The Pediatric Cardiac Surgery Inquest Report



The end of September: the nurses are distressed

By the end of September, many of the nurses were once more disturbed and distressed by the operation of the Pediatric Cardiac Surgery Program. Joan Borton, a nurse clinician with the VCHC, was so troubled that she sought to limit her involvement with the parents whose children were being treated at the VCHC. Her lack of confidence in the program increased when she overheard Odim and Giddins discussing a recently completed operation, with Odim expressing surprise to discover that the child's anatomy was not what he had expected.

She also testified that in September she spoke with Kesselman and concluded that he had doubts about the program as well.

Because the comment that I remember him making was that none of his family or his friends would be done at Children's Hospital at this point in time. I said, yes, but, Murray, that's what I have a problem with, if we wouldn't allow our own children to be done in this hospital, why do we allow other people's children to be done? It should be the same.

Q: His response to your comments?

A: He nodded his head. He didn't verbally say anything after that. (Evidence, pages 18,233-18,234)

In his testimony, Kesselman had indicated that he was satisfied with the Wiseman Committee procedure and its outcome. He was not questioned about this conversation with Borton.

Donna Feser, a senior PICU nurse, testified that the PICU nurses were not informed about the decision to take on high-risk cases in the autumn. They could, however, tell that there was a change from the types of cases that were being scheduled. This gave rise to considerable anxiety among the nursing staff, since they expected high-risk children to return from the OR in poor condition.

Feser gave this description of her memory of the fall of 1994.

For me that's when everything started to blend together that fall. My anxiety level got to the point, from my perspective I started to get into a position where I was, I would call it a functional role. I was having such a difficult time dealing with all of the emotions from what I was seeing in the unit, the sick kids were coming out with so many complications and so many-especially all of the open chests and all of the pacemakers that were, extra pacemakers that we were seeing. We were seeing kids that were really very, very sick, much sicker than we were used to seeing from the previous program.

I mean, like I said, it got to the point where I really had a difficult time in even wanting to come to work, because I really felt, every time I came to work I was feeling quite sick. It was very difficult to see these kids struggle, struggle to survive, see these parents suffer, you know, see them, you know, bring their children into us and, you know, trusting us and hoping for the best. And you know, there were many deaths that we had a very difficult time dealing with. (Evidence, pages 30,002-30,003)

She said that, in the past, she would not expect a child with a VSD to arrive in the PICU with an open chest, with excessive bleeding, with clots, or with a need for a pacemaker, but that was the way they arrived during the period when Odim was operating.

Youngson testified that she also attempted to change her role to limit her contact with parents at about this time. She had already decided that she was not going to be involved in pediatric cardiac cases after February 1995, if things continued as they were. She had even considered telling parents to "take your baby and run." (Evidence, page 8,779) She found it hard to take the children from the arms of their mothers and carry them into the operating room.

When asked why she did not warn parents away from the program when she had so many doubts about it, she said:

Well, first of all, when I see these parents, we are literally at the door of the operating room. They have gone through all of the pre-op teaching sessions, they have gone through all of the stress of preparing themselves for this particular event, and I can't imagine anything could be more stressful for a parent than something like this. I could sort of paint a picture of what it would be like if I had gone out to this parent and said, stop, you can't do this, take your baby and run or whatever. I wouldn't have said it like that, but just don't take this child, I don't want to take your child in.

What would have happened then would have been that all hell would have broke loose. They would have called Dr. Odim, they would have called Dr. Wiseman probably, called the director of nursing up. There would have been this big group of people come to this, wherever we were, waiting room or wherever. I would have been very upset by then, probably crying. There would have been Dr. Odim and Dr. Giddins and whomever, calm, cool, collected. I would have looked like an over emotional, almost crazy person. You know, they would have just thought, they would have talked to the parents, they would have said, maybe this nurse is just overreacting, maybe she is over emotional.

As a parent, I think it would depend on the parents, would they have listened? Maybe they would have backed off, maybe they would have said let's wait another day and rethink this. Maybe they would have listened to Dr. Odim, listened to Dr. Giddins, whom they knew and had met several times before, and don't forget they are just meeting me for the first time at that point. I don't think it would have done any good. I think perhaps I could have saved that one child, and I still think about that from time to time. But there would have been more kids come in, the next kid-I would have been out of there. I would not have had that job any more. I would have been out of there. The program would not have stopped, and there would have been more kids come in the next day or the next week. And nothing good would have come out of that. (Evidence, pages 8,779-8,780)

Given that there is a growing expectation that nurses act as patient advocates, and take an oath to conduct themselves with honesty and integrity, safeguard the quality of nursing care and protect patients from unsafe, incompetent or unethical care, some might argue that Youngson should have spoken to the parents about her concerns.

However, as she indicated, she was in a very difficult position-and was essentially torn between her professional responsibilities and her growing moral qualms. She and the other OR nurses cannot be faulted for their actions. While nurses are expected to act as advocates, the expectation is that they restrict their actions to those areas that they are professionally competent to judge.

Secondly, there is an expectation that they would take their concerns about a fellow medical professional to that professional first. If the concerns continue, the expectation is that the nurse would then speak with a supervisor, who would then deal with the matter or move the matter further up the line of responsibility. If this fails to bring about a satisfactory resolution, the nurse would then be expected to report the matter to a professional licensing body.

When a matter lies outside a nurse's specific area of expertise (nursing), the general expectation has been that the nurse would not take concerns directly to patients or the parents of patients. When Youngson had raised any concerns with Odim, she had not found him receptive. She had also raised her concerns repeatedly with her own supervisors.

They, in turn, had acted appropriately: Karin Dixon had brought the concerns to the attention of Isobel Boyle, and Boyle in the spring of 1994 had brought the concerns to the attention of Bishop, Wiseman and, according to Boyle's testimony, the responsible vice-president, Susan VanDeVelde-Coke. Once the Wiseman Committee process had moved the program back to doing high-risk cases, Youngson and other nurses had good reason to believe that their voices would not be heard. While they continued to raise their concerns with their supervisors, the ineffectiveness of that process drove Youngson to consider taking her concerns to the broader public.

To recap: within weeks of the program resuming full activity, it appears that the surgeon had no faith in the anaesthetists, that many of the anaesthetists were alarmed by the events in surgery and that some nurses were concerned about the morality of their continued involvement with the program.



Current Home - Table of Contents - Chapter 8 - The end of September: the nurses are distressed
Next Whistle-blowing
Previous September 30-the meeting of 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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