The Pediatric Cardiac Surgery Inquest Report



The trip to Saskatoon (June 13-14)

At its first meeting on May 18, the committee had recommended that:

The issue of an interim plan for the management of major emergency neonatal anomalies was raised. It was recommended that for the next 6 weeks the team transfer these infants to Saskatoon and participate in their management in the transferred setting. It was recommended that the cardiac surgeon, anaesthetist, and possibly one of the operating room nurses travel to Saskatoon and be involved in the infant's care. (Document 241)

While committee members were not involved in the management of all the cases that were referred out of province, in mid-June Odim, Swartz and Youngson travelled to Saskatoon to participate in the care of three patients. Odim even scrubbed in and assisted Dr. Roxanne MacKay, the pediatric cardiac surgeon in Saskatoon, with two of the operations.

Youngson said that she kept notes about any equipment used that was different from the equipment in Winnipeg. Odim had complained in the past about the pacing wires in Winnipeg, and she noted that a different wire was used in Saskatoon. While Odim said he did not want to use the wire that was used in Saskatoon, he did say that he would prefer to use the sort of needle driver that MacKay used. (A needle driver is a piece of equipment that the surgeon uses in suturing. The needle driver is used to grasp the tiny needles that are used in the suturing process.)

Youngson said that Dr. MacKay was very quick and proficient and that the team worked well together. In conclusion, though, Youngson testified:

I don't think that there was anything really noteworthy that anybody saw, that was really any better or any different than what we have here in Winnipeg. (Evidence, pages 8,493-8,494)

Odim said that he hoped the exposure to different practices would encourage other team members to be less rigid in their approach to operating-room practice. He said the trip was not beneficial to him personally.

I don't think that I learned much, because I shared the same sort of philosophy and concepts that the surgeon that I was visiting shared.

Question: Dr. MacKay?

Odim: That's right. She was in charge of her ship, she had an unified team and a small number of players. And I don't think our philosophies or beliefs in terms of how to develop a pediatric cardiac surgical team was radically different. So, personally, what it did, I did have some questions for her in terms of how she went about it, in that environment, and her concerns about the various components. (Evidence, pages 25,151-25,152)

Swartz indicated that in her view there was something to be learned from the Saskatoon experience, and that on her return she had waited for an opportunity to share it. She felt that the surgeon and the other team members had developed a close working relationship and they had a clear understanding of each other's roles. She thought that MacKay was a very fast surgeon and that one of the major differences between the Saskatoon and Winnipeg programs was the shorter period of time the Saskatoon patients were under CPB and in the operating room. She also noted small differences in the manner in which the anaesthetist performed his duties in the OR, but overall felt that the manner of anaesthetic delivery was not significantly different between the two programs.

She had wanted to share these thoughts with other committee members, but was frustrated by the fact that Wiseman did not place the matter on the agenda. Finally she asked for an opportunity to address the committee about the trip and was permitted to do so at a committee meeting in July. The committee devoted one meeting to listening to the members who went to Saskatoon and discussing their observations. Odim did not believe that the visit had any impact on the Manitoba program. He did say he believed that during this period, the people in the Winnipeg program were capable of doing high-risk cases.



Current Home - Table of Contents - Chapter 7 - The trip to Saskatoon (June 13-14)
Next The case of VM
Previous The work of the committee during the month of June
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