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As Los Angeles hospitals deliver record amounts of oxygen to Covid patients, the systems and equipment needed to deliver vital gas are failing.
It got so bad that Los Angeles County officials are warning paramedics to keep it. Some hospitals are having to delay the release of patients because they do not have enough oxygen equipment to send them home.
“Everyone is worried about what’s going to happen in the next week,” said Cathy Chidester, director of the LA County Emergency Medical Services Agency.
There is no shortage of oxygen, which makes up 21% of the Earth’s air. But Covid is damaging the lungs and crushing patients in hot spots such as Los Angeles, the Navajo Nation, El Paso, Texas and New York last spring required high concentrations of it. This has damaged the infrastructure for distributing gas to hospitals and their patients.
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The tension in these areas is caused by multiple weak links in the pandemic supply chain. In some hospitals that deliver oxygen to patient rooms, the massive volume of cold liquid oxygen freezes the equipment needed to deliver it, which can block the system.
“You can completely – literally, completely – shut down the entire hospital system if this happens,” said Rich Branson, respiratory therapist at the University of Cincinnati and editor of Respiratory Care journal.
There is also pressure on the availability of portable cylinders that contain oxygen and concentrators that extract oxygen from the air. And in some cases, suppliers who provide oxygen have struggled to get enough gas to hospitals. Even the nasal cannulas, the tubing used to deliver oxygen, are now depleted.
“It’s been crazy, absolutely crazy,” said Esteban Trejo, managing director of Syoxsa, an El Paso-based industrial and medical gas distributor. It provides oxygen to several temporary hospitals created specifically to treat people with covid.
In November, he said, he was responding to calls in the middle of the night from contractors worried about the oxygen supply. At one point, when the company’s regular supplier fell, they were carrying oxygen from Houston, which is over 10 hours of driving each way.
Branson sounded the alarm about the logistical limitations of intensive care since the SARS pandemic nearly 20 years ago, when he and others asked experts about the specific equipment and infrastructure needed during a future pandemic. Oxygen was at the top of the list.
Oxygen as cold as Neptune
Last spring, New York, New Jersey and Connecticut faced a challenge similar to what’s currently going on in Los Angeles, said Robert Karcher, vice president of contracting services for Acurity, a group purchasing organization. who worked with many hospitals during this outbreak.
To take up less space, oxygen is often stored as a liquid at around minus 300 degrees Fahrenheit, about as cold as Neptune’s surface. But as Covid patients filling out ICUs received oxygen through ventilators or nasal tubes, some hospitals began to see ice forming on equipment that converts liquid oxygen into gas.
As a hospital draws more and more liquid oxygen from these reservoirs, the super-cold liquid can seep further into the vaporization coils where the liquid oxygen turns into gas.
Branson said a little ice is normal, but a lot of ice can cause the device’s valves to freeze. And ice can restrict the flow of air through pipes sending oxygen to patient rooms, Karcher said. To combat this, hospitals could switch to an emergency vaporizer if they had one, spray ice cold vaporizers, or move patients to oxygen supplied by bottle. But it puts additional pressure on the oxygen supply to hospital cylinders, as well as the medical gas supplier, Karcher said.
Hospitals in New York City began to panic in the spring because the vaporizer icing was much more severe than they had seen before, he added. The situation became so dire, he said, that some hospitals feared they would have to shut down their intensive care units.
“They thought they were in imminent danger of their tank piping shutting down,” he said. “We got closer in two of our hospitals. It was a difficult few weeks.
The strain on Los Angeles’ healthcare infrastructure could be worse given the now mainstream treatment of putting patients on oxygen using high-flow nasal cannulas. This requires more gas pumped at a higher rate than with fans.
“I don’t know of any system that’s really tuned to triple the volume of patients – or 10 times the delivery of oxygen,” Chidester said of LA County hospitals. “They have a hard time keeping up.”
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Oxygen equipment in short supply
In and around Los Angeles, the Army Corps of Engineers has so far investigated 11 hospitals for problems with frozen oxygen pipes. Hospitals are a mix of older facilities and smaller suburban hospitals, which are seeing such demand amid skyrocketing cases in the region, said Mike Petersen, a spokesperson for the Corps.
One of the worst examples he saw included pipes that looked like a home freezer that hadn’t been defrosted for some time.
The problem is worsening for hospitals that have had to convert regular hospital rooms into intensive care units. Intensive care hoses are larger than those leading to other parts of a hospital. When rooms are converted back to a pop-up ICU, the hoses may simply be too narrow to provide the oxygen that covid patients need. And so, Chidester said, hospitals are moving to big bottles of oxygen. But suppliers are struggling to fill them fast enough.
Even the smallest oxygen cylinders and concentrators are scarce amid the surge, she said. Patients who could be sent home with an oxygen cylinder are left stranded in a hospital waiting for one, occupying an essential bed.
‘Extreme rurality’
In early December, Navajo Nation medics said they needed more of everything: the oxygen itself and the equipment to deliver oxygen to patients in hospital and recovering at home.
“We have never reached our capacity before – until now,” said Dr Loretta Christensen, Chief Medical Officer of the Indian Health Service for the Navajo Region in mid-December. Its hospitals serve a patient population in the Southwestern United States, spread over an area larger than West Virginia.
The buildings are aging and not built to accommodate a large number of critical patients, Christensen said. As the number of patients on high flow oxygen increased, several facilities began to notice that their oxygen flow was weakening. They thought something was broken, but when engineers took a look, Christensen said, it became clear that the system just wasn’t able to deliver the amount of high-flow oxygen needed. to patients.
She said a hospital in Gallup, New Mexico installed new filters to maximize oxygen flow. After delays due to snow, a hospital serving the northern part of the Navajo Nation managed to hook up a second oxygen tank to increase its capacity.
But the medical facilities in the area are still a little up to date.
“Honestly, we are very concerned about the supply here because – and I call it extreme rurality – you just can’t get something tomorrow,” Christensen said. “It’s not like being in an urban area where you can say, ‘Oh, I need this now.'”
Due to the small size of some hospitals and the difficulty of getting to some of them, Christensen said, Navajo facilities are not attractive to large vendors, so they depend on local vendors, who may prove to be more vulnerable to supply chain hiccups.
At times, Tséhootsooí Medical Center in Fort Defiance, Ariz. Had to keep patients in hospital and transfer incoming patients to other facilities because it could not get the oxygen cylinders needed to refer recovering patients home. them.
Tina James-Tafoya, covid incident commander on the board of the Fort Defiance Indian Hospital, which runs the center, said home oxygen was out of the question for some patients. Oxygen concentrators require electricity, which some patients do not have. And for patients who live in hogans, houses often heated with a wood stove, the use of oxygen cylinders is a danger.
“It’s really interesting and revealing for me to see that something that seems so simple like oxygen
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