The ambulance service used to reach its ‘status three’ crisis band once a decade. It has hit it several times in the past few weeks alone. By Rick Morton.
Exclusive: Ambulances ‘beyond crisis point’
Paramedics in New South Wales are routinely being sent to treat Covid-19 patients being cared for at home who have unreported blood oxygen readings at critically low levels because state authorities have failed to deliver on a promise to distribute crucial monitoring devices.
A NSW Health policy document governing the care of all Covid-19 positive cases in the community clearly states that “all patients must be provided with a pulse oximeter” because “the Delta variant may be associated with rapid deterioration”.
The guideline includes the Hospital in the Home program – a hospital “substitution” where people are still admitted as inpatients but are looked after in their homes, and through which more than 3500 Covid-19 patients are being cared for.
The Saturday Paper can reveal that pulse oximeters have not been made available in many cases because officials are struggling to keep up with demand. When asked directly about this matter, the NSW Department of Health did not respond to the question.
With coronavirus infections generally, and this variant especially, a condition known as “happy” or “silent” hypoxia can drain oxygen from a person’s bloodstream without them realising.
Usual warning signs such as difficulty breathing, dizziness or distress are simply not present.
“We are turning up to patients and on the outside, they look perfectly well. Their heart rate is fine, blood pressure is fine, they don’t even have a fever, they’re not flushed or short of breath,” intensive care paramedic Brett Simpson tells The Saturday Paper.
“And then you put the pulse oximeter on their finger and their oxygen levels are at 50 per cent and it should be above 96 per cent.
“The first couple of times I personally encountered it I was like, ‘Are you okay, do you feel okay?’ And the person is, ‘Yeah, yup, 100 per cent, I feel great.’ And you’re just like, ‘Well, based on the oxygen levels, you should be dead.’ ”
Simpson has been to homes where Covid-19 positive residents have oxygen levels as low as 20 per cent. For typical respiratory illnesses, the patient would be comatose, unconscious or dead.
A University of Washington study published in the journal Influenza and Other Respiratory Viruses in May this year found that Covid-19 patients with blood oxygen levels below 92 per cent were between 1.8 and four times more likely to die in hospital compared with those with normal readings.
This emerging understanding of silent hypoxia in patients has underpinned the NSW Health policy on pulse oximeters but, in reality, the potentially lifesaving devices have not been made available to those in need.
“The majority of people that we are going to don’t have them,” Simpson says. “Some of them are being treated in Hospital in the Home but the majority of the ones that I have been to personally aren’t under that model of care either because they are deemed to be a low risk when they get their diagnosis. So really, we are the safety net underneath that Hospital in the Home system.”
In the past week alone, six people in NSW have died at home from the infection, including two men in their 30s and 40s from Western and south-western Sydney.
Under the triage model contained in an internal NSW Health document, those deemed “low / medium” risk are people who have had their second vaccine dose more than a week before infection or who are under the age of 65 with no medical or social risk factors, asymptomatic or with mild symptoms.
Under this guideline, such patients are given an initial consultation one day after the infection is recorded and then welfare checks are performed on days four through 10 of the infectious period.
On Monday, NSW Police revealed a glimpse into what they are finding during those welfare checks.
“In six separate instances across Campbelltown and Cumberland Police Area Commands, officers requested the help of NSW Ambulance paramedics after finding residents struggling to breathe, suffering shortness of breath, or vomiting,” police said in a statement.
“In one of those instances, officers attended a home at Auburn to find a man lying face down and struggling to breathe. They immediately moved the man into a recovery position, cleared the house, and opened windows to assist with airflow, as they called for NSW Ambulance paramedics to assist.”
Early in September, a 37-year-old man was diagnosed with Covid-19 and given an over-the-phone GP consultation before being told to monitor his symptoms and call an ambulance if needed. His wife, who does not wish to be named, says he was coughing up blood for six days and still kept at home. By the time she begged for an ambulance, he was on the verge of shutdown.
In hospital, the man was given a bronchoscope, suction to clear his airways, injections to open his lungs, heparin to thin the blood and then oxygen support.
“He wasn’t provided an oximeter. They did provide groceries,” she says. “The fact these interventions were put in place immediately highlights the inadequacy of the [NSW] in-home care program. It also shows us our healthcare workers need more resources. Government in-home care for serious symptomatic Covid-19 is dangerous.”
Even those who receive the full scope of clinical monitoring from Hospital in the Home teams do not actually see their doctors and or healthcare workers face to face. These virtual, telehealth arrangements also allow a relative handful of staff to monitor thousands of patients.
When symptoms escalate and a patient needs help, however, it is paramedics who are sent to give care.
An emerging realisation – perhaps too late for some – is that any success hospitals have in managing their workload is built largely on the backs of paramedics. Much of the surge capacity in hospitals is based on the ability to transfer patients between facilities across greater Sydney and the state.
The ambulance system is the fulcrum on which this delicate balancing act is achieved. It is also the first part to fail. Ambulances get tied up waiting for beds, sometimes for hours. They can also be overwhelmed by the sheer number of emergency calls.
Last Friday, NSW Ambulance chief executive and commissioner Dr Dominic Morgan revealed a troubling statistic when he spoke in front of reporters.
“Two weeks ago I stood here and mentioned that NSW Ambulance has transported 2500 Covid patients in the preceding two months,” he said.
“Today I stand here saying that, as of midnight last night, there are now 5900 Covid patients that have been transported by NSW Ambulance. So in just two weeks this load on the organisation has doubled on the previous two months.”
For the previous fortnight, Morgan said, “we have not seen a single day where we have not been at ‘status two’ across the entire metropolitan area”.
According to paramedics who spoke to The Saturday Paper, the ambulance service in the state operates under three emergency bands calculated by, among other factors, the number of resources available comparative to the number of outstanding triple zero calls.
Status one is an increase on baseline or normal operations. Status two is serious. As one paramedic puts it: “It basically means less than 10 per cent of the calls will get responded to.”
When asked if that response is based on receiving care within a certain time frame, the paramedic says: “There is no plan. There is no time frame for those jobs to get a resource.”
Then there is “status three”. Essentially, at this level no cars are available. Fewer than 5 per cent of jobs will be responded to.
“When you hit ‘status three’ that is an absolute disaster,” a NSW paramedic says. “In certain sections of metropolitan Sydney, we have hit it regularly and it has happened a handful of times in the last few weeks for the entire metropolitan region.”
Before this Covid-19 period, the paramedic says, the highest emergency band available to NSW Ambulance was reached only once in a decade. During the latest outbreak it has been hit several times in a month. This is not just in individual districts but across all of metropolitan Sydney at once.
The availability of ambulances to respond to calls is recorded on a status monitoring board. It carries a line graph indicating response capacity, upgraded in real time.
“There is a number, I think it’s 150, which is this arbitrary number at the top of ‘status three’ that the graph goes up to,” the paramedic says.
“When it goes beyond 150 it stops. They literally do not have data on how bad it gets because the system isn’t designed to show it. It was never expected to go beyond that level … In sections of metropolitan Sydney we have hit the top of that graph regularly over the last few weeks.”
A spokesperson for NSW Ambulance says the service has surge arrangements in place. The spokesperson says the service had treated more than 7500 confirmed Covid-19 cases since the Delta outbreak. “This number continues to rise daily.”
Since July, 120 extra graduate paramedics have begun road duties in addition to 31 casuals “employed on short-term contracts” to help meet rising demand in Sydney’s south-west and west. An additional 130 graduates will begin on September 27. The ambulance service has also contacted Fire and Rescue NSW to seek possible assistance.
The ambulance spokesperson says: “As seen overseas and in large cities in response to the global pandemic, assistance may include firefighters driving ambulances to free up paramedics to work with critically ill patients, or co-responding to cardiac arrests where they are in closer proximity given they carry life-saving public access defibrillators.”
The Saturday Paper can also reveal the service has asked regional and rural NSW paramedics to come to Sydney on six-week “secondments” to boost numbers over the coming months. It is unclear if they will also bring their ambulance trucks, a crucial resource in a state that had only 1085 general purpose vehicles in 2019-20.
NSW is not alone in having an ambulance service beset by woes even before the pandemic arrived. But on almost every performance indicator measured by state and territory governments, it performs the second worst in the country, ahead of only Western Australia.
On Wednesday, the state’s Bureau of Health Information released the latest health systems quarterly report data, which revealed that in April to June this year, a period in which there were very few local coronavirus infections, response times and other key metrics were the worst since the bureau started collecting the data in 2010.
The proportion of ambulance crews arriving within 15 minutes after an emergency call crashed below half – to 48 per cent. Just 88 per cent of crews turned up within half an hour. In the same quarter last year, these figures were 61.3 and 94.4 per cent respectively.
Paramedic Brett Simpson, who is also a delegate for the Australian Paramedics Association NSW, says these figures are alarming in themselves but have blown out spectacularly in the past couple of weeks.
On the Friday night after commissioner Dominic Morgan spoke to reporters, in the south-west Sydney region alone there were “over 60 priority one jobs sitting in the queue without a single resource available or even attached to it”.
Simpson says, “That is what status three means. Effectively, it means that there is no ambulance for you.”
When Simpson looked at the status board late last week, it showed the average response time for an emergency job across metropolitan Sydney was 59 minutes.
That figure seems so wildly out of place when it is first put to former paramedic and current secretary of the Ambulance Employees Australia Victoria union Brett Adie, he assumes it is an average of all response times across all job categories, including non-urgent calls.
When The Saturday Paper confirms it is an average response time only for priority one emergency jobs, he pauses. “Wow,” Adie says. “That’s… that’s crazy. Crikey, that is crisis point. That is beyond crisis point.”
On Thursday, Victoria’s daily case numbers during the Delta outbreak broke through 500, the highest daily count since numbers peaked in the state’s second wave, reaching 725 on August 5 last year.
Adie, who was a paramedic for 14 years and served in a management role at Ambulance Victoria before heading to the union, recognises that Covid-19 has increased demand on these lifesaving first responders. But he is insistent that policymakers and bosses at the service are using it as an excuse to mask historic issues.
Victoria’s ambulance response times are now among the best in the nation. At $178.70 a person, the state has the third best-funded service in the country. By contrast, NSW spends just $136.68 a person on ambulance services. The only state that does worse is Western Australia at $124.28.
But these mandatory reporting obligations have become such a core focus, Adie says, that single crew ambulances have increasingly been used in Victoria as a way to improve numbers.
“Response times were very poor when the Andrews government came in, there’s no doubt about it, but the way we count them doesn’t give the full picture,” he says.
“I’ve done single officer responding and it’s particularly common these days. It can be very stressful and can definitely be a factor in the burnout of paramedics,” he says.
“Single officer responding means they [Ambulance Victoria] can spread their flock wider and they can hit their KPIs [key performance indicators]. That’s what we call it in ambulance, ‘stop the clock’. We have these people whose job it is to get to the scene as quick as possible knowing full well they can’t give definitive care, which quite often is transport, but you’ve stopped the clock. You then end up with another resource come in, with a bed, and you’ve tied up another two paramedics.
“There are certainly times when every minute counts and a single officer can make a difference, but that is not the norm. Paramedics know the primary responsibility of single officers is to ‘stop the clock’, that’s why they are sent to jobs where it doesn’t make a clinical difference.
“So, funding-wise, they’ve been able to take some shortcuts which have made the numbers look better, but it is actually increasing pressure on the service and bringing it to a point where it is no longer sustainable.”
These issues are not new to Covid-19. Adie says it has now become common for Ambulance Victoria to ask paramedics to work overtime shifts during their annual leave, contributing to a crushing fatigue issue in the service.
“Now, if that doesn’t tell you that we are significantly understaffed, then I don’t know what will,” he says. “Almost 50 per cent of the texts coming out to say that there are shift vacancies have the part in them saying ‘annual leave will be considered’.”
The system became so overused that management eventually had to place a limit – a worker can only fill two such shifts a week and must have two full weeks of annual leave where they are not allowed to fill in.
What the pandemic has done to health system preparedness generally, and to ambulance services in states hit by outbreaks especially, is exploit the fissures already present. For paramedics – the least-funded part of the health system, with some of the highest pressure roles no matter the jurisdiction – these problems are more acute.
Adam, a paramedic working in Victoria who asked not to use his real name, says the frustrating element for crews is that it feels as if they are “starting from scratch” despite dealing with a deadly wave of the virus last year.
“One example is that this time around only certain hospitals are taking confirmed Covid-19 patients and in the Western Health region there is not a single facility that will do that,” he says. “So we are having to drive 40 or 50 kilometres for a single case and then back again. The crews I’ve been speaking to have been averaging one or two Covid pickups every other shift, but that is starting to increase now.”
Modelling done for the ambulance service in Victoria, using the experience of NSW so far, is preparing management for “many hundreds of Covid-positive calls every day”.
As Adam says: “I know it sounds bad, but the paramedics themselves aren’t that worried because they know they can’t get much busier than they already are. When calls go unanswered, that won’t be on them. That’s the concern of the leadership.”
During the crisis last year, Ambulance Victoria trained Australian Defence Force personnel to work as drivers for paramedics in the state. But, according to Adam, these ADF drivers thought they would be doing only non-urgent patient transport.
“When they found out the plan was to send them to emergency calls, about a third of them dropped out and said they wouldn’t do it because they feared for their mental health.”
In the end, the drivers were never needed.
Now, in both NSW and Victoria, the resilience of the healthcare system is being tested again. While emergency plans are drawn up to reconfigure hospitals, delay some elective surgeries and pull nurses and doctors from elsewhere in the vast networks, there is almost no room for ambulance crews to move. As one paramedic says, in every state and territory these first responders are working in a system long ago carved to the bone.
Still the calls come in.
This article was first published in the print edition of The Saturday Paper on Sep 18, 2021 as "Exclusive: Ambulances ‘beyond crisis point’".
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