Low Spo2 levels not improved by CPAP advice please

I have been on a Resmed CPAP machine since August, not because a sleep study showed Apnea’s, it didn’t however it did apparently show my SPO2 levels were erratic and dropped to 88 frequently during the study night, or at least that is what I was told.

Before using the machine I got at least 8 hours sleep each night, went out when my head hit the pillow and slept like a log all night waking refreshed and ready to go the next day, however around 4:30 am I would start snoring which would wake my husband which was why I was sent for a study.
Now I am lucky if I get blocks of sleep lasting more than 3 hours often a lot shorter. When I do sleep I often wake feeling completely shattered, my face is raw, I am short of breath and I have a niggling cough that is always in the background all of which stops when I stop using the machine for a few days but if I call the clinic they tell me to persevere with the treatment.

The Resmed reports do not show how much actual sleep you get nor do they show Spo2 levels but despite the fact that I still snore from around 4:30am and am more tired now than I have ever been, the reports show I am a complete success when I use the machine because I can get a perfect score if I lay on my back with the mask on and just lay there wide awake. However I can’t actually sleep on my back as I suffer from Restless leg syndrome and sleeping on my back hurts my feet while sleeping on my side or stomach causes the mask to leak unless it’s on really tight which in turn damages my face.

In an attempt to make some sense of all this I bought a CMS50 oximetre with a recording facility and I use that nightly but that shows whether I use the Resmed machine or not, wear a mask that leaks or a tight one, my SPO2 levels still remain erratic and can drop to 88 on occasion.

However I cannot repeat the results they got from the study since, even if my levels do drop to 88, it has only happened 6 times since August; most of the time the lowest they go is around 92 so I don’t quite understand what is going on.

Any suggestions or has anyone else been put on CPAP due to low SPO2 levels and if so if there a solution that doesn’t ruin your sleep but does improve SPO2 levels so that I can get off the Resmed because it’s ruining my nights and not resolving anything.

Welcome to the forum. Please read the top message for newbies. Then download sleepyhead and follow the instructions for posting graphs from a typical night.

We also need to know what machine you have, what your pressure settings are, and if you have any particular issues.

Many people are sent home with a machine that is either set wide open or to settings that were just a guess. So, while you are using the cpap, you are probably not getting therapeutic value from it yet. The fact that you are still snoring shows that. We can help you dial in on better settings that will help you sleep better and feel better. But it is best to base the changes on actual data and not guessing.

For the record, 88 is the borderline between what is thought to be OK (if on the low side of normal) and what becomes worrisome (below 88) if gone below there for long periods of time. They may not have flagged anything 'wrong' if 88 was as low as things went.

Many of us find that it can be worth it to put the full effort into making PAP therapy work for us, if it can, since it does so much to improve how we breathe at night and does so in ways that would never show up in a home-oximeter recording.

In my opinion it is often good to do one's best to solve problems one at a time in order to make peace with a medical therapy instead of using unrelated equipment in an attempt to find a way to make a case against it.

It would also be very useful if you could obtain a copy of the sleep study and share any other serious medical conditions you have. Test results (at least in the US) have a way of being communicated that can you leave you with an incomplete picture of why the provider chose the treatment path they did.

When you did the sleep study, were you on any particular medication that has since changed? Has your alcohol consumption (if any) changed since the sleep study? Did they say the snores were totally benign?

Folks here can help tune your therapy...that is what the many questions to begin!

Hi perhaps I should have clarified.

I am in the UK, female, aged 68, Bmi 27.8, and cycle 30-100 miles every week, I only drink hot water, very weak coffee and occasionally milk, the only thing that has changed since the original diagnosis is I have been told I am no longer pre-diabetic, my sugar levels are back to normal. My original diagnosis was mild OSA based on the low Spo2 frequency.

I am using a NHS Supplied Resmed Airsense 10, and have been given two masks first an F10 and then an F20, the F20 cut into my face, caused rashes and upset my hernia blowing air down into my stomach so I went back to using the F10 which has a double layer, is less damaging to the skin and causes less bloating and digestive problems though it still leaves red marks. On my last visit they gave me a humidifier though having tried it for 6 weeks I find I get on better without it as the humidity affects my chest.

My machine and associated equipment was issued by a UK sleep clinic in a local hospital and I was told they did not approve of me altering the settings. The device sends back data to the sleep centre each day so they would see any alterations I made.

I use the machine for 5-6 hours nearly every night as they can take my driving licence away if I do not comply but I was prevented from doing so during a recent bad virus because it caused coughing fits and escalated breathing problems; I am also asthmatic so viruses usually attack my sinuses and chest. That was when I found my Spo2 readings were the same as when I had been using the Resmed, I have been producing reports from the data on the card since September and from the Oximetre since October so had the means of doing a comparison.

Ok I do snore but I don’t snore every day and according to my husband he didn’t hear me snore once when I was ill but soon after I recovered and things got back to normal the morning snoring returned, according to the reports it is still not a daily occurrence but when it does happen it’s usually between 4:30 and 6 am.

When I was first given the Resmed machine it was set to start pressure at 4 and raise pressure to 20 but that caused serious problems with my chest and breathing and stopped me sleeping altogether so the levels were adjusted by the hospital to start at 5 and raise to a maximum of 11, this has enabled me to get blocks of sleep that last 3-4 hours rather than waking every 30 minutes to an hour so a vast improvement.

I have been told I am wearing the right size mask for my face size but I have small features and apparently it leaks because my chin is too small so when my face relaxes there are leaks. I found the only way to prevent the leaks is by tightening the lower straps but that in turn causes serious welts and makes my Rosacea flare up which is very noticeable and highly embarrassing.

I had a return appointment back in October when I borrowed an oximetry reader and after returning it I bought the same model for my own use, it has been tested for accuracy and I wasn’t the only person who found it odd that we cannot repeat the original test results, especially as I rarely have actual apnea’s and have only reached a Spo2 of 88 a few times in 4 months.

I tried to see the consultant again to query the findings of the original study and request a second one but the earliest appointment was for 6 months so I am not due back until March, but that length of time without getting a full nights sleep is causing it’s own problems and is really disruptive as I ran my own business which has now ground to a halt while this reaches a less disruptive conclusion. While waiting for the appointment I have been gathering data, looking for possible solutions and seeing if anyone else has had a similar experience and can offer any insight.

As to the Spo2 readings of 88, I had little experience of sleep Apnea when I saw the consultant and he made it sound like the results were of great cause for concern so I did as I was told and accepted a machine as I am fast approaching 70 and did not want to have a stroke which he said was a distinct possibility if I ignored it. My Epworth Sleepiness Scale scores have been between 1 and 5, my neck measurement is 14.5 inches and I have never slept during any part of the day unless I have had a fever.

According to the NHS snore test I was told I am a multifactoral snorer. It said “Your snoring is most likely caused by a vibration at the base of the tongue and a problem with your nasal airway. We recommend a Tomed SomnoGuard AP 2 as the potential solution to your snoring problem” but as the sleep centre does not issue mandible devices in the Uk I was given a Resmed. I trust that will give a clearer picture of my situation and would appreciate any discussion if you have had similar experiences.

Just a reminder that these days overweight apnea 'patients' are thought to have gained because of the apnea, not the other way around, and often when Cpap is going well, the new energy helps to get rid of the weight, though most who do so must still stay on Cpap indefinitely.

Sounds like you have a lot going on with so many unknowns. First, the simpler things. There are products that can make your mask use more comfortable, like soft covers for the headgear straps and liners for the masks to protect the skin. You might want to explore those. Experimenting with humidity levels may help you discover a less problematic setting. For instance, I get congestion with lots of respiratory aggravation if I turn my humidifier over 2. Others here have to crank theirs to the highest setting to even find it tolerable. Have you tried other settings? These are merely comfort settings, and are there for your adjusting to your preference.

You do have lots of information, however, it might still be helpful if you are able to get a copy of the detailed report from your study. Not sure how available the report would be in the UK. In the US, it's ours for the asking. Did you have a home study or lab study? If in the lab, were your legs wired? You said you have RLS, which makes me wonder if you might also have Periodic Limb Movements. I would hate to see your CPAP treatment getting blamed for all your sleep troubles if there might be some shared blame. I'll wait till you respond to this before saying any more about what may be a moot point.

I am sorry I am of no help on the oxygen question. Good luck with things.

I may have missed it, but I don't see anything posted about Apnea events? AHI scores, and what they are composed of? Sounds like the oxygen score is getting all of your attention, and may not be a problem since you are around 92 and rarely lower.

Maybe a look at other factors will help! Your mask is giving you problems with fit, comfort. Is there a reason you have not tried other masks? What about mask liners? Personally, I find that if a mask is leaking or becomes easily dislodged, and for certain if it causes discomfort/pain I cannot sleep well! Maybe that is a bigger factor with you than you realize. While many do very well with a full face mask like you currently use, and some with the newer hybrid full face masks, consider using a nasal mask. One of the most recommended and widely used is the ResMed P10. Hard to find one more comfortable. Not easily dislodged when sleeping on your side. "User Friendly" is a term I would give it.

Many here will tell you that you want to fix one problem at a time. Meaning changes to your machine settings mostly, but masks and medications have a big effect also. The "sleepyhead" software recommended here is a good start if you want to monitor your therapy. Even if you don't share that information, once you learn how to read it the information available is helpful. I have never posted my sleepyhead chart, but I know from seeing others here where I am at and I am positive input from members here has helped a lot.

If you can get your mask comfortable and working in a way that it does NOT wake you, that may be a HUGE improvement in how long and how well you sleep! Adjustments to your machine settings, including humidity and temperature of the air will fine tune things.

Hi again, thanks for the replies, I will try to answer the points raised by various people in order so bare with me.

First weight, months before the sleep study my weight was 167 pounds which is almost 76kgs for someone 5ft1 that was far to much so we tried a few things and in the end found cycling helped me loose weight so that is why I cycle between 30 and 100 miles each week. Despite the Christmas Fayre my current weight is down to 145lbs/66kgs the weight loss comes from following. My dieticians recommendation of restricting my intake to 1200 calories and doing lots of cycling.

I bought and tried mask liners but they did little to prevent the soreness and other problems with my face however they did increase the leaks which in turn made the unit increase air pressure which led to my swallowing far more air and worsening sinus problems. Using the mask without a liner might not do my face much good but if the lower straps are tight enough I can at least prevent most of the leaks.

I did play around with the humidifier settings when I was using it but they didn’t really make a great deal of difference with the problems caused by humidification. The form of asthma I have is, according to my doctor quite odd for someone my age as it’s generally found in young children and is very much cough related. I get coughing fits, or perhaps I should say barking fits as I sound like a large dog, and they can cause me to get a sore throat and loose my voice, they also prevent me from sleeping, screw up my sinuses and leave me with vertigo. I take Salbutamol and Beclometasone dipropionate for the asthma, and use the Epley manover for the vertigo.

At the moment I am using the Resmed without a humidifier as that does at least enable me to get better sized blocks of sleep.

My sleep study was done at home on the hottest night of the year, and I ended up in the hottest room in the house so my husbands snoring and the heat were both preventing me getting to sleep, plus I really struggled to get any sleep with two sensors strapped to my chest, another around my head and up my nose and selotaped to my face and an oximetre strapped onto my finger. While I had the monitors on for almost 5 hours, I only managed to get a bit short of 1 hours sleep, the rest of the time I was trying to cool down, making up a spare bed or changing rooms.

You are not given a copy of the full study report over here, all I got was a copy of the letter they sent to my doctor which states is I had an Epworth Sleepiness score of 3, my AHI was 26.4, oxygen desaturation index was 36.4 and so It said I had moderate OSA, which doesn’t make sense as the consultant clearly told me the study did not show any Apnea’s but he was concerned about the oxygen saturation’s, plus as I already said the only period of sleep I got that night lasted less than an hour because of the heat so I honestly did not expect them to have been able to get any data as I wasn’t asleep long enough so I thought I would be told I needed to do the test again, it was a real shock that they had gathered any data.

Since using the Resmed the machine reports I have an average Ahi of less than 1 and the oximetre is reporting roughly 15 drops In spo2 levels per night although most of them are still above 90. I’ve just been through Nov and Dec reports and there were only 2 events that reached 88 and 1 that dropped to 85.6 and on each of those nights I was using the CPAP machine. The only time I stopped using the CPAP was while I had a virus and according to my oximetre that did not have an adverse affect on my Spo2 levels. Yes I am putting more emphasis on those, that is because that is what the consultant told me was my problem, as I said he told me I wasn’t having apnea’s.

If it helps, Last nights scores were AHI 0 pressure 4 min, 6.16 med, 9.12 max. No leaks but 3 sleep periods in 7 hours
Spo2 4 events pulse average 55 min Spo2 89,
The night before it was also ahi 0, pressure 4.02 5.72 med, 8.38 max no leaks, 6 sleep periods in 5 hours,
Spo2 9 events, pr 54 events min Spo2 90 pulse average 55
The night before that I had serious problems with the mask ahi 0.94 major leaks 37 % of time 9 sleep periods in 5 hours
pressure min 4, med 7.10, max 11 spo2 17 events pr 48, min spo2 91 pulse Average 58 obstructive .62, hypopnoa .31
I have been getting these sorts of score since the first day I used the machine

We only get the masks they issue in the UK and to date they have only given me the two I mentioned in the last message both are full face I don’t believe they issue the nasal masks and I can’t afford to buy one without some idea of whether it will work.

Thanks for the advice re the sleepy head software, but that is what I am already using. I haven’t shared the data because it’s on my computer which is a PC and this is on an apple device so can’t read the data.

Hope that makes sense and look forward to your comments.

Sleepyhead was designed on a Mac, but seems to be used at least as much on PCs... have you read the 1st 'Announcement' on the main pg = it tells you how to set up things to get reports we can all see (after you cover the personal stuff of course), but come back with any questions.

Hi Darth_Rita, welcome to the forum. I also have a problem with low SpO2 that my APAP only helped with marginally.
AHI stands for Apnea Hypopnea Index. If you search Wiki or here you will find a better definition that I can give. What it means is that you if you have no Apneas, then all the events scored on the AHI of your sleep test are Hypopneas.
Again, it's best if you research Hypopnea.
On my original sleep test my SpO2 was below 90% for more than 80% of the night.
Not good.
I got my APAP that same day and my oximeter in about 2 weeks.
With the APAP my SpO2 stayed just above 90% most of the night, without using it my SpO2 stayed just under 90%, but I had more events where my SpO2 would get down to the 82% range.
I had already started a weight loss plan before my diagnosis, and I continued with it. My BMI went from approx 30 to approx 24.5 over a period of 5 months. My SpO2 improved a great deal as well. It was now averaging 4 or 5 percentage points higher, in the 94% to 95% range. I attribute my improvements to the weight loss.
Have you lost weight shortly before or since the sleep test? Sometimes there is a latency period from when you loose weight until is shows a benefit on the test. They recommend that you are retested if you loose 10% of your body weight.
Is the weight loss and exercise program responsible for your improved diabetes? or could the CPAP be helping there?
The sleep test is only one short sample of how you are sleeping. Every night is different. That one night could have been a very bad night as far as AHI goes, or it could have been a good night. What the data tells you over a long period is the most important in my opinion.
If you can't see the specialist/consultant for 6 months then you should work with your primary care physician. Your CPAP should be helping you get a better sleep, not making it worse. Many people cannot tolerate CPAP, there are other ways of managing Obstructive Sleep Apnea.
There is lots of information on the internet about our condition and what can be done about it. There are new studies coming out all the time.
Good luck on your journey to better health.

We need to see both a SleepyHead chart or two, and an overnight oximetry report or two, posted here before we can be of much value. It's possible the oximeter dips to 88% or so are just artifacts (aka loss of contact with the finger probe/sensor).

It is normal for the oxygen saturation to decrease a bit at times while sleeping in all humans. If you have real dips below 90%, I would say it warrants further investigation.

If you truly do not have OSA, then I would recommend seeing your physician to do a basic workup, and if indicated, get a workup done from a cardiologist as well.

Darth_Rita wrote: ↑

Thu Dec 27, 2018 9:00 pm

Hi again, thanks for the replies, I will try to answer the points raised by various people in order so bare with me.

Welcome Darth_Rita, it sounds like you have a lot of different challenges on your plate. Just remember, you don't have to tackle everything at once. Buttoning down challenges sometimes happens in small steps. The key is to take those steps. Just being here is a great start. You're taking control of your therapy.

Darth_Rita wrote: ↑

Thu Dec 27, 2018 9:00 pm

First weight, months before the sleep study my weight was 167 pounds which is almost 76kgs for someone 5ft1 that was far to much so we tried a few things and in the end found cycling helped me loose weight so that is why I cycle between 30 and 100 miles each week. Despite the Christmas Fayre my current weight is down to 145lbs/66kgs the weight loss comes from following. My dieticians recommendation of restricting my intake to 1200 calories and doing lots of cycling.

As Julie pointed out, weight gain is often a symptom of sleep apnea and can resolve easier once CPAP therapy is fully buttoned down.

Darth_Rita wrote: ↑

Thu Dec 27, 2018 9:00 pm

I bought and tried mask liners but they did little to prevent the soreness and other problems with my face however they did increase the leaks which in turn made the unit increase air pressure which led to my swallowing far more air and worsening sinus problems. Using the mask without a liner might not do my face much good but if the lower straps are tight enough I can at least prevent most of the leaks.

As they say, if you're leaking, you're not getting therapy. Seeing your Sleepyhead results will give us a better idea of what you're going through with regards to leaks.

Darth_Rita wrote: ↑

Thu Dec 27, 2018 9:00 pm

At the moment I am using the Resmed without a humidifier as that does at least enable me to get better sized blocks of sleep.

If you're only getting half-hour snippets of sleep, longer blocks of sleep is a goal worth exploring. However, concern for getting one large block of sleep may not be necessary. If you're getting at least three solid blocks of sleep in a 24-hour period, you may be better off than you thought. According to modern sleep science, besides a siesta, humans historically had two other sleep periods nightly. I'm not sure these are entirely relevant but perhaps they may add perspective. Check out these articles from the BBC and Science Alert. https://www.bbc.com/news/magazine-16964783 | https://www.sciencealert.com/humans-use ... ould-again

Darth_Rita wrote: ↑

Thu Dec 27, 2018 9:00 pm

You are not given a copy of the full study report over here, all I got was a copy of the letter they sent to my doctor which states is I had an Epworth Sleepiness score of 3, my AHI was 26.4, oxygen desaturation index was 36.4 and so It said I had moderate OSA, which doesn’t make sense as the consultant clearly told me the study did not show any Apnea’s...

I wonder if you couldn't request a full copy of your sleep study including all condensed graphs. It may be that patients simply aren't accustomed to asking for details, and so techs aren't familiar with how to respond. I doubt the machines or software are any different from what is used in other G-20 countries. Perhaps it couldn't hurt to insist with your doctor. Any time I get an x-ray or an MRI, I ask for a copy on disk. Techs are usually surprised, but happy to oblige. You can open the results on your computer because the viewer software is included on the disk. In the case of the full sleep study data with condensed graphs, it can be a pdf they pop into an email. But that's on the US side of the pond. I'm curious if others in the UK can chime in on medical transparency and patients' rights on that side of the pond.

Darth_Rita wrote: ↑

Thu Dec 27, 2018 9:00 pm

Since using the Resmed the machine reports I have an average Ahi of less than 1 and the oximetre is reporting roughly 15 drops In spo2 levels per night although most of them are still above 90. I’ve just been through Nov and Dec reports and there were only 2 events that reached 88 and 1 that dropped to 85.6 and on each of those nights I was using the CPAP machine. The only time I stopped using the CPAP was while I had a virus and according to my oximetre that did not have an adverse affect on my Spo2 levels. Yes I am putting more emphasis on those, that is because that is what the consultant told me was my problem, as I said he told me I wasn’t having apnea’s.

On this side of the pond, many sleep doctors -- especially in smaller cities -- are sleep doctors on the side of their main profession. In my town we have sleep doctors who are primarily either a neurologist, cardiologist or pulmonologist. They got into sleep science on the side because it was something lacking in the region and it would be a lucrative side opportunity in return for only a few months extra formal training. I know that sounds crass, but this seems to be the case here. My sleep doctor is primarily a cardiologist. Every time I've gone in for a sleep concern, I've been told I need to have a battery of cardiological tests because that's mostly what his techs deal with. Every time, after the first visit, I've had to tell them I wasn't going to pay for a $250 superfluous cardiological test battery that was normal on my first visit and wasn't likely to change two weeks later on a follow up exam for sleep apnea and not a heart problem. In my experience, doctors who are sleep scientists first are few and far between in smaller cities in the US. I'm curious if yours might be primarily a pulmonologist?

Darth_Rita wrote: ↑

Thu Dec 27, 2018 9:00 pm

If it helps, Last nights scores were AHI 0 pressure 4 min, 6.16 med, 9.12 max. No leaks but 3 sleep periods in 7 hours
Spo2 4 events pulse average 55 min Spo2 89,
The night before it was also ahi 0, pressure 4.02 5.72 med, 8.38 max no leaks, 6 sleep periods in 5 hours,
Spo2 9 events, pr 54 events min Spo2 90 pulse average 55
The night before that I had serious problems with the mask ahi 0.94 major leaks 37 % of time 9 sleep periods in 5 hours
pressure min 4, med 7.10, max 11 spo2 17 events pr 48, min spo2 91 pulse Average 58 obstructive .62, hypopnoa .31
I have been getting these sorts of score since the first day I used the machine

Just curious: how are you measuring your data for sleep periods? Is this the number of times you take off the mask, turning off/on the machine? Like nocturia, weight gain and other symptoms of chronic sleep apnea, I wonder if this is not something that might resolve as your cpap use continues and your sleep therapy gets buttoned down. How often is your AHI zero? Are you also on oxygen while wearing the gear?

Darth_Rita wrote: ↑

Thu Dec 27, 2018 9:00 pm

Thanks for the advice re the sleepy head software, but that is what I am already using. I haven’t shared the data because it’s on my computer which is a PC and this is on an apple device so can’t read the data.

Perhaps you could log in to the forum from a Chrome browser your PC when you clip images of your data? Easy peasy lemon squeezy.

Darth_Rita wrote: ↑

Tue Dec 25, 2018 7:27 pm

My machine and associated equipment was issued by a UK sleep clinic in a local hospital and I was told they did not approve of me altering the settings. The device sends back data to the sleep centre each day so they would see any alterations I made.

Sleep therapy is often equated to diabetic treatment with regards to taking control. If we waited for an insulin specialist to determine the dose multiple times a day, many people simply could not live their lives. Unless others in the UK can clarify otherwise, I suspect that for those who wish to maintain their own sleep pressures, the more enlightened sleep doctors are going to say "more power to you." If you told your sleep doctor you want to take a fuller part in the control of your therapy, what would s/he say?

Wow thank you so much information, I will read through it all before commenting but a couple of quick comments regarding copies of my sleepyhead data and the original study

I don’t have Chrome, sill using IE but I will read the announcement as I hadn’t got that far yet and will log onto this board through my pc and upload some of the CPAP data but there is a lot of it so what’s best a current report obviously but do you want anything from when I first started using the Resmed and the Oximeter for comparison?

As to the original study, in my experience UK doctors provide as little information as possible, when you go to see your GP you get 10 minutes only and in that time you have to explain your problem and they have to make a diagnosis or decide to refeee you. This means it’s quite common for them to jump to a conclusion based on a comment you have made and miss the point entirely.

Don’t get me wrong I was bought up that doctors were specialists who knew what they are doing and put your interests first but first hand experience has made me become incredibly cynical, it’s hard enough getting a hard copy showing something like blood test results without asking for anything more lengthily. When I was 29 I had a form of early stage cancer, that I was told had been removed completely after two operations but years later I moved counties and saw a new doctor and she told me the cancer wasn’t pre-stage after all but had been in-situ and had still showed cell abnormalities for a few years later, I was flabbergasted and I am afraid that was one of the things that started my particular cynicism.

I have asked for medical reports before and either been told ‘we do not provide those’ or been told you will have to talk to the practice secretary the fee is.... Followed by what seemed to be a ridiculously high amount considering all I wanted was a computer printout that would take seconds to produce, I never got anything in writing after being treated for cancer so I can’t see it being any different for sleep Apnea.

My primary care provider I guess is my GP and he will have received the letter containing the summary that I mentioned already, but I very much doubt that he will have received a copy of the full report as that’s not how it works over here. The only way I might gain access to that would be through the consultant at the sleep centre. If I were to go back to my GP over this he would just tell me to go back to the hospital/sleep care centre. Once you are referred to someone else they take over your care in that aspect.

Often things work differently in the UK simply by moving from one county to the next but I have friends all over England who have lost faith in their GP (general practitioners) and the service they have received from them. The problem is the NHS is severly underfunded and over managed despite what our government says so everything is done to targets and on a meagre budget. It is not the fault of the staff especially in hospitals as they do an extraordinary job given what little resources they have to do it with, but there just not enough money in the system for it to be remotely efficient so I guess things are very very different from the US.