Mumbai civic body installs 15 LMO tanks in 40 days

In a span of 40 days between May and June last year, Mumbai civic body installed 15 Liquid Medical Oxygen [LMO] tanks with a capacity of 13 kilolitres each and 11 smaller tanks with a capacity of up to six kilolitres each in the city’s six civic-run hospitals and six jumbo Covid-19 centres. These oxygen storage tanks played a crucial role for Mumbai, which saw its daily demand for medical oxygen go up from 210 metric tonnes (MT) in the first wave to 270 (MT) in the past month alone.

The “Mumbai model” has won praise from both the Supreme Court and the Bombay High Court. The apex court on Wednesday appreciated Mumbai’s efforts and recommended that the Centre and Delhi take a cue on how to handle oxygen supply in the face of the severe shortage that the Capital city has been facing for the past three weeks. On Thursday, the HC said that the Brihanmumbai Municipal Corporation chief Iqbal Chahal should hold a video conference with other municipal bodies and explain how the city managed the second wave.

So what did Mumbai do to control the crisis?

“Building the additional LMO tanks helped us cope during the second wave,” additional municipal commissioner P Velrasu said. “The tanks, construction, fitting, and piping altogether cost us over ₹14 crore. At that point, we didn’t know if they would be utilised, but we still went ahead and created that infrastructure,” he said.

That’s barely 0.32% of the BMC’s total budgetary allocation for healthcare in 2020-2021.

LMO tanks are highly pressurised tanks that are installed on reinforced concrete structures and require certification by the Petroleum and Explosives Safety Organisation (PESO), a department under the ministry of commerce and industry, which has also been overseeing the supply and distribution of oxygen during this crisis.

The tanks were installed in facilities with greater bed capacity. For instance, NESCO’s jumbo centre in Goregaon which was opened last June and currently has 2015 beds was fitted with two LMO tanks, but only one was used last year. The BMC plans to construct 10 more LMOs across the city in preparation for a possible third wave expected anytime between July and September, civic officials said.

Crack teams and quick response vehicles

In April, the city’s daily average cases had touched 7,786 and this is when the oxygen crisis was felt most keenly: many patients were shifted from one hospital to another due to a shortfall of oxygen [for instance, 168 patients were moved out of six government hospitals to jumbo centres on April 17 after oxygen supply was affected], hospital staff struggled with getting supplies and often left with only a few hours of oxygen, some facilities had to refuse admissions. By mid-April, the city had only 41 ICU beds and 15 ventilator beds out of a total of 2,664 and 1,339 respectively.

That’s when the BMC announced that it would appoint six civic officials to act as coordinators between oxygen suppliers, assistant municipal commissioners of the 24 civic wards and the Food and Drug Administration. The officials will be responsible for maintaining the existing oxygen supply and also ensuring that the same is used sparingly.

Part of Mumbai’s oxygen supply model evolved to ensure the safe transportation of oxygen cylinders.

Only two civic-run hospitals, Kasturba in Arthur Road and HBT Trauma Care in Jogeshwari, have oxygen generation plants. Other big hospitals, like civic run KEM, Sion, Nair, Cooper hospitals and private-run Bombay Hospital, have large capacity LMO tanks which are refilled at least once daily. Other hospitals rely on cylinders; in fact, all hospitals are mandated to keep cylinders as backup. When the crisis hit, the civic body deployed six quick response vehicles [tempos] that would ferry oxygen cylinders and concentrators to hospitals in crisis.

“Ward-level teams were formed to coordinate and move surplus oxygen from one site to another where there was a shortfall,” said Krishna H Perekar, BMC’s chief engineer (Mechanical and Electrical).

A resource inventory of oxygen use and infrastructure of the city’s public as well as private hospitals proved helpful, as Mumbai’s oxygen often needed to go to far-flung suburbs in the Mumbai Metropolitan Region, like Navi Mumbai and Thane, which also faced severe shortage of supply.

“Our inventory has micro-details like the number of jumbo oxygen cylinders, dura cylinders, and capacity of the LMO tanks at all hospitals. We also have exact details of the oxygen usage at each hospital,” Velrasu said. This inventory came in handy when oxygen had to be transported from one hospital to another or in instances where patients had to be moved.

“We formed crack teams to ensure that the LMO tanks reach Mumbai smoothly. These teams were also deployed at the cylinder refilling plant at Navi Mumbai to ensure that Mumbai gets its quota of cylinders,” he said.

The civic body has a contract with a private agency, Satramdas Gases Pvt Ltd, whose refilling station is located in Navi Mumbai.

When a train carrying three liquid medical oxygen tanks arrived from Gujarat to Kalamboli in Navi Mumbai last month, a crack team consisting of engineers, staff, and guards from the BMC was already waiting on the platform of the goods yard of Kalamboli station. The tankers were swiftly offloaded and routed to Mumbai.

At the peak of the crisis, the city still faced a shortfall of 15 to 20MT despite all these efforts: this was managed by moving surplus stock from one place to another, and seeking oxygen from Gujarat.

Medical protocol

Last month, as the demand for medical oxygen, began to rise, the Maharashtra Covid-19 task force recommended that doctors should stop the use of High Flow Nasal Cannula to deliver oxygen (up to 80 litres/ min) due to the high pressure in the machine. Hospitals were encouraged to use the Bilevel Positive Airway Pressure (BiPAP) machine, which delivers oxygen either through a flowmeter (up to 15 litres/min) or a non-invasive ventilator (up to 30 litres/min), and with lower pressure.

“Soon after the advisory, we completely stopped use of HNFC and alternatively started using non-invasive ventilation such as BiPAP,” said Dr. Ramesh Bharmal, dean of civic-run Nair Hospital.

Dr. Gautam Bhansali, who consults at the Bombay Hospital said that they reduced the use of HNFC too. “It is hard to completely stop its use because most patients are comfortable with the nasal cannula. With the BiPAP, we have to use a face mask which some patients find uncomfortable,” he said.

As the cases in the city have also decreased, the city’s daily requirement of oxygen has now come down to 240MT per day.

The civic body now plans to construct an oxygen generation plant at each hospital, so that the dependency of LMO and cylinders reduces. “We may still require LMO as they provide better pressure, mainly for patients in the Intensive Care Units,” said Velrasu. “But having oxygen plants at all facilities will reduce the dependency to a large extent,” he said.

The BMC has announced that it would set up 16 oxygen generation plants in 12 hospitals across the city, each of which will produce an estimated 43MT of oxygen. The project will cost ₹90 crore.