using his/her life-saving skills guided by expert advice and direction given by telephone, successful and high standard treatment need not be compromised. However, telephone advice takes precious minutes to obtain; minutes that may make an important difference to the patient/child’s outcome. By possessing a fundamental knowledge of the key issues and decisions during the early, life-supporting stages of such illness, any and every anaesthetist has the capability to provide vital life-saving management in the myriad of challenging clinical environments that may face us, however, rarely.
The conceptual birth of this Supplement and its constituent articles arose in response to the challenges presented by increasing subspecialisation of anaesthetic roles, especially those involving emergency care. With the technical and intellectual advances in all these specialist areas, staying abreast of the current literature and keeping up-to-date in all fields is a major challenge. Indeed, it is a challenge reflected in the Royal College of Anaesthetists guidance on continued professional development for Revalidation .
The aim of the articles that follow was to provide guidance and insight from world-renowned experts in specialties that frequently deal with life-saving emergencies. By the nature of the breadth of areas in which we work, the articles are not all-encompassing and do not (indeed they cannot) cover all areas. For example, we do not include obstetric emergencies, major incident management, aviation medicine and ‘field’ anaesthesia, to name but a few. What is included covers the management of patients from pre-hospital perspectives and major trauma through to specialist hospital situations such as paediatric, vascular and medical emergencies, anaesthesia for emergency surgery and, for the grand finale, a crash course in toxicology. Not all reviews are aimed at informing which tubes to put down and which drugs to give; significant emphasis has been placed on both the organisational as well as clinical aspects of management. For example, in their eloquent article on the organisation and planning of anaesthesia for emergency surgery , Gray and Morris highlight the complex and challenging issues that surround this vital aspect of anaesthetic care; this they follow with a more practical review of clinical conduct for such anaesthesia . in a detailed review of trauma management and its recent widespread developments, Lendrum and Lockey  inform us of the changes that are finally taking place in trauma management after decades of knowing that such care could be improved. For any cynics of these changes, their article makes humbling reading.
On a more practical level, Booth et al.  and Mercer et al.  provide both civilian and military perspectives on the challenges faced in pre-hospital environments, the latter with particular emphasis on current UK Medical Defence Services management of haemorrhage and coagulopathy following trauma. To end, after expert guidance on the latest in paediatric, vascular and medical emergency management [7–10], Wong and Irwin demonstrate just how much fun they must be at parties with their fascinating insight into the world of acute toxicology .
We hope that these state-of-the-art reviews will educate and entertain at both cerebral and practical levels. Their breadth emphasise just how varied our specialty has become and the challenges of staying abreast of the latest in medical trends. A glance through the topics might raise the question of whether subspecialisation could diminish the number and availability of ‘generalists’ with life-saving skills, or whether it will actually increase the standard of care delivered by those who chose to specialise in emergency care.
In response to such concerns, detailed consideration of the articles within is reassuring; each review highlights the need for generic life-sustaining skills and knowledge that can be applied when an emergency develops in any specialty setting. Similarly, the articles highlight that with minimal (albeit expert) educational update, we can maintain the knowledge needed to cope with rare life-threatening emergencies. So, while discomfort may prevail when an adult anaesthetist enters the realms of paediatrics, or a hospital anaesthetist finds him/herself in the pre-hospital environment, we should have confidence that the skills and training common to all anaesthetists will enable us to cope with the most demanding of situations.