Doctor initially silenced at inquest gives inside look at ramping crisis

If you are unfortunate enough to need an ambulance to take you to the Flinders Medical Centre, the last part of your journey will be up a short ramp, before you are offloaded and taken into the emergency department.

According to emergency physician Megan Brooks, that ramp has an unenviable legacy — it has lent its name to what has become a national phenomenon: ambulance ramping.

Now a senior physician with two decades of experience, in 2004, Dr Brooks was an intern at the southern suburbs hospital.

“It was an incredibly difficult time to be working at Flinders Medical Centre,” Dr Brooks told a parliamentary committee this week.

It was the beginning of Dr Brooks’s career and the beginning of ambulance ramping.

‘The maths doesn’t add up’ — ramping a symptom

Dr Brooks this week gave evidence at parliament’s Health Services Committee.

Speaking under parliamentary privilege, her testimony was a rare window into a health system under constant pressure.

Ambulances lined up outside emergency departments are external evidence of that pressure, but as Dr Brooks told the committee, it’s a symptom of a bigger problem.

“We are constantly drawing focus to this small group of patients that are on the ramp,” she said.

“It is important and it’s not a good patient experience and that ambulance can’t get to the community, but in doing that we have lost sight of how we can improve access for all patients.”

Since 2013, Dr Brooks has worked at the Royal Adelaide Hospital.

It has 75 emergency department cubicles, including resuscitation areas and extended care beds.

Dr Brooks told the committee that often many of those cubicles were filled with patients waiting to be admitted to a ward.

“When there are 40 patients in those 35 cubicles who should be on a ward, there are only 35 cubicles to put the 230 patients that are going to arrive through,” she said.

“The maths just doesn’t add up.

“It is not uncommon, even now, to have up to 20 of the 75 cubicles we have at the Royal Adelaide occupied by mental health consumers, some of whom will be there for days.”

More ambulances lead to more ramping

Elected with a platform of “fixing the ramping crisis”, it’s a problem the Malinauskas Labor government promised to tackle. 

It is opening new hospital beds, hiring more health workers and getting more ambulances on the road — but ramping remains stubbornly high.

Rather than just look at ramping figures, the government wants to put the focus on ambulance response times.

Priority one and two cases have improved since the 2022 election, thanks at least in part to an increase in the number of ambulances and paramedics.

But as Dr Brooks told the committee, while more ambulances turning up on time is a good thing, it’s had the perverse outcome of increasing ramping.

“We have seen the number of hours lost on the ramp increase in association with having more ambulances available in the community,” she said.

When an emergency department is that overcrowded, Dr Brooks said, the risk wasn’t only to the patients waiting in ambulances outside.

“Morbidity and mortality isn’t just for a patient who is delayed in an ambulance,” she said.

“The risk of being seen in an overcrowded emergency department 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.”

Ramping inquest probes three deaths

Dr Brooks told the committee, even before COVID, the situation at the Royal Adelaide Hospital was so bad doctors and nurses weren’t always able to adequately assess and triage patients.

She became frustrated at what she believed was the failure to investigate “clusters” of incidents in the emergency department.

So when the coroner began investigating three ramping-related deaths, Dr Brooks was keen to give evidence.

“These matters have been going on for nearly a decade, and there are very few people who possess the institutional knowledge of all of the events — and I count myself as one of the few people who do, who have that longitudinal record of events,” she said.

But Dr Brooks was initially blocked from giving evidence.

The government argued it wasn’t a political decision, rather a test of the coroner’s use of new laws — one that ultimately found they were used incorrectly. 

But Dr Brooks believes there were other reasons she was being blocked, and feared she may have been charged with misconduct or maladministration as a public servant.

“It was deeply upsetting to have my motivations questioned and to say that I somehow had an agenda to embarrass the state or anything other than that,” she said.

New RAH opening plagued with problems

The one thing Dr Brooks kept returning to in her evidence — too often decisions are made without consulting with the doctors, nurses and other hospital staff who will have to implement them.

Perhaps nowhere in her career has that been clearer for her than when the new Royal Adelaide Hospital opened.

Dr Brooks became the Royal Adelaide Hospital Emergency Director in July 2017, three months before the big move.

She describes it as one of the most difficult professional times in her life.

The resuscitation rooms were too small, the new layout of individual cubicles needed a whole new staffing approach, and they were simultaneously expected to adopt a new electronic medical records system.

On top of that the phones weren’t working, and the room numbering system was so confusing medical staff struggled to navigate during emergencies.

“I got permission … to go up and buy a whole bunch of iPhones so we actually had phones that worked in the emergency department on the first day, because the phones we were given didn’t,” she said.

“I spent an untold number of hours having to argue and make the case that we needed to be allowed to number our cubicles so we could find people when they were really unwell.

“We as clinicians were spending a huge amount of time, and we couldn’t even find the sick person. 

“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,’ and I would say, ‘Well, I would quite like to find your relative if they are dying’.

Making a career of being a ‘difficult’ person

In 2022, Dr Brooks quit as the Medical Lead for Acute and Urgent Care at the Royal Adelaide Hospital, penning a strongly worded letter about her frustrations at staff’s inability to provide timely care to patients.

It made headlines, and Dr Brooks said it was not the first time she felt she had been forced to be ‘difficult’ to achieve change.

“I have made maybe a career of being a difficult person who puts myself in situations where I am quite hard to ignore. That has come at some cost for me, but we have to change the attitude to clinicians,” she said.

“If I had one wish, one thing I would change is the attitude to clinicians being one where we should maybe just assume that they are competent and know what they are talking about.”

For the past two years Dr Brooks has worked at the State Health Coordination Centre, a relatively new initiative where she said there had been some positive change.

They’ve improved inter-hospital transfers, a change she said meant thousands of patients that could have ended up ramped have managed to go straight into a ward.

But when asked whether ramping would be fixed before the next election, she said to say yes would be naive.

“Ramping is an international phenomenon,” she said.