The Pediatric Cardiac Surgery Inquest Report



Post-operative Course

The post-operative care of a child who has undergone a Norwood operation can be as difficult as the procedure itself. It is extremely important that there be a proper balance between the blood flow to the child's body and to the lungs. In his testimony, Odim said that in a sense one takes the operating room to the intensive care unit to manage these babies.

When Daniel arrived in NICU, the attending neonatologist was not present, having been called to attend in another part of the hospital. Instead, a resident met Daniel and the team accompanying him from the OR. Reimer testified that after he explained the anaesthetic issues to the resident, the resident "immediately wandered off to look after another baby, who I thought at the time had a relatively trivial problem." (Evidence, page 18,876)

Reimer testified that he was dismayed by this and by the fact that Daniel was placed in the back corner of the nursery. Reimer testified:

Traditionally, infants who are more critically ill are nursed closer to the desk. That's simply a reflection of that being a location where there are usually more people around, help is more readily available, and they can perhaps be watched a little bit more closely than they are elsewhere. (Evidence, page 18,875)

In her testimony, Dr. Molly Seshia, the head of the NICU, disputed Reimer's assertion that there were priority cubicles in the NICU. Seshia also said that as a result of the Terziski case, the NICU put into place a practice whereby, whenever a child is coming from the surgical ward, the attending neonatologist must be called back to the ward to be present. This also required some form of notice from the surgical unit that the child was about to be transferred.

In light of these events, Reimer said:

I thought there was under appreciation by the staff, again, of the fragility of this child's condition, or of a child's condition who has had this procedure, and general under appreciation for, I guess, just the degree of illness they have and how easily they can decompensate. (Evidence, page 18,876)

The major issue that needed to be watched carefully in the post-operative management of Daniel's case was the balance between the blood flowing to Daniel's body, as opposed to that flowing to his lungs. His condition was such that a fatal imbalance could develop rapidly.

According to Odim, Daniel's condition was stable for 40 minutes after Daniel arrived in the NICU. At that time, he and Giddins went to see a patient in another unit. In his testimony, Odim said that he could not provide more information about this other patient. After ten minutes, Odim said, he then returned to Daniel's bedside. By that time, his oxygen saturation had dropped into the sixty per cent range and, despite hand ventilation, did not improve. Odim opened Daniel's chest at 2023 hours to check the status of the shunt. Odim testified that he asked the nurses to organize a sterile setup so that he could quickly provide some assistance to Daniel.

There was a lot of scurrying around to get sterile drapes and towels so that I could proceed, and the Betadine to spread on the chest as an antibacterial. (Evidence, page 24,828)

Armitage testified that the scene was chaotic at this point.

We were not prepared at any time to go back into Daniel's chest. In essence, we were caught off guard very badly by the fact that we were not prepared to go back into this chest. We needed equipment and supplies and personnel in order to do that, and we had none of that available. (Evidence, page 29,434)

Armitage said that it was necessary to essentially replicate the OR setting.

And we have forceps, we have things like that available to us in NICU, but not the actual surgical instruments that are required in that circumstance. There are special kinds of sutures that we do not stock, simply because we do not use them. There are various other bits of supplies that are needed.

There, again, our concern also was in talking about personnel is that neonatal nurses are highly specialized in what we do. That does not include being a scrub nurse. We are not familiar with the instruments. We don't know what their names are, never mind what they are used for. So, for him to ask me to hand him whatever, I simply wouldn't be able to do that.

The other point that I want to make in terms of equipment or possible supplies, the OR is one floor down from us. While it might take you only 30 seconds to run there, they have a very big supply room and their supplies are somewhat overwhelming, and for me to run into that room to find out what it is I am looking for, even if I know what it looks like, there is a huge time lag and the baby may very well be dead by the time I find it.

We were fortunate in fact that Carol Youngson was still in the OR cleaning up and so she was able to come up and assist. (Evidence, pages 29,435-29,436)

After opening the chest, Odim deemed the shunt to be viable. Daniel, however, continued to deteriorate. Odim gave this description of what happened next:

. . . the blood pressure continued to drop and we lost our sinus rhythm, and Daniel was in a cardiopulmonary arrest.

I tried vigorously to resuscitate the heart with massage and drugs, but after a period of time of all these attempts, we were never able to get any action back, and Daniel expired. (Evidence, page 24,832)

Despite 40 minutes of open-heart massage and vigorous resuscitation, Daniel died at 2059 hours.



Current Home - Table of Contents - Chapter 6 - Post-operative Course
Next Autopsy
Previous The assessment of the consultants
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
Search the Report
Table of Contents