Some of the biggest challenges revolve around the volume fluctuations intrinsic to the emergency department. We can be slow and a few minutes later inundated with patients. I remember one recent day we were quite slow. In about ten minutes time we had four ambulances arrive, two with active heart attacks and one unconscious patient. Within the same timeframe we had five patients walk in with more minor problems. The walk-in patients had to wait while we treated the patients with life-threatening conditions. It is frustrating to me and the team that we can’t always see patients as quickly as we would like.