The Pediatric Cardiac Surgery Inquest Report



Pre-operative condition-second admission

Odim met with the Stills on May 2. At that meeting, Donna Still signed a consent form. Following that meeting, and after examining an X-ray taken that day, Odim wrote to Giddins that:

As you know, she had originally been placed on the schedule a little over a week ago but was recovering from an upper respiratory tract infection and had evidence of a right middle lobe infiltrate necessitating postponement of surgery. In the intervening period she has been well without evidence of infection. She still has a cough. There is no catarrh [no runny nose]. The chest X-ray today shows clear lung fields and a bulky heart. There are some residua of middle lobe infiltration. We plan to get a nasopharyngeal swab to check for RSV and if this sample is negative I think we can proceed with definitive repair later this week. (Exhibit 11, page STI 6)

The radiologist had a different interpretation of the May 2 chest X-ray. While Odim wrote that it showed clear lung fields, Dr. Martin Reed recorded in his report that:

There is slightly more consolidation in the right perihilar region extending into the lower lobe, than on the previous examination of March 18. Abnormal densities persist in the left lower lobe as well, essentially unchanged. The appearance of the heart is not changed in the interval. Interpretation: the pneumonia appears slightly worse. (Exhibit 11, page STI 62)

The reference to pneumonia was to become a troubling one in the investigation of this case.

In coming to this conclusion, Reed had to have determined that the March 18 chest X-ray had indicated that Alyssa had mild pneumonia, while the May 2 X-ray showed that the pneumonia had slightly worsened. Reed, in other words, was making a different interpretation of the March 18 X-ray and the May 2 X-ray. Reed also testified that he did not believe her pneumonia was an unexpected abnormality, in light of the cancellation of surgery two weeks earlier because of an infection.

Reed's report was written and distributed on May 4, the day before Alyssa's scheduled operation. It does not appear that either Odim or Giddins read this report before Alyssa's surgery. Nor were the Stills made aware of Reed's report.

Odim on the other hand did not believe Alyssa had pneumonia. He testified that:

With all due respect to Dr. Reed, he didn't have the advantage of hands-on contact with the patient. The patient had no symptoms, had no signs of pneumonia, was afebrile, white count was normal, if you look at the laboratory data, no leftward shift, no indication of any infectious process. (Evidence, page 24,886)

Anaesthetist Dr. Harley Wong also disagreed with the assessment that Alyssa had pneumonia before her operation. He noted that there was no sign of a fever and that her white blood cell count, which would have been elevated if she had pneumonia, was normal. He also indicated that during the induction of anaesthesia, Alyssa did not exhibit the symptoms that one would expect from a child with pneumonia.

If the child had that pneumonia when the child came into the room and we put the child asleep, there would have been a couple of problems that we would have had to deal with right away if the child had pneumonia. First of all, we would run into problems with secretions, tremendous amounts of secretions. If the child had pneumonia, I would have had to have been suctioning the child for a lot of secretions if there had been pneumonia, and I would have had problems dealing with keeping the child well oxygenated. I would have had drops in oxygen saturations that were unexpected. I would have difficulties ventilating the patient.

I can add to that that I have seen that in patients that were brought to the operating room with pneumonia in other cases, for other reasons, that did have pneumonia, and that's exactly what we experienced. (Evidence, page 19,812)

Wong went on to testify that if Alyssa had had pneumonia, she would have not had the stable blood gas and oxygenation readings she had during the early portion of her stay in the PICU post-operatively.

In this case, as in several of the cases that preceded it, questions arise as to whether or not the patient had an infection at the time of surgery. In his report for this Inquest, Cornel wrote:

A pulmonary infection 2 weeks prior to surgery may not have completely cleared (cough reported by mother and physiotherapist on 4th May). (Exhibit 353, page 37)

Cornel pointed out that Alyssa's post-operative arrest was related to suctioning of secretions that might have been related to the infection. He stated that:

In my practice these finding [sic] would constitute a contraindication to all but the most urgent surgery, and if I must operate in the face of active infection I usually perform a palliative rather than open heart surgery. (Exhibit 353, page 39)

Witnesses before this Inquest could not be definitive about the pre-operative state of Alyssa's lungs because X-rays were missing from the files. The report prepared jointly by Duncan and Cornel also commented on this issue.

Similarly, the pre-operative chest radiograph is reported as showing pneumonia, which would normally be an indication to cancel and reschedule the surgery unless the child was in imminent danger of death without proceeding. The absence of this radiograph from the master file of radiographs is disconcerting. (Exhibit 354, page 8)

However, in their testimony, both Cornell and Duncan acknowledged that Odim might have been correct in sending Alyssa to surgery in May. Duncan explained that sometimes an X-ray does not show what the patient has at that point but what the patient had in the past. In other words, the patient may have recovered from a clinical point of view, while the X-rays show evidence of the lung in the process of healing, rather than showing an active infection. Dr. Walter Duncan testified:

I don't know if you have ever seen two physicians who could agree about anything, but, no, it's not unusual to have differing opinions. And whereas the radiologist only sees the film, the physician sees the patient. So I think perhaps one is, one tends to be biased to one's point of view, I mean, that's human nature, isn't it?

Dr. Odim would have seen and examined the child, listened to the chest and looked at the x-ray and said, well, I don't hear anything in the chest, she seems to be fine, her white cell count is normal, I think I am okay to proceed.

A radiologist would look at a film, compare it to a previous film and say, film A looks different from film B because-was that grounds to cancel? I think you could argue it both sides. (Evidence, page 41,384)

In conclusion, Duncan testified that in this case he did not "think there was sufficient grounds to cancel." (Evidence, page 41,388) Cornel came to a similar conclusion, testifying:

In the absence of anything else, I would accept their view of things. I am always concerned about respiratory infections, as I keep saying, and I would be concerned if an x-ray was taken as a follow-up for pneumonia and nobody paid attention to it. But in the absence of any other findings, I accept what they say, that there was no evidence of an active infection and it was okay to go ahead. (Evidence, pages 44,828-44,829)

In his written report, Hudson stated:

Proceeding with an elective operation with a coexisting unresolved pneumonia is definitely not an acceptable standard of medical care. The only exception to this rule would be a patient who had chronic respiratory infections that could not be successfully treated, and there is nothing in these records to indicate that was true of this patient. There is not unanimity of opinion regarding the length [of] time elective surgery should be delayed after resolution of a pneumonia. However, any competent physician would agree that elective surgery should not be done when any clinical or radiographic signs of pneumonia are present. The fact that the chest radiograph was ordered by the attending cardiologist on 2 May 94 suggest that he was still concerned about the pneumonia. However, there is no evidence in this patient's records that any of the physicians involved in the perioperative management of this patient were aware of the radiographic findings indicating a worsening pulmonary infection. (Exhibit 307, pages 5.20-5.21)

Consulting witness Dr. Glenn Taylor reviewed the microscopic slides and also concluded that the lungs were moderately congested with irregularly expanded air spaces. He found no evidence of acute pneumonia. In a May 5, 1997, letter, Taylor said:

I did not see acute pneumonia in the autopsy microscope slides of the lungs that were sent to me. It is possible the sampling of lungs at autopsy missed areas of pneumonia, although 5 specimens from the lungs were examined. If pneumonia was present, it likely was focal. However, even mild acute pneumonia could adversely affect a child's recovery from open heart surgery. (Exhibit 336, page 5.6)

Taylor testified:

Again, previous experience with children who have had open heart surgery, have good anatomic heart repairs, have good cardiopulmonary bypass runs, come into the ICU with no minimal or inotropic support, and then start to develop problems, generally pulmonary hypertensive crises. I think that's where mild degrees of pneumonia or pneumonitis or bronchiolitis play a role, is that these young children have very reactive airways, very reactive pulmonary or lung blood vessels, and if there is hypoxia, acidosis, the vessels can constrict down, you get into episodes of episodic pulmonary hypertension and a positive feedback system, because the blood vessels cramp down, blood flow to the lungs diminishes, and the child becomes more hypoxic and cyanotic, that causes further constriction of the blood. (Evidence, pages 43,102-43,103)

In short, while Taylor did not find pneumonia in the material he examined, he could not rule it out completely. Furthermore, he believed that pneumonia could account for Alyssa's post-operative experiences.

In his testimony to the Inquest, Reed said that upon consideration of Taylor's report and the testimony of Odim and Giddins about Alyssa's pre-operative condition, "I think it is reasonable to conclude that the patient did not have an active pneumonia on May 2nd." (Evidence, page 37,425)



Current Home - Table of Contents - Chapter 6 - Pre-operative condition-second admission
Next Alyssa's admission to the Children's Hospital
Previous Pre-operative condition-first admission
Section 1 Chapter 1 - Introduction to the Issues
  Chapter 2 - Pediatric Cardiac Issues
  Chapter 3 - The Diagnosis of Pediatric Heart Defects and their Surgical Treatment
  Chapter 4 - The Health Sciences Centre
Section 2 Chapter 5 - Pediatric Cardiac Surgery in Winnipeg 1950-1993
  Chapter 6 - The Restart of Pediatric Cardiac Surgery in 1994
January 1, 1994 to May 17, 1994
  Chapter 7 - The Slowdown
May 17 to September 1994
  Chapter 8 - Events Leading to the Suspension of the Program
September 7, 1994 to December 23, 1994
  Chapter 9 - 1995 - The Aftermath of the Shutdown
January to March, 1995
Section 3 Chapter 10 - Findings and Recommendations
Appendix 1 - Glossary of terms used in this report
Appendix 2 - Parties to the Proceedings and counsel
Appendix 3 - List of witnesses and dates of testimony
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