The Pediatric Cardiac Surgery Inquest Report



The June 29 committee meeting

The evidence suggests that there were weekly meetings of the committee from May 25 to June 29. However, there are no notes or minutes from any of the meetings between those two dates. Additionally, the witnesses who were on the committee were unable to recall the discussion from those meetings with any degree of specificity. However, it is likely that during one of those meetings, the committee discussed the death of Gary Caribou. The first of the 12 deaths recorded in the any of the committee's notes and records, however, is that of Jessica Ulimaumi, whose case was discussed at the June 29 meeting.

On that day the committee met, with Dr. Heinz Reimer in the chair. Neither McNeill nor Wiseman could attend. McNeill had arranged to have Reimer sit as her replacement because he had been the anaesthetist for a portion of the Ulimaumi case, which was to be reviewed at the meeting.

One other case was discussed. This first case was that of KK, a four-and-a-half-year-old boy with an ASD. It was concluded that the operation had been straightforward and had not led to any concerns from nurses, anaesthetists or the ICU staff.

The second case was that of Jessica Ulimaumi. In reviewing the case, Odim told the committee that when he had first read her chart in the spring of 1994, before seeing her, he had been surprised to discover that she had not undergone surgery at an earlier date. He said that when he had examined her, however, he concluded that her clinical state was better than suggested by the information in the chart.

The course of the operation was reviewed. Reimer noted that there had been increasing difficulty in ventilating the patient during the lengthy bypass. According to Reimer's notes of the meeting:

Some discussion took place as to whether the patch leak should have been repaired immediately as was done vs. waiting a few days for the myocardium to recover and then coming back to close the leak. Dr. Odim stated that his training was that if there was a mechanical problem it should be repaired immediately, and that this was done at the institution where he trained. Dr. Reimer pointed out that in that institution the total duration of cardiopulmonary bypass even with a re-repair was probably shorter than the duration of bypass for this child with the first repair alone. Dr. Reimer also stated that at the time the decision was made to repair the patch leak he could have been more vocal in pointing out the degree of inotropic support the baby was then on and generating more discussion as to whether the leak should have been repaired immediately or later. (Exhibit 67, HSC 81)

The child's stay in the PICU and the removal from ECMO were also reviewed. The minutes state that:

During the cannulation one limb of the venous cannula was removed and not clamped. The child rapidly lost blood through this cannula and arrested.

Dr. Odim acknowledged that he should have placed a clamp on the cannula. (Exhibit 67, HSC 81)

In her testimony, Youngson said that Mike Maas had not been present at the previous committee meeting. She had phoned Maas to alert him to the fact that the Ulimaumi case was going to be discussed at the next meeting. As a result, Dave Smith, the perfusionist who was present in the PICU when Ulimaumi died, attended the meeting. Youngson said there was a discussion of the events in the PICU. During that part of the discussion, Odim explained what he did, but made no mention of the fact that the cannula that had been removed from the child, had not been clamped and that blood had escaped through it. She testified that the following exchange took place.

Dave, bless his heart, suddenly said, well, Dr. Odim, what exactly happened? I was behind my machine, I couldn't see what was going on at the bedside?

And Dr. Odim sort of sat back for a second, and he said, well, actually, what happened was I forgot to clamp off the IV-I can't remember if it was the SVC or the IVC cannula, one of the cannulas that is attached to this Y. He pulled it out, and the patient bled to death out the other cannula before anybody noticed that this had happened.

Question: Dr. Odim explained that's what happened at that time?

Youngson: Yes. He said as well that there was a lot of activity around the bed, B. J. Hancock apparently was there. She wasn't, my understanding of what he said, she wasn't standing where she normally was standing in the operating room, and that she always clamps these lines before they are pulled out, and that she hadn't clamped this line, or he hadn't realized that she hadn't clamped this line, and he had pulled it out not realizing it wasn't clamped.

Again, I sort of sat back, and I thought, aren't you nice, you are trying to blame B. J. for this. (Evidence, pages 8,475-8,476)

Youngson said that she believed Odim was familiar with the clamps under discussion, because he always referred to them in the operating room as slash clamps, while other HSC physicians referred to them as tubing clamps.

This was followed by a discussion about whether the decannulation should have been performed in the PICU or in the OR. Reimer was of the view that it would have been appropriate to have both operating-room nurses and an anaesthetist present for the decannulation. Odim told the committee that he had not requested operating-room nurses because they were reluctant to work weekends. Youngson said that this in fact was not the case. The operating-room nurses had never complained about working weekends. She insisted that if they had been called, they would have attended. She pointed out that on a number of occasions, operating-room nurses had been called in to perform surgery on weekends. They recognized that it was part of their responsibility.

Reimer also noted at the meeting that up to that time two children in the program:

had suffered fatal outcomes largely due to the fact that they had VSD patch leaks which required re-exploration. Dr. Odim replied that the problem that had occurred in both patients was difficulty in exposure of the top portion of the VSD such that there was an actual fold in the VSD which had resulted in his interrupted sutures being placed wider apart than desired. He also said he had discussed this with his assistants and was implementing a different type of retraction which would result in better exposure and hopefully circumvent the problem in the future. (Exhibit 67, HSC 81)

These minutes and the testimony about this case form the most extensive documentation about the committee's review of a case. It is apparent that this meeting was at times very tense and confrontational. However, it is not clear what, if anything, was resolved by this review. The meeting merely provided an opportunity for the key participants to give their interpretation as to what happened, instead of determining why problems had occurred and how things could be prevented in the future. It would appear that there was no discussion as to whether or not the team members, either individually or collectively, had sufficient experience to attempt this operation. It would appear that this would be the manner in which all of the reviews ended.



Current Home - Table of Contents - Chapter 7 - The June 29 committee meeting
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Previous The case of VM
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
Table of Contents