As Los Angeles hospitals provide record numbers of Covid patients with oxygen, the systems and equipment needed to deliver the life-sustaining gas are faltering.
It has become so bad that Los Angeles County officials are warning paramedics to preserve it. Some hospitals have to release patients because they do not have enough oxygen equipment to send home together.
“Everyone is worried about what’s going to happen next week or so,” said Cathy Chidester, director of the LA County Emergency Medical Services Agency.
Oxygen, which makes up 21 percent of the earth’s air, does not run short. But Covid damaged the lungs, and the crushing of patients in hot places like Los Angeles, the Navajo Nation, El Paso, Texas and in New York last spring required high concentrations of them. This has highlighted the infrastructure for delivering gas to hospitals and their patients.
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The tension in those areas is caused by several weak links in the pandemic supply chain. In some hospitals that carry oxygen to patients’ rooms, the large amount of cold liquid oxygen freezes the equipment needed to deliver it, which can block the system.
“You can shut down the entire hospital supply completely – literally, completely – if that happens,” said Rich Branson, a respiratory therapist at the University of Cincinnati and editor-in-chief of the journal Respiratory Care.
There is also pressure on the availability of both the portable cylinders that contain oxygen and the concentrators that take oxygen out of the air. And in some cases, providers that supply oxygen have struggled to get enough gas in hospitals. Even nasal passages, the tube used to deliver oxygen, are now becoming scarce.
“It was nut, absolutely nut,” said Esteban Trejo, general manager of Syoxsa, an industrial and medical gas distributor in El Paso. He supplies oxygen to several temporary hospitals specifically set up to treat people with covid.
According to him, in the middle of the night he answers calls from contractors who are worried about oxygen supplies. At one point, when the company’s normal supplier failed, they fetched oxygen from Houston, which drove more than ten hours a ride.
Branson has sounded the alarm about logistical constraints on critical care since the SARS pandemic nearly 20 years ago, when he and other experts investigated 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 is currently going on in Los Angeles, said Robert Karcher, vice president of contract services for Acurity, a group purchasing organization that the boom has worked with many hospitals, said.
To take up less space, oxygen is often stored as a liquid about 300 degrees Fahrenheit, about as cold as the surface of Neptune. But while Covid patients filled oxygen through ventilators or nasal tubes, some hospitals began to see ice on the equipment that converts liquid oxygen into a gas.
As a hospital extracts more and more liquid oxygen from those tanks, the supercooled liquid can seep further into the evaporation spirals where liquid oxygen turns into gas.
Branson said ice is normal, but a lot of ice can cause valves on the device to freeze. And the ice can restrict airflow into the pipes that send the oxygen to patients’ rooms, Karcher said. To combat this, hospitals can switch to a backup evaporator if they have one, pull down ice-cold evaporators or move patients to cylinder-administered oxygen. But that puts extra pressure on the hospital’s oxygen supply, as well as the medical gas provider, Karcher said.
Hospitals in New York began to panic in the spring because the icing on the evaporator was much larger than they had seen before, he added. It got so bad, he said, that some hospitals were worried that they would have to close their ICUs.
“They thought they were in imminent danger that their tank linens would come to a standstill,” he said. ‘We got pretty close in some of our hospitals. It’s been a rough few weeks. ‘
The strain on the health care infrastructure in Los Angeles may worsen as patients currently using oxygen are treated through high-fluid nasal cannulas. It requires more of the gas pumped at a higher rate than with fans.
“I do not know of any system that is really focused on doubling patient volumes – or ten times the oxygen delivery,” Chidester said of the hospitals in LA. “They struggle to keep up.”
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Oxygen equipment short
In and around Los Angeles, the Army Corps of Engineers has so far investigated 11 hospitals to freeze issues with oxygen pipes. Corps spokesman Mike Petersen said the hospitals are a mix of older facilities and smaller suburban hospitals that have such huge demand amid notable cases.
One of the worst examples he saw was, among other things, pipes that looked like a home freezer that had not been thawed for a long time.
The problem is getting worse for hospitals that have had to convert regular hospital rooms into intensive care units. ICU pipes are larger than those leading to other parts of a hospital. If rooms are rebuilt as pop-up ICUs, the pipes may simply be too narrow to provide the oxygen patients need. And according to Chidester, the hospitals are switching to large oxygen cylinders. But the suppliers are struggling to fill it fast enough.
Even smaller cylinders and oxygen concentrators are too few in the midst of the boom, she said. The patients who can be sent home with an oxygen cylinder are locked up in a hospital and waiting for one to take up the much-needed bed.
‘Extreme rural’
In early December, doctors serving the Navajo Nation said they needed more of everything: the oxygen itself and the equipment to get oxygen to patients in the hospital and repair it at home.
“We have never reached capacity before – until now,” said Dr. Loretta Christensen, medical chief for the Navajo Area Indian Health Service, said 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 getting older and they were not built to accommodate a large number of critical patients, Christensen said. As the number of patients with high-flow oxygen increased, several facilities began to see their oxygen flow weaken. They thought something was broken, but when engineers looked a bit, Christensen said, it became clear that the system could not provide the amount of high-current oxygen patients needed.
According to her, a hospital in Gallup, New Mexico, has installed new filters to maximize oxygen flow. After delays due to snowfall, a hospital serving the northern part of the Navajo Nation managed to connect a second oxygen tank to increase capacity.
But medical facilities in the area are always a bit on point.
“Honestly, we are very concerned about the offer here, because I just can not get it tomorrow, and I call it extreme ruralness,” Christensen said. It’s not like being in an urban environment where you can say, ‘Oh, I need it now. ‘
Because of the small size of certain hospitals and the difficulty of reaching some of them, Christensen said, Navajo facilities are not attractive to large providers, and therefore they rely on local providers, who may be more vulnerable to hiccups in the supply chain.
Tséhootsooí Medical Center in Fort Defiance, Arizona, sometimes had to keep patients in the hospital and transfer incoming patients to other facilities because it could not get the oxygen cylinders needed to send patients recovering home.
Tina James-Tafoya, commander of the incident at Fort Defiance Indian Hospital Board, which manages the center, said oxygen in some patients is out of the question. Oxygen concentrators need electricity, which some patients do not have. And for patients living in hogans, homes that are often heated with a wood stove, the use of oxygen cylinders is a danger.
‘It’s very interesting and striking to me to see something that looks as simple as oxygen