The Pediatric Cardiac Surgery Inquest Report



Post-mortem issues

After this case, Feser spoke with Dr. Murray Kesselman, the head of the PICU, to express her unhappiness with the fact that Gary's chest was closed in the unit. Kesselman testified that after speaking with Odim, he concluded that such closures were appropriate in the unit. In some cases, however, patients were taken back to the operating room in order to have their chests closed with the assistance of an OR team.

Feser, along with Borton and Jannell Plouffe, arranged to meet with Odim on March 22, one week after the operation. Feser felt that she needed more information from Odim about how cases would be managed post-operatively. The Caribou case had led her to believe she needed much more information than Odim had provided at their previous meeting. For the March 22 meeting, Feser and her staff had prepared a detailed list of issues that they wanted information about. Feser testified that at this meeting she also reviewed with Odim the PICU policies on the writing of medical orders. She said Odim agreed to provide a list of items to be placed in what was referred to as a cardiac bin. The bin would store the equipment needed for procedures Odim intended to perform in the PICU. Odim did not provide such a list until the end of April. On May 6, the bin was in place. However, in the intervening period, a number of very significant events had taken place, particularly the death of another child (Jessica Ulimaumi) in the PICU.

Feser testified that at the meeting on March 22, she and her staff raised a number of other concerns. She said that the PICU nurses were having difficulty with Odim's request that they call him at 0600 hours to update him on what sort of night his patient had experienced. While she recognized the benefit to the surgeon, she said the unit did not have the resources to carry this out at that time of day.

According to Feser's testimony, another issue that was discussed at this meeting was the prescribing of medications, and particularly pain relief, to patients in the PICU. Odim wished to prescribe what are referred to as bolus doses, which are given intermittently. The practice in the PICU was to use a continuous infusion. This difference later arose as a point of conflict between Odim and other doctors in the PICU. At that time, Feser said she made it clear to Odim that while he could make his preference known, the decision about medication was made by the attending intensivist. This was because the PICU was a closed ward. At the meeting, it was decided that a standard order form would be set up for Odim to use at the end of an operation. According to Feser, Odim was to:

. . . fill it out, but our physicians would still review it and they would still be responsible for writing orders. So they would take off of this sheet what was applicable, what we were going to use, but still write, doctors would still write their own orders post-op. (Evidence, page 29,910)

Feser also raised concerns about the types of monitoring lines that Odim used. Monitoring lines (also called intracardiac lines) are tiny tubes connected to the heart, which pass through the chest wall and are connected to monitoring devices. They are important as a means for staff to observe cardiac performance.

Normally, such lines come in one piece from a manufacturer with a connector at one end. The end without a connector is passed through the chest wall and inserted into the heart or into a blood vessel attached to the heart. The connector is then used to connect the line to a measuring device. Odim's method of insertion involved disassembling the lines.

Feser testified:

We raised a couple of concerns in doing this. I mean, there is a risk obviously - not obviously, it may be not obvious to people, but it was obvious to me from previous experience that when these lines came apart there was a risk for bleeding, there was a risk for infection. (Evidence, pages 29,902-29,903)

Reimer described the problem:

If I can describe briefly the way these are inserted, generally they are, the lines themselves are a long piece of tubing and then on the end of them is a connecter called a [Luer] lock connecter which is a sort of locking-type connecter that allows it to be connected with other lines or with monitoring devices and so on.

However, the way they were inserted is they were inserted sort of from inside out. That is, they were placed in the cardiac chamber first, and then they had to be brought through the skin so they could be used. It's not possible to bring a connecter up through the skin, or the connector that is on the catheter.

What Dr. Odim would do is cut the connecter off so he could get it through the chest wall and through the skin, and then he would suture another type of-another piece of tubing with a built-in connecter and he would sort of telescope the two together and tie a suture around them to secure them and that's what he would use.

One of the problems that was being expressed, and this was actually more of an ICU issue than an intra-operative issue, is that these lines were coming apart right at that connection. (Evidence, pages 19,341-19,342)

Reimer said that Duncan had approached the issue differently and in a manner that did not require that the connector be cut off. Because the tube had to pass through the skin and the chest wall, it had to be inserted into the end of a large needle and the needle then pulled the line through the chest wall in a manner that allowed the line to remain intact. Duncan had worked from the inside out, passing the needle from inside the chest to the outside, inserting the tubing into the needle and then pulling it back through the chest wall. He then connected the end of the line to the chest.

Feser testified that Odim said that the lines he used were what he was accustomed to using in Boston and that he found them to be quicker and more efficient to use. This issue would recur during the rest of the year.

Reimer said that because the problem of the intracardiac lines coming apart was a recurring one, he had proposed a solution to Odim.

The suggestion I made to him is that there is a particular type of epidural catheter that we use in anaesthesia, where we have a similar issue, and that the catheter can't be inserted with a connecter already on it.

So, the way that it is designed is that there is a connecter that can be attached after the catheter is inserted, and it's got-it's designed in such a fashion that it will be secure when the connecter is put on after insertion.

I showed him this, and I suggested this is something that he might want to try.

Q. Did you actually show him the equipment?

A. Yes.

Q. Did you demonstrate sort of how the equipment worked?

A. I'm not sure I took it out of the package, but I certainly showed him all the parts and how it worked.

Q. All right. What was his reaction when you showed him this equipment?

A. I mean he looked at it, and-but ultimately said that he didn't think he was having a real problem with what he was using at present and didn't see a need to change. And he was also concerned about the expense of the epidural catheters. (Evidence, pages 19,342-19,343)

According to Reimer, catheters cost between two and three dollars. He testified that Odim did not believe that his method was creating any problems and continued to employ it throughout 1994.



Current Home - Table of Contents - Chapter 6 - Post-mortem issues
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Previous Findings
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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