I wrote this article for Citizen Matters -- www.citizenmatters.in
Just a few weeks back, Pune’s health authorities were battling a severe shortage of hospital beds for COVID patients. Now, they are faced with an acute shortage of medical oxygen and oxygen-equipped beds.
“We require three times more oxygen supply during the pandemic than in the past,” says Prof Dr Dhanaji Jadhav of MIMER Medical College and Dr Bhausaheb Sardesai Talegaon Rural Hospital. “Besides COVID patients, other patients – pregnant women, cancer patients, those who suffered from heart attack, critical infants and those who have to undergo emergency operations – also need oxygen. What we are seeing now is a shortage of oxygen-equipped beds.”
“The State Government has also asked smaller hospitals to administer COVID treatment, so there is an increased demand for oxygen from them as well,” adds Dr Jadhav. “That has also resulted in the price of oxygen cylinders, and consequently the cost of treatment, shooting up.”
As the number of active, positive cases increase in Western Maharashtra, Marathwada and North Maharashtra, deficiencies in the management of the health crisis is making headlines. What particularly invited the medical fraternity’s ire was an earlier directive that patients in wards should be administered 7 litres of oxygen and those in ICU 12 litres. The directive has since been withdrawn.
“I understand the point was made by the government from the perspective of auditing hospital bills,” says Dr Ananthabhushan Ranade, a reputed oncologist. “But the authorities need to understand the orders they are issuing. A patient might need 60 litres of oxygen which is delivered on HFNO (High flow nasal oxygen machine). Does that mean that other patients should only get one litre each?”
To overcome the oxygen shortage, the state is diverting industrial oxygen to hospitals, while the National Pharmaceutical Pricing Authority (NPPA) has capped the prices of medical oxygen and oxygen cylinders.
The Ministry of Health and Family Welfare’s press statement said: “The government is committed to uninterrupted supply of Medical Oxygen especially in the times of pandemic. Oxygen Inhalation (Medicinal Gas) is a scheduled formulation, covered under the National List of Essential Medicines (NLEM).”
What the NPPA has said
- Cap the ex- factory price of liquid medical oxygen at the manufacturers‘ end at Rs 15.22/CUM exclusive of GST
- Further cap the ex-factory cost of Medical Oxygen Cylinder at the fillers’ end at Rs 25.71/CUM exclusive of GST (existing Ceiling Price is ₹17.49/CUM), subject to transportation cost fixation at state level, for six months.
- The existing rate for contracts of state governments for oxygen purchase, as applicable, shall continue, in consumer interest.
This sudden shortage of medical oxygen and even some necessary drugs is making the city’s fight against COVID more difficult by the day. “The administration is simply not prepared to handle this health crisis,” says Dr Ranade. The numbers are rising in Pune because patients from other parts of Pune district and other regions are coming to the city for medical treatment.”
Dr Jadhav adds that they have taken in patients coming in from areas like Maval, especially people who cannot afford treatment at private hospitals. (Dr Jadhav’s hospital is located in Talegaon, about 40 km from Pune. Talegaon comes under Maval taluka which is approximately 50-55 km from Pune. )
“I have been in the business of supplying medical oxygen for five years now,” says Zakir Shaikh, a medical oxygen supplier in Maval taluka. “The companies that manufacture the gas have hiked rates and that has a cascading effect. We would get oxygen supply for Rs 22/23 cubic metre earlier, now it is in the range of Rs 75. In other words, whereas we would get a cylinder for Rs 75 earlier, now it has gone up to Rs 550.”
Options available
Hospitals in Pune district get their oxygen supply from the Chakan MIDC (Maharashtra Industrial Development Corporation) which procures oxygen from companies like Linde, Indian Oxygen Ltd and Inox. It comes in the form of compressed gas in small, medium and jumbo-sized cylinders.
Liquid medical oxygen is also available in microcylinders. Then there are oxygen concentrators, machines that concentrate the oxygen available in the atmosphere and it is about 85% pure.
“The medical oxygen that we use is of two types,” explains Dr Jadhav. “One is liquid medical oxygen. A vaporiser is attached to liquid medical oxygen which is then converted into gaseous form and administered to patients. The second is from cylinders in gas form.”
The medium-sized cylinders can provide oxygen for a couple of hours, whereas the small ones are used in ambulances as they have the capacity of providing oxygen for just about an hour. Jumbo cylinders have a capacity of 7,000 litre and can provide supply for 7-8 hours.
However, this jumbo cylinder has a problem. “There is reduced pressure or flow of gas once the level drops to 1000 litres. Then you have to send it for refilling. But before refilling, the cylinder has to be emptied to zero level pressure. We had brought this to the notice of the companies, but they said the residual oxygen remaining in the cylinder is of no use to anyone,” says Dr Jadhav.
Oxygen concentrators, which cost approximately Rs 50,000, can be used for patients who are suffering from mild-moderate symptoms of the viral disease and require 2-4 litres of oxygen per minute. These concentrators can be used where field hospitals are set up, or in medical camps, or in areas where it is difficult to transport cylinders. But big hospitals require cylinders or an in-house liquid oxygen cylinder plant.
Ventilators, bipap machines and HFNO machines are other important requirements for the treatment of COVID patients. “Out of 100 patients on ventilators, only 30 persons survive,” says Dr Ranade. “The HFNO machine is an option between regular oxygen supply and ventilators. They are also available at one third (approximately Rs 3 lakhs) the cost of ventilator machines (approximately around Rs 8-10 lakhs). It doesn’t require a big set up either, when compared to ventilators. I think it is much more prudent to invest in HFNOs.”
The Bipap machine, with its cost ranging from Rs 40,000 to Rs 4 lakh, can be used before the patient is put on ventilator. It can supply 15-30 litres of oxygen per minute. But this has its own limitations.
Line of treatment
“External oxygen supply is needed when the SPO2 level in your body drops below 95,” says Dr Amitabh Chatterjee, part of the four-member doctors’ team managing a free COVID Care Centre under Lonavala Municipal Council. “Patients are put on ventilator only in extreme cases when oxygen level drops below 80. We also use a bipap machine which has an oxygen mask.”
The bipap machine is a small one that forces oxygen into your body. However, as Dr Chatterjee explains, doctors have to ensure that the patient doesn’t have any epistaxis (bleeding of nose), or any secretions from the lungs, stomach or hypertension. In such cases, excess pressure is created on the veins. These secretions may enter the lungs and they can get ruptured. “We have to take into account the contra-indications of the bipap machine,” he said.
The Lonavla COVID Care Centre doesn’t have a ventilator and critical cases are referred to a Dedicated COVID Health Centre (DCHC). “We have 65 beds and we are mostly treating mild symptomatic patients whose oxygen saturation levels are between 90 and 95,” says Dr. Chatterjee. “If their saturation levels drop further we refer them to the nearest DCHC and if beds are not available there, then we refer them to YCM Hospital in Pimpri-Chinchwad and Sassoon Hospital in Pune.”
Given the problems of finding a hospital bed, many patients in Pune are now going in for home isolation, though doctors insist that this has to be under medical supervision. Dr Ranade, an advocate of home isolation, adds a cautionary note. “The patients need to follow protocols; they should be reporting to the doctors about their symptoms on Day 1, Day 2 and what they should do on Day 3. If all these protocols are followed, then the safety factor for the patient increases. Otherwise patients think they are doing fine till Day 7 and then their condition deteriorates rapidly. We are losing more patients because of that.”
Dr Jadhav, who is himself recovering from COVID adds, “I have currently been advised strict bed rest. But the situation is such that our entire health infrastructure is on stretchers.”
The way forward
Most big hospitals are now toying with the idea of setting up a liquid medical oxygen plant to tide over the shortage. The Dr Bhausaheb Sardesai Rural Hospital in Talegaon has set up a six tonne plant. “Our liquid medical oxygen plant has been operational for 10 days now,” says Dr Jadhav. “Earlier, we had to scramble to source jumbo oxygen cylinder. Now that the Central Government has eased the process for COVID hospitals to set up their own liquid oxygen plants, we could set up one for our hospital. With this, we are thinking of increasing oxygen-equipped beds. Our current bed capacity is 350.”
The Deenanath Mangeshkar Hospital in Pune also has its own liquid medical oxygen plant. But what deters other hospitals from setting up this facility is the question of what happens after the pandemic. “What should hospitals do with the excess supply then? It’s a huge investment. Will the authorities help us out?” wonders Dr Ranade.
For now, the Central Government has allowed industrial oxygen to be used by hospitals and it has also asked for creation of green corridors for the smooth movement of vehicles carrying the gas.
Oxygen supplier Shaikh agrees that the scenario now is marginally better as the supply of industrial oxygen has been reserved for use of hospitals. “We are supplying to nine hospitals in Maval taluka and to patients who are at home,” says Shaikh. “But people manning the toll booths don’t give precedence to our vehicles despite the board of ‘emergency services’ displayed on them.”
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