The Oxygen Grid

With more people requiring Oxygen therapy to fight back Covid19 and its virulent mutated variants, Khalid Bashir Gura goes on an Oxygen audit on the public healthcare setup and identifies the issues that could puncture the pipe

A worker checks the pressure of oxygen tanks at a temporary COVID-19 hospital in Srinagar on Monday, May 10, 2021. Leading NGO, Athrot in partnership with the government set up 100 bedded oxygenated facilities at Hajj House in Srinagar. KL Image: Bilal Bahadur

A day after the May 7, government order regulating oxygen supply to private persons, societies, and NGOs without the administration’s prior approval, Zameera Reshi, a resident of Eidgah, was in an absolute panic. His aged uncle and aunt who turned Covid-19 positive complained of breathlessness and simultaneous dip in oxygen saturation. He swiftly sent an SOS and approached many NGOs. After one hour of search, one of the NGOs Aab-e-Rawan delivered oxygen cylinders to him. Reshi utilized the services of social media and has become one of the countless cases that Twitter and Facebook have catalogued as people desperate for oxygen cylinders to concentrators.

On Oxygen-abundant earth, it is strange that free air has become a prized commodity. “To be very honest, the charity that would normally go within or outside Ramzan from Kashmir homes would go to feed the poor and the underprivileged,” one uptown Srinagar, resident said. “This time, I saw people assessing if they should prefer groups working to provide Oxygen or food. People do believe that low rations will not kill but low oxygen can result in death.”

There were at least two instances in which, Kashmir was saved from the gruesome Goa moment. When the newly set-up oxygen generation plants at Srinagar’s JLNM and south Kashmir’s Anantnag developed technical snag for a few minutes, hundreds of Covid-19 patients were literally left breathless and narrowly escaped death. In these two separate instances, around 150 patients surviving on high flow oxygen were involved.

“These could have been major tragedies but thank God, the snag was quickly fixed,” one insider said. “In one instance in a Jammu hospital, few Covid19 patients did die and now the administration is probing.”

Nature’s Bounty

A healthy lung breathes 7-8 litres of air per minute. This works out approximately 11000 litres of air per day. The atmospheric air contains around 21 per cent oxygen, of which our lungs exhale back 15-16 per cent. This means our lungs use 5 per cent of the atmospheric oxygen with each breath. 550 litres of pure oxygen is what each person consumes each day from nature.

A medical oxygen plant being thrown open in a Jammu hospital. Pic: DIPR

A moderate Covid patient may require 10-15 litres per minute of oxygen but those in the “severe and critical” category require high flow oxygen, which starts from 15-60 LPM,” said Syed Mudasir Qadri, an Associate Professor at SKIMS.

The gases we breathe from the atmosphere have 21 per cent oxygen. This is more than enough for healthy non-Covid lungs that utilize the oxygen and filter out the rest of the gases mainly Nitrogen. But if the oxygen saturation stays persistently below 90-92 per cent, this means lung damage has already started and the person needs evaluation for the cause. These days this invariably means the person should report to the hospital and may need hospitalization and aggressive management to avert further damage, said Qadiri.

In absence of any treatment, oxygen is the antidote to keep the destruction by the contagion at bay. As the Covid-19 cases and deaths are spiking, so is the need for oxygen. The existing health care infrastructure is witnessing the overload and many strategies have been devised by the government to prevent the infrastructure collapse. As oxygen remains the basic need and precious commodity, the harrowing images of patients moving with oxygen cylinders, concentrators in Kashmir and Jammu offers a glimpse into the current crisis. All the beds in major hospitals are booked with Covid-19 patients. The government is also augmenting its efforts to mitigate the crisis and keep the demand and supply intact and prevent the overwhelming of the health infrastructure.

Government Hospitals

When the aged uncle of Habeel Iqbal, a resident of Srinagar, developed bilateral pneumonia, he struggled initially to find a bed at the hospitals in Srinagar.  Finally, it was at Chest Diseases Hospital that he managed to get a bed.

A female attendant of a Covid-19 patient taking an Oxygen cylinder to the ward. KL Image: Bilal Bahadur

“We were lucky to get a bed,” Habeel said, asserting that the scarcity of beds is apparent given the rush. However,  Iqbal’s uncle is recuperating and he attributes this to his being already vaccinated.  “I enquired from others and out of 10 admitted in the ward only 8 are vaccinated he said,” Iqbal said.

As more and more patients in Kashmir rush to hospitals after their saturation level drops at home, the load on the existing health care infrastructure is growing.

Mechanical Engineering Department

Chief Engineer, Mechanical Engineering Department Kashmir, Rashid Ahmad said Kashmir has 23500 LPM Oxygen generation capacity, 2100-2300 bulk cylinders at the disposal of hospitals. Besides, 20 Oxygen plants have been installed, 17 are in the offing and 9 already in transit.

According to Ahmad prior to the return of Covid-19, the hospitals would generate 8000 litres of (liquid medical) oxygen per minute, but now they have further installed 20 plants in different district hospitals and GMC-associated hospitals in Srinagar, Baramulla, and Anantnag districts.

For cylinders, Ahmad said, four industrial units have been set up for refilling and bottling but that is insufficient. According to him, J&K  is faring better as regards the availability of oxygen.

Most of these PSA Oxygen generators are imported from Germany. The government, he said, is making efforts to lift nine plants from Frankfurt, Germany. It may take another couple of days for it to reach here.

The Jammu and Kashmir government is utilizing all resources; private and public, to increase, maintain and regulate the oxygen supply chain and meet the demands and future needs. In Kashmir, the tertiary care hospitals have installed and are equipped with oxygen concentration plants with varying generation capacities.

All the major Covid Hospitals of Srinagar are presently coping well as they have adequate oxygen generation capacity and oxygen cylinders.

CD Hospital

The Chest Diseases Hospital Srinagar, which mostly receives patients with high oxygen dependence, has not faced a crunch so far given its capacity and demand.

Dr Salim Tak, Medical Superintendent, Chest Diseases Hospital, Srinagar, said that the two oxygen generation plants with a capacity of 500 LPM, and 430 LPM are working. The hospital has 300 bulk cylinders and 250 small-sized cylinders. The hospital has a capacity of around 100 beds which are fully occupied with Covid-19 patients. Besides 40- 50 are admitted at Kashmir Nursing Home.

“We have a 17 bedded ICU”, he said.

Helplessness. As patients were confirmed positive on Monday, May 18, 2020, the SMHS ambulance ferrying them to the CD Hospital dropped them on the roadside in Dalgate. It was after some time that the CD hospital staffers helped them get into the Covid-19 Special Hospital. KL Image by Bilal Bahadur

Most of the patients in the hospital are on high oxygen demand, which needs above 20-50 litre per minute and many are on ventilators.

To avert an eventuality if there is a snag in the supply of oxygen, the hospital has installed on every bed 5-10 LPM oxygen concentrators.

In order to be self-sufficient and do away with the need for refilling of oxygen cylinders, the hospital has a plan in the pipeline to install another oxygen generation plant in the coming days with the capacity of 1500 LPM.

The SMHS

A major tertiary care hospital SMHS Hospital Srinagar has also augmented bed capacity from 30 in 2020 to 300 beds in a year, said Dr Kanwal Jeet, Medical Superintendent. He added that 11 ventilator beds have also been made available for the treatment of severe Covid-19  patients. The hospital administration has upgraded oxygen supply to 3600 LPM of which 3000 LPM are supplied by 3 Oxygen plants, each with 1000 capacity, and one small plant which generates 600 LPM supplemented by 1800 bulk oxygen cylinders.

Jeet maintained that almost all beds dedicated to Covid cases are occupied presently. The hospital’s demand for oxygen is supplemented by private manufactures like Mian Gases and other manufactures. The hospital has a demand of around 6000 LPM.

In the SMHS Covid-19 ward. K Image: Bilal Bahadur

“Two plants will also be installed after Eid, each with a generating capacity of 1000 LPM,” Jeet said. To make beds available to other desperate cases, once the patient starts recovering, they are shifted to triage centres as they require 5 LPM oxygen beds. The hospital has to cater to routine emergency operations, which also creates more demand for oxygen.

The JLNM

Dr Bilquis Shah, Covid19 nodal officer at the JLNM Hospital said that the hospital has three oxygen generation plants with a total generation capacity of 1925 LPM of oxygen. The capacity of its oxygen generation plant was also increased from 300 LPM to 1300 LPM to cater to the needs of the Covid-19 patients with the hospital being a Covid19-dedicated healthcare facility.

The people who recovered from the disease at JLNM hospital receiving certificates from hospital administration in July 2020. KL Image: Special Arrangement

A few days ago another 625 LPM generation plant was installed. The hospital with a capacity of 200 beds has dedicated 150 beds to Covid19 patients of which around 130 patients were admitted. To augment the oxygen supply, the hospital has 147 bulk cylinders, 100 medium-sized and 50-60 oxygen concentrators with 5LPM capacity.

The hospital has 13 ICU beds out of which 8 are functional. According to the nodal officer, there is a need to fix the referral setup. “We should get only those patients from the districts that have severe conditions,” Dr Shah said.

The SKIMS

The JVC-SKIMS Bemina, one of the Covid-19 designated has a 750 LPM oxygen concentrator plant. The second of the same capacity was also installed recently but is facing a technical snag. The hospital is completing the deficit by getting 90 bulk cylinders from different places of oxygen manufacturers like Khonmoh, Rangreth to supplement the need. Presently 118 patients have admitted to the hospital out of which around 85 patients are on high flow oxygen demand.

Outside view of SKIMS Srinagar.
Outside view of SKIMS Srinagar.

“At present, we are coping well,” said Mushtaq Ahmad Simnani, OSD, SKIMS, adding that they have 6 ICU beds and ventilators at the hospital.

SKIMS, Soura, one of the largest tertiary care hospitals is also witnessing a massive rush of a patient with the need of high flow oxygen. According to hospital administration, all available beds are occupied presently. The hospital has five oxygen plants.

“The hospital has 900 bulk cylinders and two new plants have been installed each with a capacity of 1250 LPM,” the OSD said.  The hospital has 30 ICU beds and 20 ventilators besides 298 beds.

GMC ANANTNAG

Medical Superintendent (MS) Government Medical College (GMC) Anantnag, Dr Murtaza Fazal Ali,  said that the hospital has two oxygen plants.

“One is low capacity 350 LPM plant. The other 2000 LPM,” he said, adding that they have 80 bulk cylinders procured from Khanmoh private oxygen manufacturers which supplement the requirement. In a hospital with 100 beds capacity around 66 patients are presently admitted. It has 16 non-invasive ICU beds and seven Covid-19 patients are admitted.

GMC Baramulla

At GMC Baramulla, the hospital is equipped with three plants generating a total of 1700 LPM.  In a 120 bedded hospital, around 102 Covid-19 patients are admitted.

“We have around 150 bulk oxygen cylinders, 260 medium-sized and 6 ICU beds,” said Syed Masood, Medical Superintendent.

According to Dr Mir Mushtaq, the spokesperson health department of Kashmir, people can contact the district control room which is functioning round the clock. Also, the government has established Triage Centres, which is the first arrival point for Covid patients where they go under the screening of severity under doctor’s observation before being referred to a tertiary care centre. The Triage for tertiary care hospitals like JLNM, SKIMS, CD was established to manage the unnecessary rush and overload.

Official figures reveal that J&K is consuming approximately 25,000 cubic meters, with hospitals having an oxygen generation capacity of 24,500 cubic meters. Additionally, the industry has the capacity to generate 30,000 cubic meters.

Private Oxygen Makers

As Covid-19 cases continue to soar, the need for medical oxygen also rises. Since 2020, the private oxygen makers are supplementing the need of government hospitals, individuals, and groups. Even though there is a handful of oxygen manufacturing units in Kashmir yet they are managing the need-supply chain. Pre-pandemic, the units were working for few hours as the demand for medical oxygen and industrial use was less.

However, since last year with the onset of the pandemic, the manufacturers are working 24×7. “The demand is lot but supply is less as compared to last year,” said the promoter of the oldest unit in Kashmir, North End Enterprises, Altaf Ahmad Baba.

Earlier there was less demand as oxygen was mostly used for a medical emergency. But now given the rush of patients, the default unit is working non-stop.

Have you seen the oxygen? It looks like this when it changes from its liquefied form to the gaseous form that humans breathe. High flow oxygen is key to the treatment of Covid-19 patients. KL Image: Masood Hussain

“I am not able to stop plant even for a second,” he said. The plant was established mainly for industrial use and has a high oxygen purity level of around 99 per cent.

Unlike last year when Mian Murtaza, proprietor of Mian Gases, Khonmoh, was working tirelessly to cater to demands of oxygen at his plant, this year he is on oxygen support himself as he is Covid-19 positive.  The plant is now managed by his manager Abdul Hamid Lone. As the plant has almost 500 bulk cylinders, the plant delivers oxygen to most of the health facilities like SKIMS, JLNM, CD, and SMHS hospital.

“Earlier these numbers of cylinders were enough but now they seem to be less,” he said.

Glitches

At JLNM, where around 100 Covid-19 patients narrowly escaped death when a plant developed a snag, COVID-19 nodal officer Dr Bilquis Shah, said she acknowledges the tragedy that could have happened but it was rectified within minutes.

Similarly at Anantnag GMC, a video had gone viral wherein an elderly patient was seen gasping for breath and the attendees were crying for help. Later, DC Anantnag tweeted showing a mechanic working on the oxygen supply pipelines at the hospital. When asked about the viral video, the Medical Superintendent of the hospital refuted the news about the snag and said that it was the severity of the disease of the woman that had left her breathless.

At Jhelum Valley Hospital, SKIMS Bemina, a new plant of 750 LPM was installed but is facing a technical snag. The plant is imported from France and Germany and the experts were called in from the respective countries to fix the fault, said one of the insiders.

Government Regulation

On May 14, evening amid Covid-19 lockdown, an SOS has shared on social media platform wherein a resident of Qamarwari was shown struggling to procure an oxygen cylinder for his aged father. Running pillar to post from one NGO to another when the reporter called the pleader, he said that he had availed it finally from SRO Kashmir.

In order to check black marketing and hoarding of oxygen, which is now a prized commodity, the government ordered private players like NGOs in the oxygen supply chain to seek government approval before refilling. This added to the burden of NGOs and individuals and invited the ire of citizens who questioned the decree.

“As of now we have seven days permission from the government on refilling but the factory owners now refill our cylinders alternatively due to overloading,” said Mohammed Afaaq Sayeed, who manages SRO Kashmir’s hugely successful Oxygen Kashmir. He said they had never contemplated that this order will result in a loss of control over cylinders. “Once the patient is given cylinder and after emptying it they on their own get it refilled. We do not know the whereabouts of the cylinder,” he said.

Virtual Volunteers

Social media is inundated with pleas of people asking for a precious commodity: oxygen concentrators. People are increasingly turning to social media with SOSs for medical attention, hospital beds, and drugs. To enhance coordination with health care officials, NGOs, and patients virtual volunteers are using their network and acting as intermediaries to manage the need for oxygen as most people do not know who to approach.

A long line of attendants queued up to get an oxygen cylinder in the SMHS premises. The hospital’s in house oxygen manufacturing is overloaded forcing it to purchase from the industry. KL Image: Bilal Bahadur

“On average, we address more than 100 calls a day and hundreds of messages and we act as an intermediary in the expedition of oxygen refilling,” said a volunteer of SOSJK. Similarly, Irfa Jan has also been at the forefront of managing the supply and pleas. The group created a database of oxygen suppliers, plasma donors, and ambulance service and soon the SOS calls were connected to the nearest helpers.

Necessity and Invention

Despite oxygen in the atmosphere, its need for Covid-19 patients has made it one of the precious and expensive commodities. As the cases have surged and the market for oxygen concentrators opened, the prices of oxygen concentrators have skyrocketed. The sources of it other than nature are rare and expensive.

It is 24 x 7 literally. They deliver wherever they can regardless of the timing. Oxygen is crucial to life.

Seeing the desperation of helpless patients, Mohammad Ismail Mir, 60, a resident of Bandipora felt the need to make a low-cost oxygen concentrator, which people could afford. An inventor, he developed a prototype, which, he says will cost anywhere between Rs 10,000 and Rs 15,000. Its construction and working principle are like any other conventional oxygen concentrator.

According to Professor Sheikh Fayaz who is an innovation researcher at China’s top-ranking university, Zhejiang University, the contraption developed by Mir is a wonderful display of ‘bricolage’ and ‘frugality’. Applying bricolage, the innovator has re-used all the locally available resources to create his prototype. It is frugal because all the material the innovator has used are either low cost or repurposed old scrap.

“He deserves all appreciation for his creative genius,” Dr Fayaz said, insisting that the innovator had contributed many innovations last year to their Covid-19 Open Innovation Challenge and won many prizes.

However, for large-scale use and commercialization, the role of intermediaries, government, funding agencies, and standard organizations becomes important.

“If the government and other actors fail to support him, the innovation will die without creating any value. These peripheral innovation actors always remain outside the gaze of policy-makers,” Dr Fayaz said. “To overcome Covid like a crisis, finding alternative solutions becomes very important. Peripheral innovators, I believe can play a very important role in helping overcome the Covid crisis.”

Impressed by Mir’s work, Fayaz and his many friends have decided to set up an in situ ‘fab lab’ worth Rs 5 lac at his residence.

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