‘There is this narrative around — it’s just lazy doctors’: The true story of ambulance ramping and ED deaths
Dr Megan Brooks fronted a parliamentary select committee last week.
Her testimony, which took about 45 minutes, was about ambulance ramping, the spectacle of patients in the midst of an acute health crisis stuck in the back of an ambulance a few metres from medical care.
That the physical distances are so small and the ED so distant explains the media and political obsession, particularly when things go wrong and someone dies.
However, Dr Brooks, the former director of the ED at the Royal Adelaide Hospital (RAH), went before MPs to offer a deeper insight into the realities that would be almost comic if the consequences were not so tragic.
What follows is an account familiar to many doctors of working in a system where each day, every day involves a flirtation with catastrophe that each day, every day you manage to dodge.
Except, of course, until the day you don’t.
Resus 2 or 2C786?
Her story starts in 2017 having just been appointed director a few months before being tasked with moving the ED into a new home in the newly-built $2.7 billion tertiary hospital.
“We spent a lot of time looking at the design of the ED and trying to give feedback that it wasn’t going to work very well,” she told the MPs.
“The actual functional layout of the ED wasn’t one that was going to make it easy, particularly for us to retain line of sight for patients.
“Similarly, having three walls and a door on all the cubicles, while that was brilliant during COVID, meant we had to staff the ED in ways very different from a traditional ED where you have what’s called a fishbowl that’s up in an elevated position so clinicians [can see into] all the cubicles.
“What we had in the design of the new RAH was, in fact, the very opposite of that.”
She told the committee that at the time of the big move there was a belief within the Central Adelaide Local Health Network, which managed the hospital, that there would be direct admissions to the wards, an easy way of getting patients in and then out of ED.
As a result, the triage process was renamed by staff the ‘quick look’, Dr Brooks said, because “apparently we were only going to need to have a quick look at many of our patients and they would just be automatically going through to the ward”.
“Even up until 3 September 2017, which is the day before we moved to the new hospital, I was being told, ‘No, no, there’ll be ‘quick look’, people will just move up to the ward.’
“I was always asking how that would happen because I didn’t see any process or protocols. I [also] didn’t know how we were going to get the patients entered into the Electronic Medical Record (EMR) system.
“Time after time we, as clinicians, were saying, ‘How is this supposed to work?’
She said the first month at the new hospital was one of the most difficult professional times of her life.
“We had to start using the EMR on the first day, and I don’t know of any other group of clinicians that were asked to move into an entirely new building and use an entirely new EMR on the first day.
“So we slept in that building. We had sleeping bags in our offices, and we stayed and we slept in that building just so we could make sure that our patients were safe.”
She said even the way the rooms were numbered in the new ED became a trigger for major headaches and delayed care.
“They were numbered with wayfinding numbers, so it was ‘2C786’ instead of something sensible like ‘Resus 2’.
“Cubicle 1 wasn’t next to cubicle 2, next to cubicle 3.
“So when an emergency bell was pushed, on the overhead we would have 2C786 and something else and we would all be grappling to grab our little map to try to work out where our colleague had pressed the emergency bell because we didn’t have normal sequential numbering.”
She said she spent hours arguing the case with management to secure permission to renumber the cubicles so staff could find people when they were really unwell.
“We clinicians… couldn’t even find the sick person… But I would be told, ‘You can’t change the number because someone might want to change the light bulb in that room in 10 years’ time.’
“I would say, ‘Well, I would quite like to find your relative if they are dying.’
This battle to number the cubicles sequentially took almost a year, she said.
“But it is only in recent years that we have been able to take down the laminated plastic temporary signage because we were not even allowed to stick things on the wall.”
‘You’re too expensive!’
Dr Brooks described her first months as director of the ED as a steep learning curve. She had only been an emergency physician for three years. But she got through she says with the support of her fellow clinicians as well as the nursing staff, particularly the support of the hospital’s lead nurse Dr Tina Jones (PhD).
She told the MPs that she was soon being quizzed by managers over costs or as she put it “being castigated for running an incredibly expensive service”.
It turned out that this was a result of the ED activity not being counted accurately by the managers.
The bean counters were meant to use a measure known as a national weighted activity unit to document what the ED was doing, which was then measured against what was considered a national efficient price for that activity.
She said the counting of activity was so out of whack with clinical reality that her ED, the biggest in the state, was at one stage found by the accountants to be doing less activity than the ED at Mount Gambier Hospital, 400km away.
“To compound that, I was also being billed for a whole raft of tests that my inpatient colleagues were actually ordering. I have never ordered a mammogram in my life; I am an emergency physician.
“Yet, if that test was ordered as part of that patient’s inpatient workup, the ED would be given the bill — and that continues today.
“If my neurology colleagues order an MRI, even if the patient doesn’t have that MRI for two or three days, the cost of that is attributed to the ED.”
She said it took until 2022 and a review by Dr Paul Tridgell, a former NSW Health executive and national expert on hospital funding, for the bosses at the hospital network to accept that the source of the high costs in ED were bound up in the accounting.
“[Until that point] my recurrent experience was of going to the finance people in the department and being told that their accounting methodology was fine and what I needed to do was make sure there was never a patient in the ED who should be on a ward.
“I said, ‘That’s brilliant. How?’ What I needed was to not have the tail wag the dog. I needed the accounting methodology they were doing to actually reflect reality.
“It was only when [Dr] Tridgell met with me that I realised from his report that I finally had some vindication because I am not an accountant; I am an emergency physician.
“It was only then I understood I was in fact right, that we weren’t managing this in the same way as NSW, Victoria or Queensland.”
The patient deaths
Those who have been tracking the various sagas around the RAH in recent years will know that ambulance ramping has been a political hot potato for a long time, just as it is around the rest of the country.
Last year a coroner began an inquest into three so-called ramping deaths — two of them at the RAH during the time when Dr Brooks was director of ED.
Dr Brooks spoke in some detail before the select committee about what had been happening.
As doctors have said for years, she stressed that the ramping phenomenon was a symptom of deeper structural difficulties, the canary falling unconscious in the coalmine.
But what she said is worth repeating in detail simply because it shows how far the public debate is from grasping how hospitals work and the decisions that doctors have to make when resources are finite.
“I don’t think there is any clinician who thinks delaying access to care for any patient is acceptable and I think any emergency clinician, indeed any hospital clinician, recognises the importance of timely access to an ambulance in our community,” she said.
“There is this stereotype that I have heard more than one time that emergency physicians like ramping, that we are addicted to it and various other things, and these are deeply offensive things to say to clinicians, but I have heard them from so many different sources.”
At the RAH they initially employed an extra emergency physician who was available to the paramedic crews and could support the triage nurses whenever they were unable to offload an ambulance in timely fashion.
But the fix got crushed by the pressures, she said.
Having to use a brand new EMR that the rest of the hospital was not using was one big issue sucking up staff time, she said.
So was working in a physical space that was not fit for purpose.
But then there were the pressures stemming from the fact that for patients close to a mental crisis arriving in ED there were nothing but the ED to care for them.
“We communicated this to the executive of [Central Adelaide Local Health Network] and we also communicated that to the then-CEO of SA Health and asked for support to try to be able to mitigate the risk and be able to manage things.”
“We didn’t have enough doctors,” she added.
“We also asked the question: What is the medicolegal jeopardy here? We wanted clarification and we never got an answer to [our] letter.”
What do the triage categories really mean?
She said the number one cause of ramping was the mental health access block. She said it was not uncommon, then and now, for the ED to have 20 of the 75 cubicles occupied with mental health patients, where some would languish for days.
She said the reason the ramping issue had been so difficult to discuss was because of the limited understanding of those outside ED of what the triage categories actually meant.
“People take them to infer that just because you had a lower triage category, that means that you didn’t need to have care in an ED, and that’s fundamentally wrong.
“We know that the highest morbidity and mortality is actually associated with patients who are in triage category 3 and triage category 4 because they are often frail, elderly and have multiple medical problems.
“A triage category is actually just a description of how long that patient waits before we have to commence care.
“It doesn’t tell me anything, really, about the likelihood that patient needs admission, the likelihood that they might die or whether they could have sought care somewhere else outside of an ED.”
She added something to which the federal Minister for Health and Aged Care Mark Butler, and his billion dollar investment in Medicare urgent care clinics, should also pay note.
“There are a lot of myths around, ‘If only the triage 5 patients didn’t turn up, we would be fine,’ and that’s just fundamentally not accurate.”
She said her ED was really dealing with three streams of patients — at one end, the resuscitation patients (10% of presentations) who were critically unwell, and at the other end, the ambulatory stream (40% of presentations) whose care requirements were far less complicated, those with a single problem who are likely to be discharged.
In the middle was the ‘assessment stream’ who made up the remainder.
“When I have finished my assessment of the patient and I have decided they need an inpatient admission, I [would] put through an admission order and that’s a signal in the EMR to the patient flow team to find a bed.
“Obviously, I have had a conversation with an inpatient colleague who has agreed that that patient needs to be admitted for inpatient care.
“We try to do as much of that in parallel as we possibly can. So we are trying to find the bed at the same time that the orthopaedic RMO is coming down to clerk the patients and write up their medications.
“If it’s clinically appropriate and we happen to find a bed, I will then write an interim plan and the patient can go up to the ward…
“But at the RAH we have about 40 assessment cubicles and if 20 of those have admitted patients in them, I have only got 20 cubicles to see a hundred and something patients through.
“That is the cause of ramping at the RAH.
“Those patients don’t need resus, they’re not well enough to be in a waiting room, they might be frail and elderly with abdominal pain, but they are not sick enough to need resus and they are not well enough to be able to be managed as ambulatory.
“So it is, generally speaking, those category 3 and category 4 patients who have a 50% chance of needing admission, who are often frail and elderly, who experience long delays to accessing care on the ramp.”
The two ‘ambulance ramping’ deaths at the RAH currently subject to a coroner’s inquest were those of Anna Panella and Bernard Skeffington.
Dr Brooks said Ms Panella attended the RAH ED in 2019 just after the time that the ED had been forced to ditch the consultant-led approach to provide ongoing assessment of patients stuck on the ramp.
“So we no longer had that medical input and we had to make a decision, both as medical and nursing, that we couldn’t continue to have that very assertive, active approach to reviewing patients on the ramp at the RAH because there simply weren’t enough staff.
“We didn’t have enough triage nurses to be able to allow them to go and always visualise a patient. We didn’t have enough consultants to be able to roster an additional person.
“Many of us — and this applies to the nursing leadership as well — would come in after hours and on weekends and all sorts of times just to try to mitigate the risk, but we had to make that decision after we communicated to the executive that we couldn’t perform [the active approach] anymore.”
Months later, Ms Panella died.
Dr Brooks said Ms Panella was admitted to the resuscitation room after waiting in the ambulance for nearly an hour. Her death, she stressed, was probably unavoidable given she had experienced a massive pulmonary embolus.
“[Preventing ambulance ramping] wouldn’t have changed the outcome, but what we know is that ramping is a symptom of an overcrowded emergency department. [And we know] the risk of morbidity and mortality — and this is very well-established in the literature and has been for 20 years — isn’t just for a patient who is delayed in an ambulance.
“The risk of being seen in an overcrowded ED is experienced by the patient who is in the waiting room, it is experienced by the patient who is in a cubicle and it also is experienced by the patients who are access-blocked as well.
“To that point, ramping is a symptom; it’s a symptom of an overcrowded emergency department, where
clinicians like me are not working in an environment that allows us to make the best decisions.”
In the case of Mr Skeffington, the 89-year-old died in September 2021 during the COVID-19 pandemic, when the ED had been split in two to separate the COVID-19 cases.
He waited in an ambulance for over an hour and 40 minutes before being taken into the ED in peri-arrest.
“Unfortunately, we were very worried that something would happen like what happened to Mr Skeffington,” Dr Brooks said.
“Where we would have a frail, elderly patient, who was a category 4 or a category 3, who wasn’t suitable to go to the waiting room, who would experience a delay on the ramp, and we didn’t have the right number of spaces in the non-COVID part of the ED.”
ED can feel like working in a psychiatric unit
Dr Brooks spoke about the pressures on staff during COVID-19. But she also spoke more generally about the job of being an ED doctor.
“Being an emergency clinician is an incredibly cognitively heavy task.
“If I don’t get the right piece of information if I don’t make the right decision, someone might die.
“To do that in an environment where you are running your ED, which often it feels like… a psychiatric unit, with not enough staff, with equipment that doesn’t work, and a physical environment with poor line of sight and challenging layouts, is incredibly difficult.
“We know that we have added to the morbidity and mortality of every patient who has transited through an ED when it’s overcrowded.
“That risk doesn’t stop in the ED; it continues with that patient throughout the entirety of their journey.
“So rather than a focus on a small group of patients who have delayed access to timely care in the ED, who spend that time in an ambulance, my strong preference has always been to look at all the patients, irrespective of how they arrived, where they were seated before they got in a cubicle, and look at the harm that they might be experiencing.”
An attempt to silence Dr Brooks?
During her appearance before the committee last week, Dr Brooks was speaking under parliamentary privilege.
This is important because without that protection we may not have heard from Dr Brooks at all.
Last year she had been called to give evidence by the state coroner examining the patient deaths linked to ambulance ramping.
She said she wanted to give evidence, in part because she had seen how previous coronial recommendations had been made in ignorance of what the real issues were.
But she feared repercussions if she spoke out, saying that SA Health had refused to allow her to give “official evidence” and that she could be liable for disciplinary action if she didn’t comply — a claim SA Health has denied.
To ensure she would make public her concerns, the Coroner’s Court granted her immunity, a so-called “certificate of privilege”.
She says she then received a letter from the Attorney-General warning her about what she was doing, stating that her evidence may “intend to embarrass the state without notice”.
The government even appealed to the Supreme Court of SA, arguing the coroner’s certificate had been issued in error.
In a ruling last year the court agreed. The certificate of privilege was withdrawn. The government has always denied it tried to silence her.
During her parliamentary appearance, Dr Brooks stressed that she finally secured permission from SA Health to speak with the coroner anyway.
But she said she remained concerned about prosecution for speaking out.
“Such was the tenor of the correspondence from the Attorney-General that it was very concerning as a clinician to not be given permission to speak to the coroner.
“It’s a fundamental tenet of the coronial process that we have clinicians who are able to freely give evidence to the coroner so we can ensure that the coroner has a deep understanding of the factors that may or may not have prevented a death.”
Dr Brooks resigned as clinical director back in 2022.
She said in her resignation letter that the state of the ED “offends the very humanity of doctors”.
‘It’s just lazy doctors’
It is probably no surprise that the main theme running through so much of her testimony was about doctors and the way the attitude towards them from management, policymakers and politicians has become laced with cynicism, born of a basic failure to understand how doctors actually see the world.
“As a doctor, I like to know the data. If you ask me to change a medication I use, I want to see the data behind it,” she said at one point.
“If you are going to ask me to change my clinical practice, I want to see the data and it has to be done in a way that is really statistically robust.
“But to date there has been this narrative around, ‘Doctors don’t want to change’ … This narrative around, ‘It’s just lazy doctors,’ or other narratives that I have heard over and over and over again.
“These are very smart people who have dedicated their working lives to caring for their patients.
“Taking the time to truly understand the nature of the challenges and barriers that they face to discharging patients is really important, and that is a lot of the work that we are doing.”
She referred to clinician involvement in SIFT, the Statewide Interfacility Transfer process.
It is an attempt to deal with the access block by improving the transfer of patients between hospitals and also into rehabilitation services.
She said 35,000 patients who would have stood a very good chance of being ramped in the back of an ambulance were able to access care directly to the wards as a result of freeing up beds.
She said it worked because it was a data-driven approach which understood clinicians’ decision-making.
“We can’t just say, ‘Well, we popped out a policy. Stop this today or do this over here.’
“You have to spend the time understanding the problems. Einstein was very wise. He said, ‘If I had an hour to solve a problem, I would spend the first 55 minutes understanding it and five minutes solving it.’
“Unfortunately, we have a long history of doing the opposite, which is five minutes coming up with a solution, maybe without talking to anyone who really knows it deeply, and then 55 minutes telling people what they should do.
“It doesn’t work.”
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