For The Love of Oxygen

It’s a typical windy harmattan morning, on Saturday when Simon* presents to the emergency department of a government hospital in Nigeria. He is rushed in by his wife who reports that he has been weak for  two days despite taking his medication regularly. Simon is a 56-year-old civil servant who has been diabetic for the past twenty years and hypertensive for ten years. Last year, his doctor told him that his kidneys were showing early signs of failure. His family had rallied around him and sought a second opinion outside the country only to be told the same thing.

After waiting for several minutes, the doctor at the emergency took his vital signs and noted that his blood oxygen levels were low. The managing team immediately outlined the treatment plan and requested for oxygen. That is when wahala started.

An oxygen concentrator had to be sourced from another ward, because all the cylinders in the A&E were empty. When it arrived, the socket that it was to be plugged into was faulty and all the other sockets were occupied. Mr Simon’s son had to run across the road and purchase an extension cord that was used to plug in the concentrator. After viewing his test results and several consultations with the nephrologist, it was decided that the patient would need dialysis immediately. Simon would need to be transported to the dialysis unit but there was just one hitch- There was no stretcher or wheel chair available. In desperation, Simon’s wife and son, together with the porter, agreed to push the hospital bed (which had tyres), across the hospital corridors to the dialysis unit. However, there was another problem. Transporting the patient required another source of oxygen- a mobile oxygen cylinder.

The managing team searched high and low, but all the mobile oxygen cylinders were empty. Some forty minutes later, a call came through that one had been found at the oxygen plant. At last, the patient was on his way to dialysis. Simon’s son and the porter pushed the heavy hospital bed as fast as they could into dialysis only for the oxygen to finish as they entered the unit. The nurse at the dialysis unit noticed the defunct oxygen flow meter and delivered bad news: there was no oxygen in the dialysis ward. At the time patient’s SPO2 was 64%.

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Could dialysis still be done? The answer was no.

There was no oxygen cylinder in the dialysis unit and the one in the mobile cylinder had finished. The porter had to sprint to the A&E to get the concentrator that was left there. While waiting, Simon started gasping silently and slumped. His wife raised an alarm and the nurses and doctors immediately started CPR. The oxygen concentrator arrived and was immediately plugged in. His son stood against the wall weeping quietly as he watched his father’s chest pressed repeatedly.

Twenty minutes later, Simon was declared dead.

Whenever, I hear these real life occurrences, my heart grieves and tears flow freely. Not necessarily for the patient whom I did not know, but for myself, when the time comes. It’s like peeping into the looking glass and seeing our abysmal future.  Is this how the system will fail us?

How can we be having oxygen shortage in 2024?

Globally, oxygen therapy has been used in medicine for nearly a century. Yet, Nigeria still faces a staggering burden of deaths due to lack of access to oxygen. In Nigeria, more than 625,000 deaths annually occur due to diseases associated with hypoxaemia—insufficient oxygen in the blood or low blood oxygen saturation. In children, hypoxaemia is a major fatal complication of pneumonia, accounting for 120,000 under-5 deaths in Nigeria per year. Evidence from secondary health facilities in Nigeria also show that 25% of babies and 12% of under-5 children admitted to hospital with pneumonia are hypoxaemic (low blood oxygen) on admission.

The worst scenario however, is when these patients’ present to a hospital expecting  to be saved but meet their death instead.

In Nigeria, a handful of facility-based studies have been conducted to understand management of hypoxaemia, as well as the availability and supply of oxygen delivery systems. Evidence from these studies suggests that reliance on clinical signs for hypoxaemia screening is predominant in Nigeria, and that the use of pulse oximetry for this purpose in surveyed health facilities, is minimal. In particular, a 2016 study in four southwestern states in Nigeria found that only three of 12 hospitals assessed had pulse oximeters in paediatric areas, and that the hospitals did not routinely assess children using pulse oximeters. Additionally, in a 2016 multi-facility oxygen assessment in eight states, only a subset of PHCs (3%) and referral facilities (24%) had pulse oximeters. In the Secondary Health Facilities (SHFs) and Tertiary Health Facilities (THFs) with paediatric inpatient departments surveyed in the study, only 24% had pulse oximeters, and much fewer (11%) of these were functional.

In recent years however, especially since COVID, the use of pulse oximeters has become widespread. Almost every healthcare worker has one swinging around their neck. And yet, they can only test for blood oxygen levels. The actual treatment- oxygen in cylinders and oxygen concentrators are still in limited supply. Availability of oxygen delivery systems in health facilities in Nigeria is equally inconsistent or limited, and existing oxygen equipment is often of poor or unverified quality.

In the 2016 multifacility study, oxygen assessment in eight states found that only 4% of PHCs assessed had functional oxygen equipment—cylinders and concentrators—and that frequency of refilling cylinders varied considerably by facility. Among the SHFs and THFs surveyed, only 55% provided oxygen therapy with the neonatal wards most frequently providing oxygen therapy (93%). Furthermore, the study in the southwest found that only 5% of the surveyed facilities had oxygen analysers, instruments meant to verify that oxygen delivered to patients was at least 85% saturation, considered medical grade oxygen.

Since this study, a lot has been done by the FMOH.

Presently, based on currently available data, at least 30 public sector oxygen plants have been established in Nigeria, of which 21 are purportedly functioning; 6 are of unknown status, and three are non-operational. Factors such as inadequate power supply and wear-and-tear on pipes delivering oxygen to hospital wards are threats to optimising the use of these plants.

The access to oxygen should be the right of every person. That a modern hospital, with a bed capacity of more than 50, should be unable to provide reliable sources of oxygen to it’s patients, is an embarrassment. When a hospital is constructed on a grand scale, accompanied by extravagant architecture and fanfare, but lacks a functional oxygen-producing plant capable of supplying the entire facility, it becomes a hazardous environment. That people are still dying in numbers too disastrous to admit in a public environment is disheartening. Every day, beautiful plans and policies are laid out in government offices across the country but are abandoned over cost and lack of political will.

Our problem in Nigeria, has never been lack of policies and infrastructure. At present, there is a national policy for medical oxygen established by the FMoH that aims to reduce morbidity and mortality from hypoxaemia by improving access to oxygen systems.

And yet, Simon died last week due to poor oxygen delivery. And there are many more deaths out there.

May God not hold us accountable for their deaths.