How a nightmare unfolded at midnight

How a nightmare unfolded at midnight

There Were Not Enough Docs, Nurses To Save Everyone

Pushpa Narayan & Ram Sundaram TNN

Chennai:06.05.2021

Did the authorities at the Chengalpet Medical College Hospital ignore warning signs? Eleven patients died within two hours after the volume of oxygen flowing in the pipelines fell from about 70 litres per minute to 10 litres per minute after midnight on Wednesday.

“It was something that we had warned the management about,” said a duty doctor, a postgraduate medical student. “Oxygen supply had dipped on Tuesday afternoon and two people died,” the doctor said.

The hospital, which had more than 300 patients on oxygen support in Covid-19 and Severe Acute Respiratory Infection wards, consumes an average of 4.2 kilolitres (KL) of oxygen a day. Dean Dr J Muthukumaran said the hospital filled up about 4 kilolitres of oxygen on Tuesday evening, two hours after he received the first complaint. The hospital has five oxygen tanks —two of 10-KL capacity and three 1-KL tanks.

“Our biomedical engineers replaced a coil near the main valve, which created trouble a week ago. It was replaced with a temporary coil (with the help of oxygen manufacturer INOX) to maintain the pressure levels. Ever since the substitute coil was installed, oxygen consumption almost doubled even when the patient count was almost the same. So, we had to refill the main oxygen tank much more frequently,” he said.

On Tuesday, there were no problems once the tank was refilled, but things went horribly wrong by midnight, when the pressure dropped once again.

Patient attenders cried for help in vain. In the children’s ward, doctors and nurses pulled out ambu bags – handheld devices commonly used to provide positive pressure ventilation – to save their tiny patients. In other wards, technicians dragged oxygen cylinders to bedsides.

But there were too many patients and too few healthcare providers. For instance, in the comprehensive emergency obstetric and newborn care ward there were 150 patients including pregnant women and new mothers. This ward had two doctors, two nurses and one technician. The neighboring admin block with more than 200 patients had four doctors, two nurses and two technicians. “When patients choked, there was chaos. Their relatives panicked. Some threatened us even as we were running between beds to save patients,” said a doctor.

“An investigation will be carried out and action will be taken against those who were responsible for the technical fault,” said collector John Louis.

By Wednesday afternoon, director of medical education Dr R Narayanababu, who led the inspection team, said there was “no oxygen shortage”.