The Pediatric Cardiac Surgery Inquest Report



September 27-the case of JB

On September 27, JB, a six-month-old child, underwent surgery to close a ventricular septal defect and an atrial septal defect, and to ligate a patent ductus arteriosus. Surgery was complicated because she suffered from pulmonary hypertension.

In this operation, Odim was assisted by both Hamilton and Hancock. According to Wong, who provided the anaesthetic, the operation was marked by problems with cannulation.

Wong testified that the patient ran into trouble during insertion of the venous cannula. At that point, he said, there was a significant loss of blood and a drop in blood pressure. He attempted to raise the blood pressure by treating JB with medication, but was becoming worried that JB would arrest before she could be placed on bypass. "So I said to the surgeons, if you don't get this child on bypass now, this child is going to die." (Evidence, page 19,923) Wong testified that the surgical field was full of blood, the team had initiated sucker bypass and the patient had not been cannulated. Shortly after that, the child was successfully cannulated and the operation proceeded.

In their evidence Odim, Hancock and Hamilton said they could not recall problems with cannulation in this case. The PICU resident's notes corroborate Wong's version of events, in that they indicate that, on transfer of the patient to the PICU, Wong told her that there had been difficulties with cannulation and sucker bypass had been instituted.

JB was discharged on October 18, 1994.



Current Home - Table of Contents - Chapter 8 - September 27-the case of JB
Next The September 28 meeting of the Wiseman Committee
Previous Odim's letter of September 26
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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