It is strange to walk through the doors again. Fifteen years on and there is more familiarity than novelty. The cubicles, inevitably full of patients on trolleys, are no different. The "walking wounded" and "dressings" areas are as they were when I toiled at this particular coalface.
The casualty department of Mater Misericordiae Hospital, in Dublin, was my first job as a fully fledged doctor. Having spent the first year after qualification as an intern - essentially, a doctor with L-plates - I was now deemed fit to minister independently to my fellow humans.
Of all the junior hospital-doctor posts I filled, accident and emergency - to give it its politically correct name - is the one with the best and most varied memories.
Enough of this reverie. I am back as a journalist to see how the gateway to one of Dublin's principal teaching hospitals is gearing up for the winter onslaught.
Much of its seasonal workload can be attributed to an increase in infectious illness. The elderly, in particular, are vulnerable to flu and other infections that can easily overtax their respiratory and cardiovascular systems.
People with asthma and those with chronic obstructive airways disease are more likely to find themselves in need of emergency medical treatment during the winter. In the 1980s, this almost inevitably meant a hospital admission for up to a week.
Chest pain is another common symptom of those who arrive at the emergency department. It is one that needs to be dealt with expeditiously; delays can cost lives. In the "good old days", we had no difficulty in rapidly assessing and admitting such patients to the coronary-care unit.
As A&E departments have become clogged up over the past few years, people with breathing difficulties and cardiac problems are finding it more and more difficult to access emergency medical care. It is particularly annoying for patients with established cardiac and lung disease - and their doctors - not to have access to the level of care that everyone agrees they need.
So it is interesting to hear of initiatives aimed at bypassing the accident-and-emergency blockade.
Dr Sean Gaine, who returned a year ago from a post as assistant professor of respiratory medicine at Johns Hopkins University, in Baltimore, to a consultant post at the Mater, brought with him some novel ideas for improving the situation.
The emergency medicine acute respiratory care programme began in March. It is modelled on a US system of fast-tracking the treatment for acute worsening of asthma or chronic obstructive airways disease. As part of the programme, the Mater recruited two respiratory nurses and developed a protocol under which they could evaluate and quickly treat patients within the A&E unit.
Since March, a patient who comes to the Mater with an acute respiratory problem is directed to a newly equipped part of the A&E department. The first thing he will notice is that he is placed in an armchair, not on a trolley. The nurses quickly assess his condition and begin immediate treatment according to the pre-arranged guidelines.
Medication will be given via a nebuliser - a pressurised-air mask that delivers drugs to the lungs - and, if necessary, the nurses will order a chest X-ray and other investigations. All of this occurs before a doctor is called.
Again, the protocol determines how quickly medical assistance is required. For those who are especially ill, this will be immediate. For others, the nurse will advise the doctor on duty that they are treating the patient, but that there is no need for immediate medical attention.
In the recent past, lengthy waiting times meant a patient with breathing problems could have worsened considerably before treatment began.
Statistics show that 80 per cent of these patients required hospital admission. Amazingly, a study of more than 150 patients treated this year found that the nurse-led service has managed to discharge 75 per cent of cases within four hours of arriving at A&E.
It is a staggering turnaround in the quality of care, apart altogether from the beneficial effects on scarce hospital inpatient facilities.
"There is a sense that this initiative has made a big difference to the operation of the emergency department," says Gaine. While A&E visits are up, admissions have not increased to the same degree, which eases the pressure on the rest of the hospital, he says.
Patients are appreciative also. Auveen Kelly, one of the respiratory nurses, describes a meeting with the wife of one of their "regulars", who was in the department with a non-respiratory problem. "I wish it was his breathing he came in with, because he is looked after so well," was her response to the delays her husband faced.
For those who are not fit for discharge, a clear decision to admit is made after four hours. And because they have already been fast-tracked onto treatment, the process of admission is speeded up also.
In a related development, cardiologists at the Mater established a chest-pain-assessment unit in August last year. Four beds have been set aside next to the coronary-care unit, and a clinical nurse specialist for chest pain has been recruited, according to Dr Declan Sugrue, consultant cardiologist. Given the nature of the disease, it is inappropriate to discharge patients as quickly as the respiratory service does. But since its introduction, the average length of stay for patients with cardiac problems has been reduced from 11 days to three.
The new service effectively bypasses the crowded accident-and-emergency unit. With a dedicated medical registrar available, as well as the specialist nurse, patients with cardiac chest pain generally suffer no delay in receiving the most appropriate treatment for their condition.
Dr Eamonn Brazil has just started work as the department's second consultant in accident-and-emergency medicine. What changes would he like to see in Irish hospitals, based on his experience working in London and Leicester? "We need to look to maximise the efficiency of A&E departments by improving the triage system [the process of prioritising patients according to the degree of medical urgency] at the patient's point of entry. Patients must be fast-tracked to acute respiratory care and to the chest-pain clinic, as we have recently started to do."
The appropriate use of an A&E observation ward, where patients can be admitted for up to 48 hours under the care of staff, for conditions such as minor head injuries, fractures and soft-tissue infections, is also important, he says.
Brazil is keen to emphasise that you could quadruple the number of A&E consultants in the hospital, but that without increasing the number of beds, in order to admit more people, and the number of cubicles, in order to examine more patients, the extra staff wouldn't make a difference.
A project to ring-fence beds for people who require emergency medical admission is something the Mater is about to start. Dr John Crowe, a consultant physician, is chairman of the hospital's medical emergency division project, which will begin a revamp of the Mater's facilities on December 1st.
"The original thrust for this project came from the difficulty reconciling the unremitting daily demand for A&E beds with the hospital's other responsibility to provide specialist services for patients from the waiting lists, out-patient clinics and tertiary referrals," he says.
From next month, all emergency admissions will be centralised into a 44-bed cardiac unit, a 62-bed general medical unit, a 55-bed unit dedicated to the acute care of the elderly and a seven-bed A&E observation ward. This will enable more focused management of these patients; the medical-emergency-division wards will be staffed with higher than usual levels of nurses, physiotherapists, occupational therapists and social workers.
The initiative is a partnership between the hospital, the Eastern Regional Health Authority and the Northern Area Health Board. It will pose a significant challenge to hospital staff, who will be expected to work according to new protocols. Its success will also depend on how effective and innovative the Northern Area Health Board is in helping elderly patients and the young chronically sick back into the community or into long-term care.
A conservative estimate puts the potential for additional bed days at 15,000 a year, if the new system goes according to plan. In other words, the hospital could admit 3,000 extra people for five-day stays to undergo procedures such as gall-bladder removal or hernia repairs.
It is an ambitious plan. But the medical-emergency-division initiative, coupled with a better approach to the treatment of chest pain and breathing problems within the A&E unit, shows the Mater has not been defeated by the hospital crisis.
With the Government's new health strategy due for publication shortly, the hospital is already ahead of the game. We should know by April how successful it has been.
You can e-mail Dr Muiris Houston at mhouston@irish-times.ie or leave a message at 01-6707711 ext 8511. He regrets he cannot reply to individual medical problems