The album's title is a reference to the ER (called Accident & Emergency in the United Kingdom), where Pierce spent several weeks in 2005 with a bout of double pneumonia. The effects on his sound are apparent: His typically scratchy voice is even more so here, and it is drenched with frailty on "Don't Hold Me Close" and weariness on "Death Take Your Fiddle" (which is eerily punctuated by the repeating sound of a ventilator).
Listening to Pierce muse on death can be draining, so he breaks up the album with six brief palate-cleansing numbers titled "Harmony" and subtitled by the main instrument featured (accordion, glockenspiel, piano, etc.). Interspersing short numbers in an album is not always a successful tactic, but Pierce's vignettes pull his longer pieces together instead of driving them apart.
"A&E" does have a few weak points (the singsongy "dit-dit-dit-doo" chorus of "Baby I'm Just a Fool" feels particularly out of place), but his final number, the beautiful, glacially paced lullaby "Goodnight Goodnight" shows how strong his songs can be when he is so vulnerable.
-- Catherine P. Lewis