On Saturday evening, oxygen cylinders were still being dragged down the corridors of the Baba Raghav Das Medical College in Gorakhpur. The liquid oxygen supplied through pipes to the wards had run out around 7.30 pm, Thursday, August 10, after the hospital failed to pay the dues of the private company supplying the oxygen. Thirty children died in the 48 hours that followed, even as the hospital pressed oxygen cylinders into service.

The outrage over the deaths brought the state health minister and the Union health secretary rushing to Gorakhpur on Saturday. The state health minister Siddharth Nath Singh denied that the deaths had been caused by lack of oxygen supply. “Between 7.30 pm and 11.30 pm [on Thursday], the cylinders were used,” he said. However, he admitted that between 11.30 pm and 1.30 am, there were not enough cylinders in the children’s wards. “After 1.30 pm, more cylinders were brought and the oxygen supply was restored,” he said.

But parents who lost their children in the hospital told reporters that because of the shortage of oxygen supply, doctors had asked them to use manual resuscitators also called ambu-bags – bag-like devices to inflate the lungs of unconscious patients – to keep their babies oxygenated and alive. Sri Kishan Gupta who lost his four-day-old baby said: “Wo bole aap dabaate rahiye, machine hai hi nahi.” Keep pressing on the bag, they said, as there were no machines.

Chief Minister Adityanath, who has won five elections from this eastern Uttar Pradesh city since 1998, avoided comment on the deaths, but blamed the outbreak of encephalitis in Gorakhpur on the lack of cleanliness. However, a statement released by the hospital on Saturday showed only five of the 30 children who died on August 10 and August 11 were suffering from Acute Encephalitis Syndrome, which causes high fever and brain inflammation. Seventeen deaths were reported from the neonatal intensive care unit, where newborns are admitted.

Government doctors who specialise in treating children in intensive care units said that disruption of oxygen supply can prove fatal. “Oxygen is just like a medicine,” said Dr Jayshree Mondkar, head of neonatal intensive care unit, Lokmanya Tilak General Medical College in Mumbai. “If the oxygen delivery to the child is stopped, the baby will turn blue (because of lack of oxygen) in his body and may even die.” It is the same for adults if the oxygen being delivered to them is stopped – the outcome is fatal.

Children admitted in the Baba Raghav Das Medical College, Gorakhpur where at least 30 children died in the past 48 hours. Photo credit: PTI

Why liquid oxygen supply failed

Managers of Pushpa Sales, the company that was contracted to supply oxygen to the medical college and hospital, had written to the principal Rajiv Mishra on August 1, asking for unpaid dues amounting to Rs 65 lakh. The oxygen supply operators at the hospital wrote to Mishra, the chief medical superintendent and the nodal officer of the National Health Mission, on August 3 and August 10, alerting them to the fact that the company might cut oxygen supply to the hospital if dues were not paid.

Deflecting blame for the failure, on Saturday, Ashutosh Tandon, the state minister of medical education, said Uttar Pradesh government had released the funds on August 5, reported The Indian Express. Tandon claimed Mishra confirmed the funds had been deposited in his account by August 7. Scroll.in could not speak to Mishra to confirm the minister’s claims.

On August 9, a day before the oxygen supply was disrupted, Chief Minister Adityanath had visited the hospital. After inaugurating a 10-bed Intensive Care Unit and a six-bed Critical Care Unit, he had visited a ward meant for children with Acute Encephalitis Syndrome. On Saturday evening, however, the state health minister Siddharth Nath Singh said no one had brought the problem of dipping oxygen supply to the chief minister’s notice.

Despite all the attention to the incident, more than 72 hours later, the piped oxygen supply to the hospital was yet to be restored. At the time of writing this report on Saturday night, the hospital was still ordering oxygen cylinders from private companies.

Oxygen cylinders being unloaded at Baba Raghav Das Medical College in Gorakhpur on Saturday. (Photo: Menaka Rao)

When the liquid oxygen supply failed on Thursday, the hospital had 52 oxygen cylinders in reserve, a statement released by the hospital said, while more than 80 cylinders were ordered from other companies on Friday. A day later, the hospital appeared to have stepped up orders. Amit Modi of Modi Chemicals Private Limited said his company had received an order and had delivered 300 cylinders of about 46 litres each to the hospital. Modi said that his company will be able to supply these cylinders only for a few days, not on a long-term basis. “Only liquid oxygen will be able to fulfil the requirement of the hospital,” he said.

A doctor at the hospital, who did not want to be identified, said there was never any worry about oxygen supply while liquid oxygen was being piped in. He added that one of the causes of the large number of deaths was congestion at the hospital that was causing cross-infections. In the neonatal ward, one bed was being used for three to four babies.

How hospitals supply oxygen to patients

There are three ways in which hospitals can connect patients to an oxygen source.

Liquid oxygen: A big tank is filled with liquid oxygen on a periodic basis. From here, the oxygen is supplied in pipes to the wards. This is also called piped oxygen. Centralised oxygen: In a room, several big oxygen cylinders are kept from where the pipes or tubes are connected to the wards where patients are admitted. If the hospital’s piped oxygen gets over, it could make arrangements for these cylinders. Portable cylinders: These are small cylinders, which can be carried around. If there is a problem with the main liquid oxygen supply, these portable cylinders can be attached next to the bed of the patient and oxygen supply can be restored.

Public hospitals have designated officers to maintain the smooth functioning of liquid oxygen systems. The piped oxygen systems are equipped with dials which indicates the amount of oxygen left. When the indicator crosses a particular mark, the officers are supposed to call the suppliers and ask for the tank to be refilled. Even oxygen cylinders have an inbuilt dial that shows when the level of oxygen gets reduced and needs to be refilled.

A view of the children's ward in the hospital. Photo credit: Menaka Rao

Checks and balances

Authorities who are responsible for managing an uninterrupted supply of oxygen to the hospital wards in Maharashtra expressed surprise at reports of the Gorakhpur hospital running out of liquid oxygen supply.

“There are several checks in place to ensure that the liquid oxygen in the plant never runs out,” said Dr Pallavi Sapale, dean of Government Medical College in Miraj in Maharashtra who, in her capacity as the dean, is closely involved in the process of maintaining the oxygen plant. “We have an officer who takes the reading of the plant twice every day to check the quantity available,” she said. “Once it crosses the mid-level mark, we inform the supplier to send us the oxygen and it is replenished.”

Sapale recalled an incident where the supplier was not in a position to supply liquid oxygen and another supplier was contacted immediately. “Another thing we do is use jumbo cylinders, which are as safe as liquid oxygen and can be used to deliver oxygen to patient,” she said.

Apart from these large oxygen cylinders, there are small portable oxygen cylinders that are generally used when transporting patients in ambulances or within the hospital on stretchers. “The effect of oxygen delivered by the cylinder compared to the liquid oxygen plant is the same,” explained Mondkar. “You have to monitor the cylinders and immediately change to another cylinder, when the oxygen in the cylinder attached to the patient is about to finish.”

Sapale said the saturation levels of the patients will be affected if the oxygen delivery is disrupted. “There are so many alarms to know that the oxygen is getting over,” she said. “First, there is a meter – like you have on motorcycles – which shows the level of oxygen in the cylinders,” she said. “Also, if the oxygen supply to the patient is lowered, his saturation levels will be affected and the doctor or nurse can immediately check.”