"How much have we let hospital preparedness be neglected ... "
California's Covid-19 cases are surging four times higher than the state's summer surge. Intensive care units are overflowing with sick patients, as already weary health care workers scramble to keep up.
On top of dwindling hospital beds, city hospitals are running out of another crucial resource: oxygen.
Ambient air is, of course, all around us. But for patients with respiratory viruses like Covid-19, those in surgery, or some who simply struggle to breathe on their own, medical-grade oxygen is essential. This week, in Los Angeles, there simply isn't enough to go around — nor the adequate mechanisms to pump it out.
For Amesh Adalja, a senior scholar at the Johns Hopkins University Center for Health Security, the oxygen shortages represent a "sign of the times" — the latest example in a laundry list of ways hospitals have been compromised throughout the pandemic.
"This is just another example of how that hospital preparedness has been neglected for so long," Adalja tells Inverse.
When hospitals are running out of something that simple and as ubiquitous as oxygen, Adalja explains, sustainability becomes a concern. And while oxygen shortages are unlikely to balloon into a nationwide crisis, hospitals face potential spot shortages if the pandemic continues to rage unabated.
What is medical grade oxygen?
Medical grade oxygen was discovered independently by a Swedish pharmacist Karl W. Scheele in 1772 and by an English amateur chemist named Joseph Priestley two years later in 1774. Shortly after, in 1783, a French physician named Caillens treated a young woman with tuberculosis who ‘very much benefited’ from daily inhalations of oxygen.
Over the next century, oxygen therapy was born and billed as a panacea for both serious illness as well as common, minor ills. But it wasn't until the early 19th century — with the outbreak of World War I and the ensuing chemical warfare — that scientists developed modern oxygen therapy.
Now, supplemental oxygen is ubiquitous in hospitals — critical for the care of patients experiencing trauma, undergoing surgery, or being treated for respiratory distress and a variety of acute and chronic medical conditions.
It's especially crucial for patients suffering from Covid-19, a disease that wages war on the lungs and often comes along with hallmark symptoms like shortness of breath and low blood oxygen levels. One in five Covid-19 patients will require oxygen therapy, while another five percent need ventilation, according to the World Health Organization.
Ambient air contains 21 percent oxygen concentration. Medical grade oxygen can ramp that proportion up and is dispensed at a higher flow rate — helping patients efficiently oxygenate their bodies.
"Oxygen is really essential for many functions of modern medicine," Adalja says.
Where are the oxygen shortages?
Until Los Angeles' crippling oxygen shortages, Adalja can't recall any similar deficits in the United States in recent years. However, other countries including Peru, Haiti, Ethiopia, Colombia, and Egypt have reported crippling shortages, even preceding the pandemic. In August, the management firm McKinsey & Company published a report on the "severe shortage of medical oxygen," writing "the Covid-19 crisis is exacerbating what is considered a critical vulnerability in the health infrastructure of many developing countries."
When oxygen supplies deplete, “everything stops,” pediatric surgeon Tihitena (Tito) Negussie Mammo told the World Health Organization in September. Mammo works in a hospital in Ethiopia.
“I have even had it happen in the middle of emergency surgery. When it does happen, we have to use a bag and valve mask, attaching a small portable oxygen cylinder if there’s one on hand.”
To alleviate this global oxygen bottleneck, agencies and institutions are investing in new oxygen plants, stores of liquid oxygen, oxygen concentrators, ventilators, and compressed gas oxygen cylinders.
Many hospitals have large supplies of liquid oxygen and a supply of compressed gas oxygen cylinders that allow several days of reserve. However, there is still a dire scarcity in many countries around the world — a problem that's showing up even in relatively well-resourced health systems like Los Angeles.
"We're left asking: How much have we let hospital preparedness be neglected that we're in these types of situations?" Adalja wonders.
There's no clear body responsible for the recent oxygen shortages. Instead, the problem is complicated by complex logistical supply chains and infrastructure.
"It's not as if there's like less oxygen on Earth or something," Adalja explains.
"It's more about hospitals being equipped to deliver so many liters of oxygen at any given time based on the infrastructure and outlets that they have in the wall."
Few hospitals anticipated the scale and scope of the pandemic, or how overwhelming the cases would become.
In Los Angeles County, hospitals are stretching the oxygen supply in an effort to meet the unrelenting demand from patients requiring it. Emergency workers have been told to conserve oxygen and administer the minimum amount of oxygen to keep patients’ oxygen saturation level at or just above 90 percent.
Health authorities in LA County have also directed ambulance crews not to transport some cardiac arrest patients whose survival is unlikely, the New York Times reports. Emergency rooms are so overburdened that some patients are having to wait inside ambulances for as long as eight hours before entering the hospital.
To counter the pressing shortage, the U.S. Army Corps of Engineers and the California Emergency Medical Services Authority have been deployed to help deliver and refill oxygen tanks in the county.
Ultimately, the root of the oxygen problem, in LA and elsewhere, stems outside the hospital. It links back to the daily choices communities make, Adalja says.
"When people don't follow common-sense precautions, it's not some abstract thing that happens — it's actually very concrete," Adalja says. "You can put your hospitals into crisis very easily with a virus like this."
Now is an especially perilous moment of the pandemic. As people stare through a fog of "pandemic fatigue", a more transmissible variant spreads, and vaccines are haphazardly rolled out, social distancing, mask-wearing, and handwashing remain the best defense.
"Your actions do have consequences," Adalja cautions. "And they can put your community hospitals in the position where they may not be able to provide care."