The Pediatric Cardiac Surgery Inquest Report




He said that there were multiple levels to the communication problem.

I felt that communication seemed to be better from the perfusion point of view, because if they didn't hear anything, they would pipe up, and they never took offense to my raising a question because I didn't hear. I didn't get the sense that other members of the team responded in that fashion. When I asked a question, I would get no answer, and it was viewed negatively and not as I just need to know what's going on and all you need to do is acknowledge. (Evidence, pages 25,066-25,067)

Odim said he felt communication with the perfusionists was better because "they seemed to have a better appreciation of the normal conduct in a cardiac operating room." (Evidence, page 25,067) On other levels, he said information on the clinical course of a patient's treatment was not communicated to every team member.

Odim also said that at times, some members of the team would interpret a question, such as "Have you turned the flow down?" as a challenge or a suggestion that the person being asked was remiss, as opposed to them being asked a simple question. As a result, he said, people might respond by saying, "Well, of course," as opposed to simply answering the question (Evidence, page 25,085). He also indicated that he had asked members of the team to be quiet. In addition, he spoke of difficulties in getting nurses in the intensive care unit to call him early in the morning to let him know how a patient had passed the night.



Current Home - Table of Contents - Chapter 7 - Communication
Next Team meetings
Previous The issues raised by Odim
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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