The Pediatric Cardiac Surgery Inquest Report



Intra-operative incidents

A number of incidents arose during this operation that deserve mention. These included the apparent dribbling of adrenalin on Vinay's heart, the testing of the patch by the forceful injection of saline into the heart chambers and the early removal of a cannula.


Dribbling of adrenalin on the heart

After the repair was done and before Vinay was weaned from bypass, Odim wanted to infuse adrenalin from a syringe through a line directly into Vinay's heart. According to several of the witnesses, including Swartz, Irene Hinam and the operating-room nurses, after administering some adrenalin intravenously to Vinay, Odim dribbled the adrenalin remaining in the syringe onto the heart. Almost immediately, the heart changed color and contracted violently, creating noticeable changes in Vinay's blood pressure readings. These changes were noted on the anaesthetic record, as was the event. The other team members were surprised by this action. Swartz said this was something that she had never seen before and questioned the wisdom of doing such a thing to such a fragile heart. When Swartz asked why he did it, Odim asked-in what she interpreted as a sarcastic tone-if he should have thrown the rest of the drug on the floor instead.

Odim's recollection was different. He said that he decided to give the adrenalin into the heart through the intracardiac line to ensure that it was in a blood vessel. He said that Swartz was upset at this, but followed Odim's request. Swartz denied being upset, saying that she was familiar with the technique of infusing adrenalin directly into the heart. Odim said that once the blood pressure went up, he told Swartz to turn off the epinephrine (adrenalin) drip. Odim said that it was not uncommon to see a quick rise in blood pressure when one treated a patient with adrenalin in this way. He did not recall dribbling the adrenalin directly onto Vinay's heart. He did not, however, deny that it happened.

Hinam also testified that Odim put adrenalin straight on to the heart, making the heart turn colour, and causing the blood pressure to rise dramatically.

The testimony of the several witnesses, as well as the clear indication on the anaesthetic record of this incident, is convincing evidence that this incident occurred as the witnesses said it did. Why Odim did what he did is unfathomable. It is possible that he was simply interested in observing how the heart muscle would respond to such an event. There was certainly no medical reason for it.


Testing the patch

After he had repaired the patch leak, Odim performed a test of the patch repair that took the team by surprise. Youngson, Swartz and Hinam testified that Odim took a syringe filled with saline and injected the saline into the heart with considerable force. Youngson said that Odim pushed the saline into Vinay's heart through the syringe with the heel of his hand. They were all shocked by the intensity of the procedure. Youngson testified:

Because, first of all, we had just done a repair inside of this heart, what is that going to do to the repair, first of all? And secondly, there is lots of very delicate tissue, and this heart is very kind of friable, kind of mushy, the tissues aren't very strong. And to me that seemed like, it didn't seem like a very good thing to do. (Evidence, pages 8,398-8,399)

Swartz said that Odim pushed the syringe with as much force as he could, and she was concerned about that tearing the tissue. She had never seen this method of testing the integrity of a patch and was concerned by the amount of force he was using and that it might damage the heart. She testified:

I was unfamiliar with this method of assessing integrity of the patch. But I was also concerned at the time that he was using a lot of force in injecting relatively, as he said to me, blindly. And I didn't know where-you would imagine that the saline would come out at a very high pressure and that the chances of damaging the heart enters one's mind, and that thought came into my mind. (Evidence, pages 15,542-15,543)

Odim testified that he administered the saline from a syringe attached to a red rubber catheter inserted into the left atrium. He wanted to see if the saline would appear on the right side of the heart. Odim said that he did not have any concerns about injuring any of the tissue by using this technique to test for leaks. He said that the tissues of the heart were probably not more friable (fragile and easily torn) at 30 days after the first operation. Odim said he didn't think this method led to tears. In his operative report, he said that the left side of the heart was filled vigorously with cold saline. By vigorously, Odim said, he meant a firm squeeze of the syringe's plunger because the red rubber catheter attached to the syringe provided a resistance that had to be overcome.

Soder said that he had seen this technique done with some frequency to test a patch repair, although he could not comment on the degree of force used.


The premature removal of a cannula

After being weaned from the bypass machine, Vinay was in unstable condition and was bleeding from the chest wall cavity. There was disagreement between Swartz and Odim as to whether or not the bleeding was due to a coagulopathy or to a surgical cause. This led to a series of dramatic, and eventually tragic, events.

A coagulopathy is treated by giving a patient various blood products, thus helping the patient's blood to clot properly and stop bleeding. Swartz said that normally when a patient was treated with blood products, clots formed. She said that the sequence of bleeding without clots, followed by the presence of clots after the administration of blood products, showed that the patient had a coagulopathy and that it was resolving. However, if the bleeding was coming from an operative site that had not been completely sutured, the bleeding was termed 'surgical', and it was necessary to find the leak and repair it. In Vinay's case, the bleeding continued despite the administration of clotting drugs. For this reason Swartz thought that there was a surgical bleed.

While Odim was searching for the leak, Swartz asked Maas to transfuse blood into Vinay through the aortic cannula to compensate for the loss of blood and maintain Vinay's blood pressure. At that point an alarm went off, indicating that there was a blockage in the cannula through which Maas was attempting to deliver blood. When Maas asked what was wrong, Odim informed him that he had removed the cannula through which Maas was trying to transfuse blood.

The fact that the aortic cannula had been removed came as a surprise to almost everyone in the OR. Odim testified that he had announced that he was removing the aortic cannula. Koga, one of the perfusionists, recalled Odim saying the aortic cannula was out but could not recall him informing the team before removing it. Hancock testified that she vaguely remembered going through the sequence of removing the cannula. From the testimony, however, it appears that none of the nurses, the anaesthetists or the other perfusionist knew that the line was out.

Youngson had no memory of assisting Odim to remove the cannula. She testified that Swartz told Odim that he should not have taken the cannula out without telling her. Maas appeared confused as to what was happening. In his testimony, Maas said he could not recall being told the cannula had come out. Maas testified that typically the perfusionist and the anaesthetist were made aware that the aortic cannula was going to be taken out. He said that in Vinay's case they were not told that it was going to be or had just been removed, and they learned that it was out only after the fact.

The removal of the cannula greatly compromised the anaesthetists' and the perfusionists' ability to keep up with Vinay's blood loss, since other lines that the anaesthetists could use to transfuse blood could not provide the same volume of blood as the one Odim had removed. Swartz, McNeill, Maas and Hinam struggled to find another way to transfuse Vinay because it was not possible to reinsert the cannula. In addition, removal of the aortic cannula meant that it was not possible to transfuse Vinay with the blood products still present in the bypass machine. Instead, a member of the team had to leave the OR to get additional blood products.

Normally, in the decannulation process, the aortic cannula is the last one to be removed. This is precisely because it is kept in place in case it is needed for transfusing large amounts of blood to the patient. All of the available evidence compels the conclusion that Odim removed the cannula from the cannula site on his own, without warning the other members of the operating team that he was doing so. In removing the cannula, he severely compromised the team's ability to transfuse blood to the patient, who was losing blood at an alarming rate.

Furthermore, it was not appropriate to remove the cannula until the existence of a surgical bleed had been ruled out. Eventually, Odim did in fact discover that there was a surgical bleed (a tear in the heart) and sutured the defect. Odim testified that he did not know how the tear in the heart had occurred.

Unfortunately, the repair of the surgical bleed occurred too late for Vinay. His blood pressure did not recover after the bleeding was controlled and he quickly deteriorated to the point of cardiac arrest. Vinay was pronounced dead at 1907 hours in the OR.

Odim said that at the time he took out the cannula, it seemed that the problem they were dealing with was a coagulopathy. His evidence, that he believed he had told the team that he was going to take out the cannula, is difficult to accept, given that every other person in the room, except for Hancock, was certain that he had not.

Odim admitted that Vinay's death could have been prevented if they could have kept up with the blood loss. The loss of the cannula directly contributed to the team's inability to transfuse blood properly.

There were no incident reports filed on any of the events that took place during the second operation. Swartz testified that she had written a note about the incident concerning the removal of the aortic cannula, but she admitted that she might not have placed the note in the chart. She was unable to locate the note.

No member of the HSC staff made use of the incident report system to flag any of the issues. Indeed, it is distressing that many staff members did not even believe that the reporting system applied to them.

When questioned as to why she had not filed a report, McNeill, who witnessed the events, testified, "I wouldn't-I didn't write an incident report, and even in my practice now I wouldn't, because I don't sort of consider-I don't consider it a tool that I use." (Evidence, page 13,179)

Swartz testified that within 15 minutes of Vinay's death, she spoke to Odim and asked him why he had taken the cannula out and why he had failed to inform people that he was taking it out. She testified that Odim explained that he had taken it out because he was worried about problems with clotting. In addition, he acknowledged that there had been communication problems in the OR.

Shortly after surgery, McNeill also asked Odim why he had removed the cannula. In her testimony she said that she found Odim's explanation unsatisfying. She testified that:

the whole experience was unsettling and was, I don't know how more to say it. I just didn't, I didn't feel that we had sort of dealt with it, or that we had adequately, or that I adequately understood why and how it all happened. (Evidence, page 13,181)

This dissatisfaction led her to take her concerns to her section head, Dr. Suzanne Ullyot.

Odim testified that the case was discussed at a subsequent Morbidity and Mortality Round. He said he concluded that Vinay might have been saved "if we had been able to keep up with the coagulopathy and the blood loss." (Evidence, page 24,603)



Current Home - Table of Contents - Chapter 6 - Intra-operative incidents
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Previous The Operation-April 18
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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