A paramedic in the small Australian state of Tasmania late last month wrote a letter warning that ambulance ramping is causing his colleagues widespread and undeniable psychological injury. Six per cent have considered self-harm and 42 percent want to leave their job because of the practice, where an ambulance is unable to offload a patient to a hospital because of lack of beds. Patients are moved into a room where they are treated by the paramedics who brought them in.
The high incidence of ramping is product of the wider crisis of the Tasmanian hospital system which has been chronically underfunded under successive Labor and Liberal state governments. A report last October by health analyst Martyn Goddard found that the lack of resources was most clearly seen in hospital emergency departments where staff and beds failed to keep up with rising demand.
The report stated that bed block—when patients have to remain in emergency departments because no bed is available—is far higher in Tasmania that other states. Of the state’s two major hospitals, Launceston General Hospital had the worst bed block of any of Australia’s 287 public hospitals, and only eight had a worse result than the Royal Hobart Hospital. Goddard estimated that there were in excess of 80 premature deaths a year in Tasmanian hospitals because of emergency department bed block.
This situation places extraordinary stresses on paramedics, who are compelled to look after patients for hours while they are ramped outside emergency departments. While they are highly trained as first responders, they do not have the training or the equipment to provide the necessary diagnosis and care in what are often complex and demanding medical cases.
The letter, addressed to Ambulance Tasmania CEO Neil Kirby, describes ambulance ramping at the Royal Hobart Hospital as an “unmitigated crisis, with consensus amongst front line staff that it is entirely unworkable” and affecting the mental and physical health of the ambulance crews. Individuals have been “reduced to tears on a daily basis.”
“Ambulance Tasmania is in a state of utter disarray with the psychological impact of ramping affecting paramedics in extremis…I hold genuine and immediate concern for the welfare of my colleagues and fear that without swift and decisive intervention the consequences could be catastrophic.”
The letter’s author conducted a survey of Tasmania’s Southern region paramedics, with 71 respondents, representing 40 percent of the workforce. Of these, 90 percent reported that ramping was having a negative impact on their mental health and 79 percent indicated that ramping was affecting their mood out of work hours. Fifty-six percent said that they had difficulty sleeping prior to a shift, due to stress related to ramping. Ramping makes 69 per cent anxious about coming to work, and 38 percent have taken sick leave to avoid it.
Furthermore, 97 percent felt that Ambulance Tasmania was not doing enough to manage the impact of ramping on paramedics.
“These issues are compounded by the sense among staff, that we are on our own. With no visible leadership regarding ramping, paramedics are forced to manage it on a daily basis at an individual level. Far from a sense of feeling supported by the organisation, staff are routinely pressured into clinical situations which are unsafe and inappropriate, with reported safety issues being routinely dismissed or ignored.”
The writer made a series of recommendations including: no paramedic should be subjected to more than two hours of continuous ramping, more than five hours of ramping on a shift, or ramped between midnight and 6.30 am.
On May 1, Labor Opposition leader Rebecca White asked questions in parliament based on the letter.
“Do you acknowledge that ambulance ramping increases the risk of patients dying?” she asked Health Minister Michael Ferguson. “What do you say to those ambulance paramedics who are at their wits end, with a distressing 6 percent identifying they have contemplated self-harm as a consequence of the pressure they are facing?”
Ferguson brushed the issue aside saying only that the government was employing a further 42 paramedics—a move that will not alleviate the lack of hospital beds or end ambulance ramping.
White’s posturing, however, is completely hypocritical. The current hospital crisis did not begin with the current Liberal state government. The former Labor-Greens coalition government that came to office in 2010 imposed a pro-market agenda, including cuts to hospitals and the public health care system.
Tasmania has the worst Code One ambulance response times in Australia, and paramedics say they have worsened in the past six months. A Code One response is defined as “immediate response under lights and sirens”. The median wait time was 12.9 minutes for an ambulance to arrive at the scene of an emergency, the slowest in the country. The time within which 90 percent of first responding ambulances arrived was 26.3 minutes.
One paramedic told Australian Broadcasting Commission (ABC) News late in April: “There has been a number of cases I’m aware of where patients have had delays to treatments that may have related in patient deaths or worse patient outcomes. This may be as simple as delay to antibiotics in patients that have severe infections, which we know causes an increase in mortality rates.”
He said that a patient recently transferred from Tasmania’s north with a known abdominal aortic aneurysm requiring surgery was ramped at the Royal Hobart Hospital (RHH) for hours, until the blood vessel burst, requiring emergency life-saving surgery.
The death of Tasmanian paramedic Damian Crump, who took his own life in December 2016, prompted his colleagues to lobby for an official inquiry. The resulting Australian Senate committee inquiry into the mental health of first responders (paramedics and other emergency services) made a report in February this year. It noted the stresses placed on first responders by ramping, adding: “However, a strategy to address this problem was not in place at the time of the committee’s public hearing [in Hobart.]”
Emergency doctors are also placed under intolerable pressures.
Last month emergency department doctors at Royal Hobart Hospital wrote to management expressing grave concerns about extreme bed block and ambulance ramping. They stated they “will no longer be complicit in sub-standard patient care and an unsafe work environment.”
The letter said that waiting and ramping times at times led to patients waiting more than 170 hours for an in-patient bed.
According to ABC news, the doctors explained that the entire ambulance fleet in Tasmania’s southern region was often ramped at the hospital, leaving up to 13 triple-0 cases to remain “unresponded”, including heart attack calls.
Hobart doctor John Saul said: “We are looking after people and emergencies we’ve never looked after, because the ambulances can’t attend in a timely fashion. It’s the same message we’ve been saying for decades and it’s escalating. Things seem to be getting worse. We just need urgent support.”
While the crisis in ambulance and emergency care is particularly acute in Tasmania, similar problems are to be found in all Australian states. Labor and Liberal governments at the state and federal level are responsible for the rundown of public hospitals and health services and the promotion of private, for-profit facilities and services. Ambulance ramping is one very sharp expression and has terrible consequences for paramedics and patients alike.