The Pediatric Cardiac Surgery Inquest Report



September 20-the case of ML

ML was an 11-month-old child who underwent an open-heart procedure on September 20, 1994. She had originally been scheduled for surgery on May 19, 1994, but her operation was deferred because of the hiatus in the program.

This procedure included:

  • creation of a bilateral, bi-directional cavopulmonary anastomosis
  • ligation and division of a right modified Blalock-Taussig shunt
  • ligation and division of a rudimentary main pulmonary artery
  • ligation and division of the patent ductus arteriosus.

Youngson and McGilton acted as scrub nurses for this operation. McNeill was the anaesthetist, while Hinam provided anaesthetic nursing services.

In her testimony, Youngson said that ML arrested during the attempt to take her off bypass. At this point the aortic cannula came out. Youngson testified:

Now, when we secure a cannula, when we cannulate initially, the aortic cannula is secured with a heavy piece of silk. It's what we call a super stitch. It's just a real heavy piece of silk that is tied around the cannula and sutured into the patient. So it holds that cannula in place so it doesn't come out.

In all this excitement, I don't think that super stitch was put in. So the cannula came out. (Evidence, page 8,600)

According to Youngson's testimony, there was a danger that air would enter the cannula if it was being re-inserted quickly, as it was in this situation, and time was not taken to clear any air from the tip of the cannula. Youngson testified that she felt it necessary to remind Odim to de-air the cannula.

ML was put on bypass for a second time. At that point, the team did not know why she was arresting. After approximately half an hour, there was a second attempt to wean her off bypass. Once more her heart began to arrest.

According to Youngson's testimony, Odim seemed to think the arrest was being caused by a reaction to protamine or to blood products. Youngson testified that Hamilton disagreed, saying that it was something the surgeons were doing in the operative field that was causing the problem. McNeill, McGilton and Hinam corroborated Youngson's account of the difference of opinion between Odim and Hamilton over the cause of the arrest. McGilton testified that Hamilton stated that the arrests were linked to the surgeon's touching a certain part of ML's heart with the forceps. Eventually ML was weaned from bypass.

Youngson observed that ML had experienced considerable bleeding throughout the operation. She felt the child should not have left the OR until the bleeding was controlled. Despite these concerns, ML was taken to the PICU. Hamilton could not recall this case, and Odim was not asked about it.

ML was sent to the PICU without her sternum being closed. She had a lengthy stay in the PICU, and the first night was particularly difficult. Dr. Murray Kesselman attended ML in the PICU. Her significant bleeding problems continued from the time of her arrival until the next morning, requiring constant attention and blood transfusion. In addition, she had a difficult time with hypotension (low blood pressure) related to her ongoing bleeding. Kesselman called Odim back to the unit several times during the evening, to look for the cause of the bleeding. For the first few times, Odim said, the bleeding was the result of a coagulopathy. Kesselman was not certain that that was the case; however, he testified, "The surgeon comes and looks around and says there is nothing for me to suture. So, that's what you go with. That's what you have to deal with and cope with." (Evidence, page 34,067)

ML's condition did not respond to treatment for coagulopathy and, in Kesselman's opinion, she was in serious danger from ongoing blood loss. She suffered a cardiac arrest late that night, but was resuscitated. At about 0700 hours the next morning, Odim sutured blood vessels in ML's chest and the rapid blood loss stopped. This clearly suggests the blood loss was surgical and not a coagulopathy, as Odim had earlier insisted. From then on, the PICU team was able to stabilize her. She was discharged on October 16.



Current Home - Table of Contents - Chapter 8 - September 20-the case of ML
Next Wiseman's memorandum to the department heads
Previous Dr. Brian Postl is appointed head of pediatrics
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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