The Pediatric Cardiac Surgery Inquest Report



Preparing the NICU staff

Daniel was one of the first neonates upon whom Odim operated in Winnipeg and was the first to die. Debra Armitage, the senior nurse in the NICU, said that she recalled a pre-operative meeting for this operation quite vividly. She recalled that Belik asked Odim detailed questions about post-operative care.

And the answers that he was-these were very specific questions from Dr. Belik-the answers that we were getting from Dr. Odim were less specific, they were actually quite vague. In actuality, they were to the point that he was answering the usual, or what you are used to, or not being really specific. Our previous experience had been that we were very much aware which inotropes we used, how much we needed to use of them and specifics like that.

We then moved on to ventilatory support of the child post-operative, and again Dr. Belik was asking very specific questions about how Dr. Odim liked his post-operative management in terms of ventilation, and again was asking very specific questions about the degree of pressures that the ventilator delivers, and the rate of the ventilator, and whether or not-where he liked to keep the pH of the blood at in terms of what it was that we were trying to accomplish. Again, the answers were vague, with him repeating, the usual, or whatever you are used to.

And I was somewhat disconcerted at that point, because I certainly expected much more from him. I felt like I was essentially standing there with a light bulb on over top of my head, because I was struck with this amazing sense that he didn't know what he needed or wanted post-operative. (Evidence, pages 29,430-29,431)

Armitage said that, in the past in situations like this one, the surgeon would set very clear parameters as how to monitor and assess the patient in the NICU. The evidence suggests that Odim failed to assist the NICU in planning for Daniel's care. That failure seems to have stemmed from his inability to communicate what he wanted them to do and what they ought to do.



Current Home - Table of Contents - Chapter 6 - Preparing the NICU staff
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Previous Pre-operative status
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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