It was not frequent in Rwanda to admit patients under oxygen in hospitals before covid-19, except for special cases; medical oxygen was kind of expensive and not all health facilities had the required infrastructures. Most health facilities used oxygen cylinders to transport medical oxygen from its plant to the hospital and to the patient’s room or/and bed.
“Before the pandemic we saw patients suffering from pneumonia, malaria, sepsis and a variety of other conditions, as well as far too many premature babies died due to a lack of medical oxygen,” said Dr. Marc Biot, MSF director of operations. “COVID-19 brought this issue into sharp focus; unstable oxygen supplies kill.”
For a patient who uses the oxygen cylinder, many cylinders are required to replace the emptied one, and this immediately after finishing it because it can’t wait. But in Rwanda the plants for medical oxygen are not many and are far from many health facilities, hospitals or others, so they had to make a long way to ‘fetch’ it from the plant and store it in those cylinders waiting to be used.
With covid-19 increased cases, many patients were admitted, hence the insufficiency of medical oxygen; sometimes patients had to be transferred because the hospital in which they are admitted doesn’t have enough oxygen.
“Patient must rely on bulk, expensive and easily depleted oxygen cylinders or small oxygen concentrators which are not sufficient for critical patients” said Dr. Biot. “Oxygen is the single most important medicine for severe covid-19 patients, yet oxygen supply is often insufficient because of infrastructures.”
With covid-19, cylinders’ circus
“You have admitted a covid-19 patient under oxygen, and he consumes the oxygen you had, you then take the oxygen cylinder and go refill it at the oxygen plant which is far from there, you put the cylinder in the transportation car and bring it to the patient, he then consumes it and you go back to refill, it’s an endless process,” said Dr. Menelas Nkeshimana; a sub cell lead covid-19 case management at Rwanda joint task force for covid-19.
“The transportation of oxygen cylinders is not secure at all; it requires specific cars with high precautions, and it’s so much costly. The oxygen in the cylinder is compressed with high pressure; any mistake can make it burst like a bomb, a simple traffic accident with a car transporting oxygen cylinders can create an unimaginable scandal.”
Cylinders bother patients and medical staffs
Mama Munyana (nickname) 55 and mother of four, tested positive for covid-19 and was admitted to Nyarugenge Hospital located at Nyamirambo center, soon after, she was put under oxygen.
“There you see people covered in white costume carrying that long cylinder, then you realize that they are putting it around you, except that you are fighting to breath, you have no choice at all, but that long cylinder is so scary to see.” she said.
Solange Mutimukeye (names changed) is a nurse at Rwamagana hospital; she says that it was difficult whenever a patient was admitted under oxygen, because they had to be there every time to watch over the cylinder so that they can change the emptied one by a new one on time.
“It was not an easy job to carry that cylinder of more than 10 kg and keep vigilance so that you could replace it once emptied by the patient under oxygen.” Said the nurse.
Better having a source than fetching away
“Every household need water, but would preferably like to have a source of water than going to fetch it elsewhere”, Dr. Nkeshimana comparing the importance of having the medical oxygen plants inside hospitals than going to get it with cylinders from far.
Dr. Nkeshimana says that all the struggles and risks in using oxygen cylinders led to the improvement and finally it was possible to produce medical oxygen within hospitals.
There are different sizes of machines that transform air to medical oxygen;
As of September 2020, the country has seven operational public oxygen plants producing roughly 7,000 cylinders (50L) per month, with a total maximum oxygen production capacity of 355 cylinders (50L) each day or around 10,800 cylinders per month.
“The oxygen plant are machines that are stationed somewhere in the hospital, it transforms the atmospheric air into medical oxygen, then connected by pipes it brings medical oxygen through hospital’s walls and get to the patient’s ward and straight to his bed. Nowadays, we have oxygen plant in every hospital, and our target is to have it in every health facility in Rwanda,” said Dr. Nkeshimana.
Officials say that the oxygen plants acquired are enough, but the government decided to buy more to avoid any shortage in case the situation with new variants of covid-19 might get out of hand. Rwanda spent over Rwf4 billion (approximately $4 million) to import oxygen plants to increase local production.
Medical staffs were relieved
“But now the oxygen comes from hospital’s walls, I don’t know how they did it but it made our job easier because we no longer carry the cylinders, we only put patients under oxygen without worrying that it will be emptied,” Mutimukeye said.
Some patients who have been admitted to hospitals where the indoor produced medical oxygen is used, say that it’s comfortable and secure; it’s the case with Vivian Uwizeye a.k.a Miss Vivi or Miss Rwanda heavy weight, who was among the most affected by covid-19 in Rwanda.
Niyingabira was looking after her pregnant wife in Masaka hospital, and it happened that she was put under oxygen; he affirms that the patient’s room looks cleaner when the oxygen is coming from wall to the patient’s bed than having cylinder around the bed.
“When you see a patient under oxygen and the cylinder is around there, you will just say that your patient is not fine. But when it comes without seeing the source, even if it’s also oxygen, at least you can feel secure in that room,” he added.
Dr. Nkeshimana says that now in Rwanda they have enough oxygen to serve any possible number of patients once admitted in hospitals.
Even after covid-19, the use of medical oxygen produced within hospitals will still be abundant, not only for covid-19 patients but also for any other patient that can be needing it, either in maternity or pediatric, anywhere, concluded Dr. Nkeshimana.
There some limitations
One of limitations is the electricity costs that are too high. Officials say the cost of running oxygen plants is rising due to higher electricity charges. Currently, hospitals are charged a residential power tariff of Rwf227 ($0.27) per kilowatt. They want the government to review their tariff structure and get moved to non-residential power tariff of Rwf126 ($0.15) per kilowatt.
“A hospital is a lifesaving facility and it should be charged non-residential power tariffs,” said Augustin Sendegeya, the Managing Director of University Central Hospital of Butare.
Abdallah Utumatwishima, the managing director of Ruhengeri hospital told Rwanda Today that the hospital currently spends a lot of money on electricity bills partly due to higher costs associated with running an oxygen plant.
According to the management of Ruhengeri Hospital, it costs them over Rwf266,000 ($264) every day to make 900 liters of pure oxygen.
While the hospital initially sought to cut costs by manufacturing its own oxygen, it says its electricity bill has more than doubled from about Rwf4 million ($4,680) to Rwf8 million ($9,360) per month.