The Pediatric Cardiac Surgery Inquest Report



The operation - November 27

On Sunday morning, November 27, Jesse underwent emergency surgery for expansion of his ascending aorta, repair of his interrupted aortic arch, closure of a ventricular septal defect with a dacron patch, suture closure of an atrial septal defect and closure of a patent ductus arteriosus. Myocardial protection was to be provided by both bypass and profound or deep hypothermic cardiac arrest.

Jesse Maguire - pre-operative heart
Jesse Maguire - pre-operative heart

Diagram 8.8 Jesse Maguire - post-operative heart
Diagram 8.8 Jesse Maguire - post-operative heart
1 - Patch expansion of ascending aorta
2 - Suture closure of atrial septal defect
3 - Ligated and divided left subclavian artery
4 - End-to-end repair of interrupted aortic arch
5 - Ligation and division of ductus arteriosus
6 - Buckled ventricular septal defect patch

Compare pre- and post-operative diagrams side by side


The operating team is set out in the accompanying chart.

TABLE 8.7: Persons involved in the operation on Jesse Maguire, November 27, 1994
OR team member   Persons involved
Surgeon J. Odim
Surgical assistants B.J. Hancock, D. Miltenburg (resident)
Anaesthetists J. Swartz (relief provided by R. Graham and L. Patel), L. Stanko (resident)
Scrub nurses C. Youngson, M.J. Wasney
Circulating nurses H. Skomorowski, C. Davidson
Perfusionists M. Maas, D. Smith

TABLE 8.8: Length of phases of the operation on Jesse Maguire, November 27, 1994
Phase of the operation   Time taken
Induction 2 hours 29 minutes
Bypass 6 hours 12 minutes
Total circulatory arrest 2 hours 49 minutes
Total surgical time 11 hours 7 minutes
Total operating-room time 13 hours 59 minutes

To undertake the repair, the team inserted cannulas into Jesse's blood vessels, using double-arterial cannulas (one in the ascending aorta Y-connected to one in the pulmonary trunk) and a single venous cannula (in the SVC). Intermittent cold blood cardioplegia and deep, hypothermic, total circulatory arrest were to be used for myocardial protection. At 1247 hours, the anaesthetist applied ice to Jesse's head to protect his brain. Bypass was then started. Solumedrol was given intravenously at 1300 hours, conceivably to decrease swelling of the brain, or cerebral edema, and total circulatory arrest (TCA) was then instituted. At that point, the cannulas were removed to give the surgeon a relatively clear operative field. While cannulation is always a significant factor in any open-heart procedure, it is particularly significant in the repair of an interrupted aortic arch, since the aortic cannula is being inserted into the very vessel that is to be repaired.

Repairing the VSD while on TCA

After repairing the aortic arch and ligating the left subclavian artery to improve the mobility of the descending aorta, Odim went on to repair the VSD and ASD while Jesse was still on TCA. Swartz testified that she was surprised by the decision to repair the VSD on TCA, since she thought that the team would return to what is termed low-flow bypass for this repair. Low-flow bypass differs from regular bypass, in that there is a lower flow of blood through the patient and the low temperatures of circulatory arrest are maintained. Low-flow bypass does provide some perfusion of the body, in contrast with TCA when there is no blood flow.

Swartz testified that she spoke to Odim about this decision not to return to low-flow bypass for the VSD repair.

After Jesse had been on circulatory arrest for 45 minutes, I said to Dr. Odim-I can't remember the exact words that I said, but I basically said, aren't we going back on low flow? And he said no. And I said, well, we have been on, you know, deep hypothermia for 45 minutes. And he said to me, are you worried? And I said yes. And he said me too. And that was it. So, he didn't go back on low flow and we continued on deep hypothermic circulatory arrest for the duration of the repair. (Evidence, pages 16,250-16,251)

Swartz was afraid that there was increasing danger of neurological damage as a result of the length of TCA. Youngson confirmed the exchange between Odim and Swartz. According to Youngson, Swartz asked Odim if he was repairing the VSD. He replied that he was and then asked if she were worried. She said yes, to which, Youngson testified, he said, "'I am doing it' or something like that. He made a kind of offhand kind of remark and kept on working." (Evidence, page 8,637)

When the repair was finished, the cannulas were reinserted and Jesse was placed on bypass at 1532 hours. He had been on TCA for 102 minutes. It had taken Odim about 57 minutes to repair the VSD while the child was on TCA. Consulting witnesses who prepared reports for this Inquest indicated that this was a dangerously lengthy period of time for TCA. Cornel wrote that with a TCA of this length, "there would have been a probability of brain damage." (Exhibit 353, page 65) In the report prepared by Duncan and Cornel, it was noted that it would have been preferable to repair the VSD on low-flow bypass. Hudson wrote that the 102-minute period was exceedingly long and would have been likely "to cause significant morbidity and/or mortality in a neonate." (Exhibit 307, page 11.3) Soder testified that the time of the initial bypass "would probably have produced a bad outcome." (Evidence, page 44,203) Soder, too, thought it would have been appropriate to repair the VSD on low-flow bypass.

Odim was asked why he chose to repair the VSD on TCA. He responded:

Because I felt that it would be easier to do. The field was bloodless, we did not have the cannulas in the way in this small baby, and I thought it would be easier to get the VSD accomplished under circulatory arrest.

Q: What do you mean by easier?

A. Easier in the sense that, from the technical point of view, in a very, very small baby, the advantage of circulatory arrest is that you don't have the cannulas in your way, and you don't have venous return coming back to the heart, so the field is bloodless. (Evidence, page 25,868)

Odim testified that it took between 50 and 90 minutes for him to complete the repairs on TCA. He was asked if it would have been possible to repair the VSD and the ASD on bypass. In regard to the VSD, he said:

Yes, I think that might have been an option. I don't know how easy it would have been to do it on bypass, in terms of the technical aspect of it in a very small baby, the issues of the cannula clutter and the venous return and the visualization and the exposure. So there is a trade off. (Evidence, page 25,873)

He noted that while the ASD could have been closed on bypass, closing the ASD only added two or three minutes to the total time on TCA. Odim was asked whether or not he recalled Swartz's questioning of his decision to undertake the VSD repair during TCA.

Yes, Dr. Swartz the anaesthetist as well as the perfusionist did point out to me the circulatory arrest time, and there was a comment to the fact that, isn't this kind of long and you are doing the VSD, and my reply was, yes, it is long, and we do have a VSD to do. And that was the extent of the conversation. (Evidence, page 25,885)

When asked why he continued with the VSD repair under TCA, given the worries over time, he said:

Because it was my preference for exposure reasons and my experience to get this done under one circulatory arrest period. I do know that some of these periods will exceed 60 minutes, 70 minutes or even 80 minutes, but I was trying to weigh the potential difficulty of doing it under low flow with the blood return and exposure issues, and at 40 minutes felt that the exposure was better and that it would be easier to tackle the VSD without the interference of the cannulas and the return. (Evidence, page 25,886)

In his testimony Odim said that it had always been his intention to perform the major repairs while Jesse was under TCA. In a pre-operative note in the chart, however, Odim had indicated that he in fact intended to use deep hypothermic circulatory arrest with low-flow bypass. He maintained, in fact, that once the major repairs were completed, he went on low-flow bypass for the completion of the operation. The team went back on bypass at 1532 hours.


The dislodging of the cannula

Youngson testified that at approximately 1630 hours, while Jesse was being rewarmed, she heard a member of the operating team gasp. She turned to see that the aortic cannula had been dislodged. With the removal of this cannula, Jesse was no longer receiving blood from the bypass machine. Michael Maas, the perfusionist, turned off the bypass machine to stop it from draining blood from the child. According to Youngson:

At that point in time, there is this concerted effort by the two surgeons to get this cannula back in. They were having a very, very difficult time getting this cannula in. They were just taking it and trying to shove it back into the aorta, any way just to get it back in and get back on pump. To me that was their objective, to just get this cannula in, and let's get this baby back on bypass. Neither one of-

Q. Just taking it and trying to shove it back in?

A. Neither one of them could seem to do this. I know that Odim tried a couple times, couldn't do it. B.J. took it away from him and said, let me try. And she tried a couple of times, she couldn't get it in. Sort of back and forth like this. They were rough. (Evidence, page 8,641)

At the same time, Youngson testified, she was suctioning blood from the operative field in an effort to assist the surgeons to recannulate Jesse's aorta. By Youngson's estimate, it took approximately five minutes to re-insert the cannula.

In notes that she made right after the operation, Youngson wrote:

During the rewarming process the Aortic cannula was dislodged and fell out. Both the surgeon and the assistant (DR. Hancock) struggled for 6 or 7 minutes to replace the cannula. They were very disorganized and panicky. They argued with each other and grabbed the cannula and instruments from on [sic] another and it was very obvious that NEITHER ONE HAD THE SKILL OR EXPERTISE TO HANDLE THIS SITUATION. [Capitalization in the original.] Dr. Odim was extremely rough, "jamming" the cannula in again and again. Prior, to this event there had been some problems with the purse string sutures breaking. Instead of replacing them the surgeon asked the scrub nurse to shorten the rubbers on them so that they were now approx. 2.5 to 3 cm. long and much too short to work with. It was noted that the surgical field was extremely messy and unorganized throughout the case.

During the time that the surgeon was trying to reinsert the cannula these purse strings hampered their efforts because they were so short. As well there was almost no communication from the surgeon to the perfusionist and he (Mike Maas) had to resort to asking the scrub nurse what was taking place. It fell on the scrub nurse to inform the perfusionist to de-air the cannula again and again during this event, and to keep him informed as to what was happening. (Exhibit 20, Document 278 D)

Swartz corroborated this account. She testified that the surgeons were scrambling to control the bleeding and to re-insert the cannula.

Well, one person would try, then the other person was trying, then the other person would try. It was a very disorganized surgical field. And there was bleeding, they were suctioning, and it was-they were trying to push it back in. (Evidence, page 16,275)

During this period (which she estimated lasted five to seven minutes) Swartz was transfusing blood to Jesse through an intravenous line.

In his testimony, Maas said that the cannula became dislocated at 1630 hours. He testified that while he did not know how it became dislodged, there could have been no reason for it being removed at that point in the operation. He said Odim stated that the cannula was out.

So, obviously, for me that is a major event, and we have to shut the pump and all the systems down, without exsanguinating the patient.

Because if I continue to leave the venous line open, and I have no in-flow, I will drain the patient totally of blood in seconds. (Evidence, pages 7,051-7,052)

The anaesthetic record indicates that the total time from the cannula coming out and its re-insertion was six to eight minutes. Swartz testified that she did not record the times as the events were occurring, but made the entry after the end of the operation by checking the computer readings from the anaesthetic machine and determining that the cannula had been dislodged at 1630 hours.

The perfusion record indicated that the cannula was out for approximately one minute. Maas testified that the entry in the perfusion record was not made while attempts were being made to re-insert the cannula, but after the problem had been resolved. Neither he nor the other perfusionist, Dave Smith, had recorded the time, and the figure of one minute was an estimate that Smith had entered into the record. This estimate was based on Maas's guess that the cannula was out for one to two minutes. Maas said that, after reviewing the anaesthetic records, he was satisfied that the cannula was more likely out for five to six minutes. The time on the anaesthetic record is likely more accurate, given that it was determined retrospectively from computer-generated records.

Maas also testified that it appeared that Odim and Hancock experienced difficulties reinserting the cannula:

You could tell they were struggling at the table, as far as we could tell, to get this thing back in. They are dealing with very, very small areas, first of all, very small exposures, very small vessels. And already it has a major repair on the vessel, the suture lines.

It has had two cannulas sites in the aorta, when they initially cooled the patient and the going back on again. I can imagine that would be very difficult to get that back in. (Evidence, page 7,055)

Maas said that this was the first time in 18 years that he had witnessed such an event. He further testified that, after the operation, he had asked Odim what had happened.

And he had no explanation for how it became dislodged. And we asked him, I asked him what happened next. And he explained there was a rent in the aorta, and he had to repair that, and it made his initial repair inadequate, I guess, and that's why we had to go back and do a second circ arrest to repair that. (Evidence, pages 7,072-7,073)

(Odim's subsequent testimony suggests that in his response to Maas's question he was referring to a later event in the operation.)

The testimony of Irene Hinam and Dave Smith corroborated the account of Maas, Youngson and Swartz.

In their testimony, Odim and Hancock surprisingly said that they could not recall the cannula being inadvertently removed. Nor could they recall the events described by Swartz, Youngson, Hinam, Smith and Maas. Odim was asked if he could help explain the difference in the evidence that he and Hancock gave, compared with the evidence from the nurses, perfusionists and anaesthetist.

I really can't explain it, I've looked at these records and the problem I have is I'm trying to match up my recollection of the events with two different records and I'm getting confused as I try to do that. (Evidence, page 25,991)

From the weight of the evidence that has been presented, including both the testimony and the records kept by the anaesthetists and the perfusionists, it would appear that this event did, in fact, happen. At 1630 hours, the aortic cannula somehow became dislodged. From this time on, a series of problems occurred that eventually led to Jesse's death in the operating room.

Once the cannula was reinserted, shortly after 1630 hours, Jesse remained on bypass until taken off at 1802. However, the team was not able to get proper blood pressure readings from the lower part of Jesse's body. This problem suggested that there was a lack of blood flow to Jesse's lower body. A number of steps were taken to determine the reason for this poor blood flow. It was suspected that the aortic cannula itself was creating the blockage. In a post-operative letter to Jesse's doctor, Odim wrote, "There was a problem with obstruction from the arterial cannula which is not unusual for babies this size with a 5 mm aorta." (Exhibit 8, page MAG 21) This obstruction from the cannula meant that it was necessary to remove the cannula. However, when it was removed at approximately 1810 hours, there was no improvement in lower body blood pressure.

In his operative report and in his testimony, Odim stated that he believed the purse-string tourniquets probably caused the continued obstruction. These were tourniquets that he placed in the aorta when he removed the cannula (to close the hole through which the cannula had been inserted).

It was agreed at the time that the only option was to return to bypass and attempt to find the obstruction to blood flow and repair the cannulation site. To go back on bypass, it was necessary to reinsert the cannula. Odim once more experienced difficulties with cannulation. In his evidence, he said:

[W]e struggled to get the cannula back in. There is no question I felt at that time took an eternity. We simply could not get the aortic 8 French catheter back in and seat right. Multiple times it went in and came out we could just not get it to sit straight in the lumen, and ultimately after several minutes I had to go with a larger cannula to get it back in the aorta and go back on pump, and in the course of doing that, we disrupted the anterior suture line of our repair and had to repair that site and, unfortunately, that certainly played a role in Jesse's demise. (Evidence, page 25,992)

According to Odim's testimony, the cannula was finally re-inserted at 1832.

According to Swartz, at this point Odim said he had torn the original repair of the aortic arch. The team went back on bypass at 1834 hours. According to Odim:

Once we got back on bypass, it became quite clear that with the larger cannula in and the friable tissue around it, that we essentially had encroached our anterior suture line.

Q: Sorry, go ahead and finish it.

A: And that we had an area of our anterior suture line that needed to be repaired. And the question was, can we repair this without having to use circulatory arrest? (Evidence, page 26,057)

Odim made the decision to go back on TCA to repair the tear in the anterior (or front) of the original repair to the aorta with pericardium. While this carried considerable risk for Jesse, it was felt that there was no other option available to the team. TCA was re-instituted at 2015 hours.

During the second period of TCA, Swartz was relieved by another anaesthetist and left the OR. While she was out of the OR , Swartz spoke with Ward and informed him of the first unplanned dislodging of the aortic cannula at 1630 hours. She testified that after she returned to the OR, Ward subsequently entered and spoke with Odim. While she could not recall the specifics of what Odim told Ward, she did recall that Odim did not mention the dislodging of the aortic cannula. In his testimony, Ward said that while he could not recall the specifics of what he was told by Swartz and Odim, he had had trouble at the time reconciling what he had been told.

The repair was redone while Jesse was on TCA for an additional 67 minutes. He was placed on bypass once more at 2122 hours. His body was then rewarmed and efforts were made to start his heart beating once more. These efforts included defibrillation, pacing and treatment with a variety of drugs, including adrenalin. However, his heart never started beating on its own. Odim, Ward, Swartz and Casiro concluded that it was not possible to resuscitate Jesse. He died in the OR at 2239 hours.

Swartz testified that, following Jesse's death, Odim said to her that he should have been more meticulous in his cannulation. Odim said that he recalled speaking with someone after the operation and stating that the cannulation had been the Achilles heel of the operation.

Youngson also testified that after Jesse had died, Odim spoke to Ward about informing the parents.

Dr. Odim looked over at him, and he said, I guess you will have to go up and tell the parents that Jesse has died. He said I think it is best that we just say that we couldn't wean Jesse off of bypass, and best not to mention that, you know, we had had this problem with the cannula. (Evidence, page 8,662)

Swartz confirmed this conversation. In her testimony, she said that "Dr. Odim suggested that it would-they should say that they had trouble weaning from bypass." (Evidence, page 16,330) She testified that she was surprised by this comment:

The reason I was is because when a child dies, it is a very stressful situation for everybody, including the family. And so the question is, when do you-how do you approach telling the sort of the sequence of events or the true events that have taken place. And you don't want to hurt them. Because you are not sure how to do this, probably the best thing to do is just say it. But I was, I thought, how do they know what to say to the family? How can they actually say this to the family and when will the family actually find out what happened, and will the family ever find out what happened? And those were the thoughts that were in mind at the time. (Evidence, page 16,331)

Youngson was similarly upset by the conversation.

I was shocked. I mean, Jesse Maguire was my worst nightmare come true. This was what I had been afraid of all along, that something like this was going to happen, and here it had happened.

And whatever, what little respect I had for this surgeon at that point, it was dropping by the month or by the week. That was it, I lost all respect for him, because I felt you screwed up here, and you don't even have the courage to go out and admit it to these parents. You don't have to go out and say I screwed up, but you can at least be honest with the parents and tell them about the problem. (Evidence, page 8,665)

In his testimony, Ward testified that he had asked Odim what he thought the parents should be told.

And he said, Well, why don't you just tell them that-basically they'd been kind of pre-warned that things weren't going well. So I think he suggested, from memory, that we just inform them of basically the fact that Jesse hadn't come off pump.

Q. Um-hmm.

A. And then he would deal with the other stuff or we would deal with the other issues later, the technical issues and why there were problems coming off pump and exactly what the problem was. (Evidence of Dr. Ward, pages 105-106)

Ward said it was standard not to go into the technical issues at that point. Martin Corne, the lawyer representing Jesse's parents, suggested to Ward that Odim specifically told Ward not to tell the parents about the cannula. Ward testified:

I can't remember that specifically, but I think I've said on more than one and probably more than three occasions already that it's customary for us to go out and tell the parents that the child has died and that's usually enough for the parents to cope with at once. To talk about the technical issues at that first instance is usually not useful and it goes right over their head.

Q. Whether it's useful or not, Sir, did Dr. Odim tell you not to tell the parents about the cannula-the problem with the cannula?

A. I can't recall that specifically. What I'm trying to indicate to you is what we usually say is, Okay, I'm going out there. What do you want me to say to the parents? Now, specifically what was said, I can't honestly recall. But that wouldn't surprise me because it's not something that you usually address in the first instance. (Evidence of Dr. Ward, pages 187-188)

Odim testified that he could not recall this conversation. He testified that he did speak with Jesse's parents that evening.

I don't remember the specific wording, but the gist of the conversation was that we had done the operation, things were looking good, the heart was beating strongly, and there seemed to be a problem at the cannulation site, and I took the cannula out and we had to repair that area which required going back on bypass.

After we had done that, essentially the heart was not strong enough to sustain things, and that was sort of the gist of what I told Mrs. Maguire. She was obviously distraught, and I welcomed her to, at any other time, if she wanted to talk some more about things, but that's the gist of what I told Ms. Maguire when I got out of the operating room and met her. (Evidence, page 26,092)

Richard Shumila and Laurie Maguire had spent most of the day of surgery at the HSC. At approximately 1930 hours, Laurie Maguire went to the Women's Pavilion for medication. While she was away, Ward came to speak with the family. According to Richard Shumila, Ward said that there were problems weaning Jesse from bypass. Ward then went to the Women's Pavilion and informed Laurie Maguire. This was the first indication that Jesse's parents had received that Jesse's operation was not going well.

Laurie Maguire said that between 2300 and 2330 hours, Odim, Ward and Casiro came out with the news that it had not been possible to wean Jesse from bypass. She testified that "Dr. Odim was fairly cool, but Dr. Ward was crying. And, well, they-I mean it was obviously traumatic for them as well." (Evidence, page 4,155) She testified that no one spoke to her about cannulation at that time. She also testified that Ward said it would be appropriate to arrange a meeting in approximately six weeks time to discuss the issues surrounding Jesse's death. However, she said that she chose not to follow up on that offer at that time.



Current Home - Table of Contents - Chapter 8 - The operation - November 27
Next Post-mortem findings
Previous Pre-operative status
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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