GMC failed to raise O2 shortage on time

The committee headed by the Indian Institute of Technology-Goa Director, Dr B K Mishra, to probe the oxygen crisis at GMC, after the intervention of the High Court has indicted the Goa Medical College for failing to raise the issue of oxygen shortage in the GMC in the second week of May, which recorded the highest number of deaths during the peak of the second COVID wave. Goa’s largest state-run hospital is run and controlled by the Health Department headed by Minister Vishwajit Rane.

While Herald has earlier reported some of the recommendations of the committee to last month it now has access to the full report including detailed observations.

The committee was formed after public-spirited citizens moved the High Court.

Deaths and Oxygen shortage not directly linked but Dean GMC’s affidavit quoted where he says the reduction of oxygen saturation “can also cause death”

The Committee however stopped short of co-relating the high number of deaths in GMC during that period directly to shortage of oxygen. However, it did mention the affidavit of the Dean of GMC on the oxygen crisis to the probe committee “whenever the oxygen saturation gets reduced for a significant duration, the same causes tissue hypoxia and irreversible damage. This causes more problems for those who are co-morbid and old aged persons. Such a situation can also cause death.”

The number of COVID patients in GMC was much beyond the infrastructure planned

The probe report stated “The number of COVID patients in GMC was much beyond the infrastructure planned for or could handle. Therefore the families of the deceased might have been aggrieved for lack of proper care, insufficient attention, or absence of beds or lack of other health infrastructure. Yet GMC remained the best bet for people in need of special care.”

However, the Committee raised the issue of GMC being “hesitant” to send patients to the Super Specialty Block which had sufficient liquid oxygen

The Committee felt that “GMC was hesitant” to send patients to the Super Specialty Block which the administration had readied before the second wave even though it was in the adjacent building and had sufficient LMO (Liquid Medical Oxygen) based oxygen supply. It has however stated that doctors are the best judges of this.

The Committee, in its observations, had highlighted some serious lapses in part of the GMC and delays which further intensified the oxygen crisis. Some of the critical observations are:

• The committee observed that GMC did not raise the issue of lack of oxygen at the appropriate time nor sought the augmentation of oxygen, except putting their demand in an affidavit before the High Court. The report stated “The official guidelines highlight formula to calculate the expected oxygen demand. However, the GMC neither used the prescribed formula nor took any action on setting up a system in place for ensuring the rational use of oxygen.”
• In another scathing indictment, the probe report stated in its conclusions that the GMC ignored the letter written by the Goa Association of Resident Doctors, on May 1 2021, which had demanded prompt action, pointing to the collapsing oxygen procurement system.
• The committee further said that the government also failed to undertake any assessment of the rational use of oxygen except appointing a nodal officer, as suggested by the Government of India, thus failing to enhance the capacity to deal with this crisis

Observations regarding the oxygen supply and the role of SCOOP oxygen

• In June, the decision of the Public Health Department, to extend the scope of work to M/s Scoop all across the state of Goa resulted in the creation of a single supplier for all public health institutions. After this extension, the health institutions had no alternate source of oxygen, in case of emergency. As GMC’s Oxygen demand rose, M/s Scoop stopped supplying Oxygen to other public hospitals hospital except for GMC, without any warning, letter or message.
• GMC and its oxygen supplier did enhance their capacity to deal with this unprecedented crisis but the crisis was much beyond the capacity of GMC. Still, the GMC and its oxygen supplier instead of seeking held tried to handle the issue itself. Seeking timely assistance would have helped GMC

It may be recalled that even after the huge public outcry the Goa government in the last week of July had claimed that no death had taken place due to lack of oxygen; stating that at no point in time, did the oxygen at GMC run out of stock and thus, no death had been reported due to non-supply of oxygen. The Herald, Goa