It is a typical Monday morning in the emergency department (ED). The weekend on-call teams make their way around the de-facto admissions unit, formally known as the acute or majors’ area of the ED, conscientiously reviewing diagnoses, investigation and treatment plans for the patients who arrived over the past 2–3 days seeking urgent medical attention.

Meanwhile, the emergency physician in charge (EPIC) and the ED charge nurse scan the board together, looking through the bundles of charts belonging to patients in the waiting room, searching for those who can be attended to with the scarce remaining and quickly dwindling ED resources.

A child with a fever waiting for 13 h, or an elderly lady with dizziness and increasing falls? A young lady with bleeding in early pregnancy, or a student who has been vomiting and complaining of abdominal pain since Sunday morning? Who will they bring in to the only open bed remaining? Is there anyone who can be seen in the waiting room or at triage? Are there any admitted patients who can be moved out to join those already crowded on stretchers along the hallway, sharing the lack of privacy and facilities with those who have arrived by ambulance only to line up with their accompanying paramedic escorts for more waiting? And what is to be done if a trauma or critically ill patient arrives any time soon by ambulance?

It is common knowledge to all working in emergency care that the traditional skillset of resuscitation, diagnosis, initial management, and careful disposition is no longer sufficient to ensure that timely and quality care is provided to patients in our emergency departments.

Simply accessing care, of whatever quality, is a challenge for many patients, and a major stressor for staff committed to providing that care [1].

A deeper understanding of the principles of patient flow, and a working knowledge of the management of patient flow has become critical for everyone on the frontlines.

Yet, as the integrative review and modified Delphi study from Young et al. [2] in this issue of CJEM describes, there is a concerning lack of curricular content on patient flow in emergency medical and nursing programs.

Their paper recommends that flow training should be prioritized and standardized in training programs for emergency physicians, nurses, nurse practitioners, and practicing healthcare professionals and that gaining insight into the skills that ED staff require to improve flow and efficiency and the appropriate training strategies and modalities to teach these competencies is critical to enhancing ED flow.

We would go a step further and advocate for patient flow concepts to be a core curricular topic for all training in medicine, nursing, and medical administration. As previously outlined, many if not most of the flow problems facing emergency care do not stem from deficiencies in emergency department flow or from incompetent emergency care professionals. Rather, the failure to invest adequately in resources and infrastructure for primary care, preventative care, and long-term care has resulted in the arrival of patients who have no other choice but to flow to and through our emergency departments.

When the RMS Titanic sank on the evening of April 14th 1912 off the coast of Atlantic Canada, J Bruce Ismay, chairman and heir to the White Star Line shipping company, owners of the Titanic, was one of the lucky few who managed to board one of the 20 lifeboats that the infamous ship had been fitted with. Twenty lifeboats on a ship that could hold over 2800 people [3]. The ongoing societal failure of unequal access to an inadequate supply of essential healthcare in Canada and many other nations is not the only parallel…

The Titanic, we are told, was sailed into a known iceberg field with the overconfidence built on a belief that the ship was unsinkable. Are we sailing head on into a predictable healthcare catastrophe, an iceberg field where we face rising numbers of elderly patients with growing health needs, having previously suffered reductions in investment in healthcare training, with reduced access to healthcare resources, and having for some reason assumed that our emergency departments (the lifeboats) would somehow be able to pick up all those patients and safely deliver them to their healthcare destination?

Investment in resources, training and compassion for our teams and patients remains the most likely pathway through the iceberg field we all face (4). Investment in system wide patient flow processes, both in and beyond the ED, on a local and regional level is essential, as is formalized patient flow training for those tasked with managing and working in these systems. Yet, for the foreseeable future we will still face the difficult choices of who gets to board the lifeboat next, and for that we must retain and grow our compassion for our patients, our staff and ourselves.