A visit to the emergency department is something many Australians would dread, but it is something almost all will need to do at some point in their lifetime.
But as the complexity and frequency of emergency department (ED) visits increase, hospitals and their staff are being stretched past their limits.
One visible symptom of Australia's struggling health care system is ambulance ramping.
Ramping occurs when ambulances end up parked outside the ED, on or near the ramp, because paramedics are not able to unload the patient into a free hospital bed.
It is the result of a busy ambulance service trying to transfer patients into an equally busy hospital system.
While politicians like to blame each other for issues like ramping, health experts say it's been caused by a complete health system "failure" that's been brewing for decades.
They are calling for a national overhaul, to get patients the help they need on time, and to prevent lives being lost in the overrun acute care system.
Every minute counts
Every minute counts in an emergency, and Mel Mountstephen, 35, often reflects on the minutes leading up to her brother Jason's death.
Jason, a former SA Ambulance Service volunteer who eventually retired after being diagnosed with pulmonary arterial hypertension, collapsed at his home in 2019.
"Mum and dad just heard a cough coming from Jason's room and they went in, and he had collapsed," Ms Mountstephen said.
"When they got into his room, they rang triple-0 and they needed to start performing CPR."
The family said it took 20 minutes for the first ambulance to arrive, which was a volunteer crew, and 40 minutes before paramedics were able to attend to her brother.
"We live three minutes away from the ambulance station and we're well aware the ambulance isn't always going to be there, but we are also probably 15 minutes away from the next paramedic station being in Victor Harbor," she said.
"There were some crews that were ramped, other crews were just busy on jobs."
Despite being worked on by paramedics for an hour, Jason, 34, couldn't be revived.
The SA Ambulance Service at the time said its records showed that a Goolwa crew arrived on scene first, alongside an intensive care paramedic (ICP).
"SAAS is satisfied that its response was in accordance with emergency deployment procedures," it said.
Ms Mounstephen said the response time was something her family now had to live with.
"Whether he would be here today or not is just something we can't allow our brains to play with," she said.
Why does ramping occur?
The latest report card from the Australian Medical Association showed that no state or territory met its target for transferring patients from an ambulance to the emergency department in 2021.
Dr Malcolm Boyle was an on-road paramedic for 35 years and is now a medical researcher at Griffith University.
Dr Boyle said ramping was not a new issue and no jurisdiction was immune to its consequences.
"I think we're feeling ramping more now because we've had COVID," he said.
"But ramping's been around, if you read the scientific literature, since the mid '90s."
The former paramedic said ramping was the result of hospital "bed blockage".
"The problem in the hospitals is what they call bed-block or through-put, depending on what terminology you want to use," he said.
"You've got these people that are taking up a bed that don't really need to be there and that blocks up the bed for somebody else."
It means the system becomes clogged with patients, unable to move efficiently from admission through to discharge, making the entire system busier and more stretched for resources.
GP access a key issue
As ambulances struggle to reach patients on time, or unload them at hospitals, at the same time more people than ever are presenting at emergency departments.
According to the Australian Institute of Health and Welfare, the number of patients attending EDs has increased by almost 800,000 over the past five years.
But emergency doctors say it is often a patient's only choice, especially after hours.
Meisha Tame was born with a mutation in the BRAT1 gene, leading to a neurodevelopmental disorder.
"She has seizure activity, she has apnoea where she stops breathing and she also has dystonia and other physical ailments," her mother, Cathy-Jo Tame, said.
Ms Tame describes herself and her 11-year-old daughter as "ED frequent flyers".
"I can be there two to three days because they're waiting for blood results and if she's got a rhinovirus or influenza or anything like that, we may need to be there for a few more days," she said.
"It's the waiting there and the endless having to explain yourself over and over again, which is very distressing."
Ms Tame said they spend most of their time in the hospital explaining her daughter's condition to staff and waiting for test results.
She prefers when Meisha can receive the same treatment from her doctor at home.
"So much more valuable than sitting hours and hours at a hospital emergency and in the end you go home with not many answers as well," Ms Tame said.
But with access to general practitioners tightening, they are often forced to go to the ED.
"Nine times out of 10 if you go to a doctor, my doctor is unavailable or whatever, and you have to go to an unknown doctor," she said.
"Nine times out of 10, because they don't know, [they] will just say 'call an ambulance'."
'Need to join the dots'
President of the Australasian College for Emergency Medicine, Dr Clare Skinner, said a shortage of GPs is a significant issue.
"This is a far greater problem because often that deterioration in condition was entirely preventable if they had been able to access that care in the community when they needed it," Dr Skinner said.
The emergency care clinician said the problem was not just patients being forced into the emergency department, but also patients that could not actually leave the hospital.
"There are people who could be discharged into aged care or community care services," she said.
"But that just isn't available because the whole system is overloaded and not working as well as it could."
She said efforts to add more hospital beds and employ more staff are welcomed but are not a long-term solution.
"There's band-aid measures that happen all the time, but what we need is to actually think about the whole system," she said.
"Ambulance ramping and ED overcrowding are not problems with ambulances, are not problems with EDs.
"In fact, this represents a failure of an entire system."
Dr Clare Skinner said that more effective solutions required a national overhaul of the entire health system, to better coordinate services.
"We have a series of disconnected health services," she said.
"We need to join the dots, we need to link the system."
Dr Malcolm Boyle agreed that problems with aged care and the National Disability Insurance Scheme (NDIS), which fall under the responsibility of the Commonwealth, have made it near impossible to address the pressures on state-run hospitals.
"There are some state-related issues, but it needs to be looked at, like a lot of things in recent times, nationally," he said.
Worried for the future
Four months after the death of her brother Jason, Mel Mountstephen became increasingly sick and put it down to her overwhelming grief.
But Ms Mountstephen's cardiologist insisted she have a test done, where she learned that she had the same incurable illness as her brother.
Ms Mountstephen, whose mother Felisa also has the same condition, is worried about being put at risk.
"I am scared for the day I do need an ambulance," she said.
"It's hard to see that we live in such a lucky country, but this is happening all over Australia."
Ms Mountstephen said she hoped the country could work together to improve the health system, just like her brother tried to as a volunteer.
"He'd make the effort for anyone," she said.
"He knew [the service] was starting to go down. He wanted the service to change."
