How Lacor hospital is beating oxygen crisis

On the stretch of Gulu-Nimule road, astride the border of Gulu and Amuru districts on the outskirt of Gulu City, sits northern Uganda’s surgical centre, St Mary’s Hospital Lacor.

Complex illnesses and surgical procedures unable to be conducted in other facilities around Acholi, Lango and West Nile sub-regions are referred here. 

As a centre of surgical excellence in the region, a team of medical specialists have for the last six or so years been visiting the facility annually to offer backup in surgical procedures that would otherwise lack specialists in the region or even the country.

This pool of medical activities at the region’s medical and surgical hub is boosted by a range of critical technologies.

The recent installation of two WATO EX-65 PRO Mind-ray anaesthesia machines and ACUSON NX2 SIEMENS Ultrasound machines in November 2020, is an addition to the collection of hi-tech machines Lacor now uses to serve the population.

Dr Cyprian Opira, the hospital director, says the installations meant a revamp and a big boost to their operations since the hospital had suspended certain procedures due to frequent breakdown of equipment.

“As you heard before, certain types of operations at the hospital had been suspended because the old machines broke down but now the surgeons and anaesthesiologists can work continuously without postponing surgeries,” Dr Opira says.

Lacor hospital’s major funder, the Italian-based Corti Foundation, says there are currently overwhelming numbers of patients who require treatment for a range of complex conditions at costs that overweigh the facility despite its emphasis to treat the poor at the lowest cost possible. 

Data from the hospital indicate that in 1967, patients contributed 67 per cent of the hospital’s bills, while donors chipped in 25 per cent and government eight per cent.

But the Foundation’s 2018 report says when the poverty levels escalated in the region, the contribution trend switched, with donors now contributing 63 per cent, while patients pay 29 per cent and government cutting down its share to only five per cent.

Despite the challenges, Lacor hospital was on November 6 recognised by the government (Ministry of Health) as the best faith-based health facility in Uganda after winning the Mission and Faith-Based Health Facility award at the Heroes in Health Awards held in Kampala.

In the same collection is the modern oxygen generation equipment that was recently designed to save the hospital’s unimaginable demand for oxygen due to numerous illnesses treated and thousands of surgical procedures conducted there.

For example, the hospital conducts at least 6,000 surgeries per year, excluding complex cases and referrals from other facilities across the region, where 70 per cent of the cases will require oxygen.

“This kind of trend has been persistent since the early 1980s when the Lord’s Resistance Army (LRA) war broke out. We realised oxygen was a key component in our surgical success and that meant we needed to prepare ourselves adequately by putting such facilities in place,” Dr Martin Ogwang, a senior consultant surgeon and institutional director at the hospital, says.

Early preparations
To equip itself with the current oxygen generation and dispensation system, Lacor hospital learnt from history.
Started in 1959 as a 30-bed maternity facility, the founders realised they also needed to treat cancer, especially in women, more than any other condition. 

But because cancer treatment goes together with the necessary operations, they deemed it fit to immediately install an intensive care unit (ICU) facility in the 1970s since surgeries go alongside intensive care management.

“We deliberately prepared ourselves mainly because one, the number of very ill patients who are always referred to this facility by other hospitals in the region, and secondly because we have been a major surgical centre in the north since the start of the war,” Dr Ogwang says.

Many hospitals in the region now lean on Lacor hospital by getting (borrowing) or refilling oxygen from here.
In early 2000, at the peak of the LRA insurgency, the hospital foresaw a situation where it would require more than triple the amount of oxygen it produced the moment it started to exceed its normal consumption capacity.

At that time, they used normal cylinders and oxygen concentrators but the more admissions demands increased, the more it needed the oxygen cylinders.

But Dr Ogwang says trucking the cylinders to and from Kampala for refilling was not just an expensive venture for the hospital, but also quite risky and time-wasting.

Industrial oxygen plant
Today, as Uganda struggles with challenges of shortage of oxygen supplies for Covid-19 patients, Lacor hospital, at least for now, can cope and even extend a helping hand to neighbouring hospitals.

This contrasts sharply with reports on Thursday that at least 30 Covid-19 patients had died at Mulago National Referral Hospital on Tuesday night after the facility’s oxygen supply malfunctioned.

But Lacor’s success story of ample oxygen supply has been a long journey of foresight and early preps.
“Our first strategic plan was in 2007 to have a modern and industrial plant but there was no money. However, in the second strategic plan of 2012, we succeeded in mobilising resources,” Dr Ogwang says.

But it was not until December 2017 when the hospital engineers started fitting the equipment. The hospital has so far trained its technicians to run the plant and also identified some companies, which now help to frequently troubleshoot to avoid breakdowns.

“The system can run and supply oxygen at a maximum capacity of 28,000 litres per hour, and we have also established an alternative backup system that can sustain and supply the same quantity in case of a breakdown,” Dr Ogwang notes.

On Wednesday, this newspaper visited the hospital’s oxygen plant and found inside it, two giant OGP-14 (Atlas Copco) oxygen generation machines. 

To date, the equipment has become a safer, permanent and cost-effective means of providing oxygen to patients admitted to Lacor, thereby foregoing the hazards associated with the use of heavy high-pressure cylinders of medical gases. 

The on-site oxygen generation equipment provides a reliable supply of high purity oxygen with a working principle based on pressure swing adsorption technology (PSA) where zeolite pellets selectively isolate oxygen molecules in compressed air. 
The equipment has been a major contributor to Lacor’s success due to reliable and adequate supply of oxygen required in any basic procedure. 

Dr Ogwang says the generated oxygen used by patients is routed through a piping system and fitted on walls inside the different wards of the hospital.  

“We fitted 200 ports that are installed in the wards for normal consumption. Before Covid-19 broke out, some patients would take three litres, others five and none would take more than eight litres per minute except those inside the ICU,” he says.

Covid-19 lessons
Although now ranked as one of the few health facilities with the best oxygen generation and supply system in the country, Lacor hospital did not prepare to ever tackle a situation like that of Covid-19, Dr Ogwang says.

Whereas the coronavirus pandemic is forcing healthcare facilities’ managers into panic to take unprecedented steps in improvising or managing the medical oxygen system, Dr Ogwang says the government needs to learn to plan better and in advance.

“What we have learnt and want to share with government and healthcare facility managers is the increased and high oxygen demand forced by the pandemic. Plan according to your capacity and also manage equitably the limited resources at your disposal,” he says.

While other hospitals now have to rush to Kampala every time to refill their oxygen cylinders, Lacor has been building up a backup of cylinders that can sustain the hospital for a while in case of an eventual breakdown in the main generation plant.

“We have also been supporting other hospitals who come and refill from here at a subsidised rate so that with time, as other facilities start having their oxygen plants, the oxygen capacity in the region is sustained,” Dr Ogwang forecasts.

“Since the installation of the plant, we have never gone to Kampala for oxygen, instead we have been helping other facilities until recently when Covid-19 struck and we stopped because we receive a big number of Covid-19 patients that require more oxygen,” he adds.

Just like the rest of the major facilities handling Covid-19 patients around the country, Lacor hospital is overwhelmed.
 Mr Samuel Moro, the medical gas plant technician, says they have been forced to generate more than the plant’s maximal generation capacity as more and more Covid-19 patients come in with extreme conditions. 

“For Covid-19 patients, we run two lines, those in the unit for suspected cases and the isolation unit with confirmed cases. The isolation unit consumes the biggest chunk of what we generate more than the general (medication) wards and the ICU can consume,” he says.

Before the outbreak, the plant would run only one of the machines while the other remained in the backup mode, but Mr Moro says the two machines have now been running concurrently for more than three weeks and producing beyond 28,000 litres of oxygen per hour.

“But at the moment, as Covid-19 is at its peak, we are running both machines and the two lines have been running for three weeks. These machines have to run 24 hours a day. We are producing 28,000 litres per hour but the consumption now has climbed to 30,000 or 32,000 litres per hour,” he says.

“The risk is that we have been forced to overwork both machines. Should they break down, that will mean a disaster for us because it takes quite a long time to order for the spares,” Mr Moro worries.

The hospital has since inception been depending on the goodwill of people from outside the country.
The government’s subsidy to Lacor, together with user fees collected, only form 30 per cent of the Shs25 billion budget it requires to operate annually.

Mulago, other hospitals

Last Monday, Mulago National Referral Hospital management came out to admit that they don’t have sufficient oxygen at the facility due to the sharp increase in admissions of Covid-19 patients, who need oxygen support.

The hospital says they are now getting supplements of medical oxygen from private firms such as Oxygas, Roofing and Steel and Tube to minimise the impact of the shortage.

The situation has become more worrying following the second  and more virulent wave of Covid-19. 
Public hospitals, especially in the major cities and towns, have run out of oxygen supply.

At Lacor hospital, currently, at least 40 Covid-19 patients are undergoing critical care at any given moment. They consume nearly a third of the total oxygen generated at the plant per hour, risking undersupply to the rest of the wards.
“We know we are getting overwhelmed by relying on the machines alone, but we have reserved cylinders somewhere and oxygen concentrators but those are not enough,” Dr Ogwang warns.

Across the region’s health facilities, there is an acute shortage of oxygen. Gulu Regional Referral Hospital, for example, currently depends on Lacor hospital to refill its oxygen cylinders since their oxygen plant broke down recently.

Last week, Dr Paska Apiyo, the hospital’s head of isolation unit, said due to the challenge, they were referring Covid-19 patients that require critical care to Lacor hospital. 

Extreme pressure has been exerted on Lacor hospital due to the patients’ treatment demands.
In the Madi sub-region, Obongi, Moyo and Adjumani districts are currently grappling with Covid-19 cases due to a shortage of basic facilities to manage the overwhelming numbers.

Dr Michael Ambaku, the medical superintendent of Adjumani hospital, says the medical facility is currently managing a big number of patients but the number keeps increasing.

“On June 11 alone, the hospital detected four new cases, while Dzaipi Health Centre III recorded 14 cases, which were already too much because we have run out of basic medication to handle the cases,” Dr Ambaku says.

Adjumani District now has 333 positive cases with seven deaths. Of the 333 cases, 56 are refugees, four are foreigners, while 273 are Ugandans.

“Due to lack of capacity, we are now encouraging home-based care management,” Mr Data Taban, the Adjumani Resident District Commissioner (RDC), says.

Just like its neighbour Adjumani, Obongi District has an isolation facility of only eight patients yet the district lacks oxygen cylinders to manage critical cases.

“Our health facility is not a hospital, it is a health centre IV, and so we refer critical cases that need oxygen to Arua Regionaleneral Referral Hospital or Moyo hospital,” Mr Dominic Lomurech, the Obongi District acting health officer, says. 

But such transfer costs have to be met by the patient, this newspaper has established. For a patient to be referred to either Adjumani, Gulu, Arua or Kampala for critical management, they have to part with at least Shs900,000 to fuel an ambulance.

But Dr Franklin Iddi, the Moyo District health officer, says Moyo hospital was not only challenged by lack of oxygen cylinder supplies but also faced with erratic power supply in the hospital, especially for its ICU section that currently has eight Covid-19 patients.

About the hospital

The hospital was founded in 1959 as a 30-bed hospital by Dr Lucille Teasdale-Corti and Dr Piero Corti (pictured), who arrived in 1961, by July 2005, it had 483 beds. 

Teasdale-Corti later died in 1996, of the HIV/Aids she had reportedly contracted from a patient while performing surgery. 
The hospital maintains remote Level III health centres in Amuru, Opit and Pabbo, with an additional 24 beds, including a nursing school and other health worker training programmes. 

Each day, the hospital hosts an average of 600 inpatients and their attendants, as well as 500 outpatients, for a daily total of about 2,000 individuals.