The Pediatric Cardiac Surgery Inquest Report



Odim's letter of September 26

At the same time that the Pediatric Cardiac Surgery Program was returning to full operation, Odim wrote a letter to Blanchard outlining his assessment of the program. The contents and tone of this letter of September 26 suggest that Wiseman may have been too optimistic in his assessment of the work his committee had done to re-establish a measure of trust and confidence amongst team members.

Odim wrote that, when he had come to Winnipeg six months earlier as a young surgeon involved in restarting a complex and depleted program, he realized that the experience would not be easy. The letter went on to exhibit a high degree of frustration and even anger over the events of mid-May.

Within two and one-half months of my welcome here, and unbeknownst to me, there was a concerted effort by the department of anesthesia at the Children's Hospital to derail the efforts of a building, albeit fledgling, pediatric cardiac surgery program. In effect, this was accomplished by a "walk-out" and an alleged circulated memo to department heads and leaders within the Health Sciences Centre. I was not sent a copy of this memo and hence have neither read this manifesto nor did I receive the common professional courtesy of a priori discussion of their concerns. Naturally, these events have led me to question not only the commitment of these individuals to pediatric cardiac surgery, but their motives and more importantly, their character or lack thereof. In addition, I must confess that the basic trust that develops between surgeon and anesthetist as they care for a child in the operating theatre has certainly eroded [sic] by this conduct. One only hopes that this state of affairs is remediable and not irrevocable. (Exhibit 19, Document 255)

Odim testified that he was not imputing a specific motive to the anaesthetists, but was wondering aloud why they would have refused to provide anaesthetic care without first consulting him. He agreed that a lack of trust could have an effect on the course of an operation. In his testimony, Odim said that in late September he continued to trust the anaesthetists, adding:

I don't think there was an issue of trust. At the time, my sense was that it was just a personality situation, some individuals seemed to hang tenaciously to their own concepts and practice, and I attributed some of that difficulty to personality, not trust or lack of trust. (Evidence, page 25,599)

When the portion of his letter that stated that the basic trust between surgeon and anaesthetist had been eroded was read back to him, Odim testified:

Let's take a step back. The conduct is referring to the fact that they would withdraw services without the professional courtesy of discussing issues with the surgeon.

Now, if this is their typical conduct, then how do I know when I go into the battle field that issues won't be discussed with me? And that's the intent, or that's the meaning of that statement. It has nothing to do with the fact that I didn't trust them. My concern was that if they could take a step like that, without discussing things with me, then I have to be concerned that this could happen in future, in the operating room, where there is silence and no communication. And that's the background to that statement. So the conduct I'm referring to is the manner in which things had happened. (Evidence, page 25,600-25,601)

Odim wrote that during the suspension of the program, 10 children had been sent out of province, with a 30 per cent mortality rate. In actuality, 14 cases had been transferred out of Manitoba during the hiatus. He complained that during this period, the anaesthetists dictated who could undergo cardiac operations in Winnipeg. While the program was now going to be working at full service, he said, there were a number of obstacles to its long-term success. To Odim, these obstacles related to anaesthetic services.

When I arrived here in Winnipeg there was no leadership within the division or group for pediatric cardiac anesthesia. There are four part-time individuals of varying expertise and experience who participate in cardiac anesthesia at the Children's Hospital. It is difficult to figure out, on a case-to-case basis, which of the individuals is scheduled, particularly given the varying level of expertise and experience and the complexities of the cases. Furthermore, because of the limited caseload, no one of this group gets an opportunity to develop any considerable experience in order to maintain their skills in a rapidly changing field. In fact, skills in intraoperative transesophageal echocardiography, a standard throughout North America is lacking. While I am very sympathetic to their anxiety and comfort level, particularly since these individuals are all part-time who for the most part are involved in minor surgical, office based, day surgical, low anesthetic risk procedures at the Children's Hospital. Given the part-time nature of their commitment to pediatric cardiac surgery, it is quite understandable why such a group find four and sometimes five anesthetists necessary to cover 50-60 open heart procedures over a twelve month period. Unfortunately, this sharing of commitment and responsibility, dilution of experience, does not make for better patient care. When the pediatric cardiac surgery team evolved and it became readily apparent that there was no leadership in pediatric cardiac anesthesia, a spokesperson, who in my opinion has the least experience and expertise in pediatric cardiac anesthesia, was elected by vote. This is simply not a satisfactory solution. In addition, attempts to find out what the requirements are for maintaining skills in pediatric cardiac anesthesia at the Children's Hospital have been in vain. When rebuilding a pediatric cardiac surgical service commitment from all players is mandatory. Moratoriums simply skirt around the fundamental issues while rust and a loss of skills accrue from inactivity. (Exhibit 19, Document 255)

Odim then stated it was necessary to make more use of the expertise of the adult anaesthetic staff. He said there should be only two anaesthetists providing services on pediatric cardiac cases. He also believed that it might be necessary to recruit at least one of these two persons. Another solution would be to place cardiovascular anaesthesia under a single head. Odim also called for the consolidation of post-operative care.

In closing the letter, Odim stated that he would welcome an external review of the entire Pediatric Cardiac Surgery Program.

To date, our internal review process has focused primarily on surgical issues. I think an expansion of this process to include other aspects, in particular the competence of pediatric cardiac anesthesia and the requirements for maintenance of skills in these areas. I think these issues are critical if the Children's Hospital is to discard its present masquerade as a tertiary care Children's Hospital for the province and central Canada. (Exhibit 19, Document 255)

Odim testified that he was not questioning the competence of the anaesthetists; instead, he was requesting an examination that would ask if people could maintain their competence while doing a limited number of cases.

Odim provided Blanchard with both a mission statement and a summary of his proposals. The latter included the development of a single cardiovascular anaesthesia service and the move to have two anaesthetists provide care for pediatric cardiac surgery, consolidation of the two ICUs and the appointment of a nurse clinician. In addition, Odim sought to expand service into the United States and establish relations with a pediatric cardiac centre in the Third World.

Odim also wished to perform pediatric heart transplants. Blanchard said he thought that the latter point in particular was unrealistic in Winnipeg.

Blanchard testified that he was surprised at the strength of feeling in the letter. He said that he had spoken to Odim on occasion during the summer and had been left with the impression that progress was being made on the issues in pediatric cardiac surgery. Blanchard was asked:

Reading this letter, did it seem to be that perhaps that dissension, instead of being remedied by the Wiseman Committee, was ongoing and festering?

Blanchard: That's all I could infer from this. (Evidence, page 36,597)

Blanchard was then asked:

I guess what I was ultimately coming to is, after you read this letter and after you spoke to him, did you give consideration to either having-taking some steps, either an external review, slowing down the program, or doing something to get at these issues. Because if the letter is an accurate reflection of what Dr. Odim thought, it would suggest that the Wiseman Committee had not succeeded in a lot of these, in the issues in terms of inter-personal conflict. Would you agree with that statement?

Blanchard: That was my assumption. So when I spoke with him I told him, you know, that he has suggested an external review. I said that an external review is a very serious matter, and I said, you know, if there is an external review, you will come under very, you know, strict scrutiny, as well as anaesthesia or whatever other things you might be concerned about. So you need to realize that too. But I said, do you really think that the problems are of that nature?

And he said-well, I don't remember exactly what he said, but he was willing to go ahead with an external review, but at the same time he felt that the program was functioning okay. So I said, well, I will run this through the department heads, and we will talk about an external review.

Question: So based on that assurance, and I guess whatever other information you had about the program, you allowed the program to continue and then started discussions about an external review, correct?

Blanchard: Yes. (Evidence, pages 36,600-36,601)

Odim testified that several weeks after receiving the letter, Blanchard spoke to him a second time about an external review. He testified that Blanchard recommended waiting until Dr. William Lindsay arrived. Lindsay was coming to Winnipeg as the new head of cardiovascular and thoracic surgery and cardiology for both the HSC and St. Boniface General Hospital. Once he arrived, it was hoped that Lindsay might conduct a review of the program.

Odim's letter must be considered from a number of perspectives. First of all, it raises a number of quite legitimate matters. It was quite legitimate for Odim to question whether or not the program would be better served if there were only two, as opposed to four, anaesthetists. It was also quite legitimate to propose a different approach to post-operative care. Representatives from the Department of Anaesthesia did not agree with Odim's view on how many anaesthetists should provide care in the program. This was a matter of legitimate debate, just as the post-operative care issue was one on which there could be legitimate and differing points of view.

However, there is a great deal about this letter that is disturbing. Throughout the entire Wiseman Committee review, the evidence indicates that Odim acted in a restrained manner and raised only a limited number of issues. A number of witnesses indicated that he did not give any sign of having been personally wounded by what was undoubtedly a very distressing event, namely the May 17 memorandum and withdrawal of services.

Yet it is clear from this letter that the anaesthetists' withdrawal had touched him deeply. That is understandable. But many of the views expressed in this letter are little more than petulant. While Odim was not sent a copy of the May 17 memorandum, he was present at a meeting where it was discussed on the morning of May 17. He had every opportunity to read it and respond to it at that time. He seems to have stubbornly refused to do so, however.

Odim's comments on the anaesthetists' character and motives raises a more serious issue. It is not surprising that he harboured strong feelings towards the anaesthetists, but it is clear that these feelings went beyond personal dislike. In this letter he was indicating that, as a surgeon, he had lost much of his trust in them as anaesthetists. There is no indication that he raised this issue during the previous three months when the program was restricted to low-risk cases. If he had done so, then it is likely that it would have sparked a heated but needed discussion at the Wiseman Committee.

It is difficult to believe that the committee could have concluded that the program was ready to go back to full service if Odim had tabled such a letter or given voice to the sentiments in the letter at a committee meeting.

It is clear that Blanchard also found this letter disturbing. When Blanchard distributed the letter to them at the end of October, Postl and Craig were also disturbed by it. It was clear to all of them that an external review was necessary. Their intention was to have Lindsay conduct this review.

The letter, however, should have led Blanchard to question the wisdom of allowing the program to remain at full service. It would have been the proper thing to immediately speak to Wiseman and to have asked for his views on the issues it raised. Blanchard also should have distributed it to the other department heads immediately, instead of waiting until the end of October to show it to them.



Current Home - Table of Contents - Chapter 8 - Odim's letter of September 26
Next September 27-the case of JB
Previous Wiseman's memorandum to the department heads
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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