Because Los Angeles hospitals provide Covid patients with a record number of oxygen, the systems and equipment needed to deliver vital gas are failing.
The situation has gotten 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 concerned about what will happen next week or later,” said Cathy Chidester, director of the LA County Emergency Medical Services Agency.
Oxygen, which makes up 21% of the Earth’s air, is not running out. But Covid harms his lungs, and crowding patients at critical points like Los Angeles, the Navajo Nation, El Paso, Texas and New York last spring required high concentrations of him. This stressed the infrastructure to deliver gas to hospitals and their patients.
Full coverage of the coronavirus outbreak
The tension in these areas is caused by several weak links in the pandemic supply chain. In some hospitals that channel oxygen into patients’ rooms, the large volume of cold liquid oxygen is freezing the equipment needed to deliver it, which can block the system.
“You can completely – literally, completely – shut down the entire hospital supply if that happens,” said Rich Branson, a respiratory therapist at the University of Cincinnati and editor in chief of Respiratory Care magazine.
There is also pressure on the availability of portable oxygen-containing cylinders and concentrators that pull oxygen from the air. And in some cases, oxygen providers find it difficult to bring enough gas to hospitals. Even the nasal cannulas, the tube used to deliver oxygen, are now low on load.
“It’s been crazy, absolutely crazy,” said Esteban Trejo, general manager of Syoxsa, an industrial and medical gas distributor based in El Paso. It supplies oxygen to several temporary hospitals created specifically to treat people with greed.
In November, he said, he was taking calls in the middle of the night from contractors concerned about the oxygen supply. At one point, when the company’s usual supplier failed, they were transporting oxygen from Houston, which is more than a 10-hour drive each way.
Branson has been sounding the alarm about critical care logistical limitations since the SARS pandemic nearly 20 years ago, when he and other expert interviewees on the specific equipment and infrastructure needed during a future pandemic. Oxygen was almost at the top of the list.
Oxygen as cold as Neptune
Last spring, New York, New Jersey and Connecticut faced a similar challenge to what is now happening in Los Angeles, said Robert Karcher, vice president of contract services for Acurity, a group purchasing organization that worked with many hospitals during this increase.
To take up less space, oxygen is often stored as a liquid at around minus 300 degrees Fahrenheit, almost as cold as Neptune’s surface. But as Covid patients filling the ICUs received oxygen through ventilators or nasal tubes, some hospitals began to see ice forming on the equipment that converts liquid oxygen into gas.
When a hospital draws more and more liquid oxygen from these tanks, the supercooled liquid can seep further into the vaporization coils, where the liquid oxygen turns into gas.
Branson said some ice is normal, but too much ice can cause the device’s valves to freeze in place. And ice can restrict airflow in the pipes that send oxygen to patients’ rooms, Karcher said. To combat this, hospitals could switch to a spare vaporizer, if they had one, frozen vaporizers with a hose, or move patients to oxygen supplied by cylinder. But this puts additional pressure on hospitals’ oxygen supply to the cylinder, as well as the medical gas supplier, Karcher said.
New York hospitals started to panic in the spring because the vaporizer ice was much bigger than before, he added. The situation got so bad, he said, that some hospitals worried about having to close their ICUs.
“They thought they were in imminent danger of the tank plumbing being closed,” he said. “We came very close to some of our hospitals. It was a difficult few weeks. “
The pressure on Los Angeles’ healthcare infrastructure could be worse, given the now common 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 systems that are actually configured to triple the patient’s volume – or 10 times the oxygen supply,” said Chidester of LA County hospitals. “They are having a hard time keeping up.”
Download the NBC News app for complete coverage of the coronavirus epidemick
Missing oxygen equipment
In and around Los Angeles, the Army Corps of Engineers has so far surveyed 11 hospitals for oxygen tube freezing problems. The hospitals are a mix of older facilities and smaller suburban hospitals, meeting high demand amid cases that fire in the area, said Mike Petersen, a Corps spokesman.
One of the worst examples he saw included pipes that looked like a domestic freezer that hadn’t been defrosted in a while.
The problem gets worse for hospitals that have had to convert regular hospital rooms into intensive care units. The tubes in the ICU are larger than those that lead to other parts of a hospital. When rooms are reused as pop-up ICUs, the pipes can simply be too narrow to provide the oxygen that greedy patients need. And so, said Chidester, hospitals switch to large oxygen cylinders. But suppliers are struggling to recharge them quickly enough.
Even smaller cylinders and oxygen concentrators are missing from the surge, she said. Patients who could be sent home with an oxygen cylinder are trapped in a hospital waiting for one, occupying a much-needed bed.
‘Extreme rurality’
In early December, doctors attending the Navajo Nation said they needed more of everything: the oxygen itself and the equipment to bring oxygen to patients in the hospital and recovering at home.
“We have never reached capacity before – until now,” said Dr. Loretta Christensen, medical director of the Navajo Area Indigenous Health Service, in mid-December. Its hospitals serve a patient population in the southwestern United States that spread over an area larger than West Virginia.
The buildings are aging and were not built to house a large number of critical patients, said Christensen. As the number of patients receiving high-flow oxygen increased, several facilities began to notice a weakening of the oxygen flow. They thought something was broken, but when the engineers took a look, said Christensen, it was clear that the system was simply not able to deliver the amount of high-flow oxygen needed by patients.
She said that a hospital in Gallup, New Mexico, placed new filters to maximize the flow of oxygen. After delays due to snowy weather, a hospital serving the northern part of the Navajo Nation was able to connect a second oxygen tank to increase capacity.
But the medical facilities in the area are always a little tense.
“Honestly, we care about supplies here because – and I call that extreme rurality – you just can’t get something tomorrow,” said Christensen. “It’s not like being in an urban area where you can say, ‘Oh, I need this right now.'”
Because of the small size of some hospitals and the difficulty of reaching some of them, said Christensen, Navajo facilities are not attractive to large suppliers, so they depend on local suppliers, who may be more vulnerable to problems in the supply chain. supplies.
The Tséhootsooí Medical Center in Fort Defiance, Arizona, sometimes had to keep patients in the hospital and transfer patients arriving to other facilities because it was unable to get the oxygen cylinders needed to send the recovering patients home.
Tina James-Tafoya, the coveted incident commander at the Fort Defiance Indian Hospital Board, which runs the center, said oxygen at home is out of the question for some patients. Oxygen concentrators require electricity, which some patients do not. And for patients who live in hogans, homes usually heated with a wood stove, the use of oxygen cylinders is a danger.
“It is really interesting and revealing to me to see that something that looks as simple as oxygen