Replacing Duncan

Dr. Helmut Unruh, as the acting head of cardiovascular and thoracic surgery at the HSC, played a central role in recruiting a replacement for Duncan.

Unruh had graduated in medicine from the University of Manitoba in 1977. He completed his residency in general surgery in Manitoba in June 1980 and trained in thoracic surgery for a year in England. From July 1984 to December 1984, he was a clinical fellow in cardiovascular and thoracic surgery at Montreal General Hospital, which was affiliated with McGill University. While at McGill, Unruh had worked with Dr. David Mulder, the chairman of that department, Dr. Tony Dobell, the department's program director, and Dr. Ray Chiu, the department's director of research.

Unruh's specialty was in thoracic surgery, as opposed to cardiac surgery. A thoracic surgeon's field of practice is limited to doing everything in the thoracic (or chest) cavity except cardiac surgery. While at one time thoracic surgeons had combined the specialties of cardiac and thoracic surgery, each field had evolved over time into separate specialties.

After finishing his training at McGill, Unruh returned to Manitoba in January 1985, and was appointed an associate staff member of the Department of Surgery at the HSC. He was concurrently appointed assistant professor in the Faculty of Medicine at the University of Manitoba. He became an active staff member of the Health Sciences Centre's Department of Surgery in 1988 and was the service chief of thoracic surgery from 1988 to 1995. In 1993, he also became a staff member of St. Boniface General Hospital, in its Department of Surgery.

In 1988, Unruh was appointed the acting section head of cardiovascular and thoracic surgery in the Faculty of Medicine. Following Parrott's departure, Unruh was appointed to a concurrent position as the acting section head of cardiovascular and thoracic surgery at the Health Sciences Centre. In the latter capacity, Unruh was responsible for the day-to-day management of the cardiovascular and thoracic section of the Department of Surgery at the HSC.

The search committee

Dr. Robert Blanchard, the head of surgery, believed that it would be difficult to attract a capable candidate for pediatric cardiac surgery to Winnipeg and it would be even more difficult to retain such a candidate. In a letter to Manitoba's Health Minister, Don Orchard, dated March 30, 1993, (Exhibit 25, Document 93/3), Blanchard wrote that Unruh was initiating contacts to see who might be available to be recruited as a replacement.

A meeting was held on April 19, 1993, between Collins, Blanchard, Unruh and Bishop, to discuss Duncan's replacement. According to the minutes (Exhibit 18, Document 233), the discussion focused on the savings that the province would realize by not having to send children out of province for treatment and by the general benefits that a pediatric cardiac surgeon provided to the HSC. If the HSC was to continue to evolve into a full-service tertiary-care hospital, it was thought that pediatric cardiac surgery should be offered to the public. For those reasons the group decided that Duncan should be replaced and the program should be maintained.

The minutes of that meeting stated that "Dr. Unruh was encouraged to continue his efforts to recruiting a pediatric heart surgeon." (Exhibit 18, Document 233) Since a pediatric cardiac surgeon would be appointed to the Department of Surgery, and to that department's cardiovascular and thoracic section, Blanchard and Unruh played the lead roles in identifying candidates.

The evidence provides differing interpretations of that recruiting process. Unruh said that there was a three-person committee, consisting of himself, Blanchard and Collins involved in the appointment of the new surgeon. He also said that Collins's role in the committee was pivotal, since he spent more time with the candidates than either Unruh or Blanchard.

Collins, on the other hand, testified that he was not part of the search committee, although he said that he was consulted about all the candidates and met with most of them. Unruh, Blanchard and Collins all agreed that no candidate would have been accepted without Collins's approval. Although Blanchard and Unruh communicated with each other by letter on the recruitment process, they generally did not provide Collins with copies of their correspondence. It would seem, therefore, that the process involved Unruh finding a suitable person, vetting the name with Blanchard, and seeking Collins's final approval. It would be less than accurate to say that a formal search committee was in place.

The recruiting followed both a formal and an informal process. Advertisements were taken out in various medical publications and Unruh began working his network of contacts in the world of cardiac surgery. By May 1993, he had come up with a list of potential candidates. According to Blanchard, Unruh was expected to do the initial interviews by himself and pass on those candidates who he believed should be considered.

During this period, Unruh had heard rumours that Collins was going to leave the HSC, but he did not believe them. Therefore, Unruh never told any of the people applying for the position of the significant changes that were taking place at the VCHC.

In late April or early May, Dr. Ray Chiu, one of Unruh's former colleagues at McGill, introduced him to a former student of his, who was looking for a position as a pediatric cardiac surgeon. The meeting took place in Chicago at a cardiovascular and thoracic surgical conference. The doctor Chiu was recommending was Dr. Jonah Odim.

Dr. Jonah Odim

Odim was a U.S.-trained doctor who had undergone a portion of his training in Canada. After graduating from Yale Medical School in 1981, he interned at the University of Chicago. From 1982 to 1987 he was a resident in general surgery at the University of Chicago. As a part of his training there, he participated in pediatric cardiac surgery. During his stay at Chicago he rose from the position of junior resident to senior resident, eventually becoming the chief resident in 1985. During the two years that he held this position, he was not extensively involved in cardiac surgery.

Following the completion of this residency, Odim could have gone into practice as a general surgeon. However, he had been attracted to cardio-thoracic surgery and sought additional training.

For this training he went to McGill University in Montreal, where he was a resident in cardiovascular and thoracic surgery from July 1987 to June 1989. His training at McGill followed a series of six-month rotations. From July 1987 to January 1988 he was in general thoracic surgery at Montreal General Hospital. In this position he often acted as the primary surgeon.

From January 1988 to July 1988 he was involved in pediatric cardiac surgery, also at the Montreal General. At that time Dr. Christo Tchervenkov was the dominant pediatric cardiac surgeon there, working under the tutelage of Dr. Tony Dobell, who was then on the verge of retirement. Dobell was training Tchervenkov to take over his position within the hospital.

During this period, Odim assisted at Tchervenkov's operations, usually as a first assistant. In simple cases, Tchervenkov allowed Odim to perform the operations with his assistance. As an assistant to Tchervenkov, Odim told the Inquest that he was responsible for getting patients into the operating room, putting in all of the lines, inserting the Foley catheter, prepping the patient, draping the patient, making the incision and starting to open the chest. He would assist with cannulation, although in some cases he completed the entire cannulation process. Odim estimated that at McGill there were approximately one hundred bypass cases a year. He also said that in his experience there were only two anaesthetists who worked on these cases.

From July 1988 to January 1989, Odim was Chief Executive Resident at Montreal General Hospital. For the following six months he was at Montreal's Royal Victoria Hospital where he did adult cardiac surgery. He stated that by the end of the rotation he was doing most of the cases with the assistance of the staff surgeon. However, because he was still in training, he was required to be under the supervision of a senior surgeon when performing surgery. Following this training he undertook the appropriate examinations of the Royal College of Physicians and Surgeons of Canada and qualified as a cardiac and thoracic surgeon in 1991.

At this point, Odim chose not to go into practice. Instead, he was encouraged by Chiu, who was also at McGill, to complete a three-year research project leading to a Ph.D. This research involved using skeletal muscle, as opposed to cardiac muscle, to rebuild and power failing hearts. This was intended to provide a treatment for people who were in the end stage of heart failure and had been turned down for heart transplants.

Odim explained that the decision to go into research was not unusual for someone who, as he did, intended to work in a teaching hospital setting. While the work with Chiu largely revolved around animal research, there were six patients whose treatment, as a part of the research project, required cardiac surgery. Odim was the first assistant in these operations. When asked if he worried about any erosion of his surgical skills during this three-year period, he said:

I was doing a lot of bypass work in the animals, using the same techniques that I would be doing in the human operating room. So I wasn't, I was attending all of the conferences, I was making rounds. (Evidence, page 23,887)

In addition, he said, he assisted Chiu in a number of emergency operations.

Following the completion of this period of research in 1992, Odim decided to take further training in pediatric cardiac surgery. He was accepted as one of five residents at one of the world's leading centres for such surgery, Boston Children's Hospital, which is affiliated with Harvard University.

The residency at Boston Children's is broken down into two six-month periods: the first six months being clinical in nature, the second six months consisting of clinical research. The six months of clinical work is devoted almost exclusively to work in the operating room and intensive care. Working on a series of week-long rotations, one resident would work in the intensive care unit, while the other four worked as either first or second assistants in the operating room. At Boston Children's there were two operating rooms devoted to pediatric cardiac surgery, and a total of four operations would be performed every day. Two residents were assigned to each operating room. Each resident would serve as first assistant on one operation and second assistant on the other operation.

Odim gave the following description of the responsibilities of a first assistant:

In general the responsibility was to get the patient in the operating room to start at 7:30 sharp. You put in the lines, cut down for an arterial line, you assisted the nurses with scrubbing the patients. And you began to open the chest and isolate the great vessels, prepare for cannulation. And usually around that juncture, depending on how efficient you were, the staff man would be entering the room, and once he was scrubbed up, he would come to his side of the table and you would switch and the case would proceed. (Evidence, pages 23,895-23,896)

He said the assistant would normally have accomplished the following steps by the time the surgeon arrived in the operating room.

You would have opened the chest, opened the major skin incision, opened the sternum. You would have removed the thymus, which is a gland that cloaks the inlet of the chest cavity. You would have opened the pericardium, and you would have dissected out the great vessels. You might have put your purse strings in and you may have even begun to cannulate. (Evidence, page 23,896)

According to Odim, he had quite a bit of experience during this time with cannulation. He gave the following description of the work of the first assistant during the course of the operation.

You have to guide the surgeon. You have to know the steps and be ahead of him so that you are prepared, which means spreading tissue, applying counter traction, so that the path way is open for him to see, tying sutures, cutting sutures, removing clamps, decannulating, all of those types of things are done by the first assistant. (Evidence, page 23,898)

In this passage, 'guiding' means anticipating the surgeon, not providing the surgeon with direction. Following the operation, the first assistant might carry out decannulation. Odim said that, for the most part, none of this was new to the residents. Instead they were "learning some of the nuances from some of the leaders in the field." (Evidence, page 23,901)

In certain situations, Odim performed a number of operations as the primary surgeon. These included what he called simple cases, such as repairing atrial septal defects. The attending surgeon would act as the assistant in these operations, but would always be in a position to take over from the resident if anything problematic occurred.

Odim described Boston Children's Hospital as being unique in terms of its manpower and resources. Most of the operations that were performed there were complex re-operations. There were only two to three anaesthetists who, as far as Odim could discern, did almost exclusively pediatric cardiac work. There was also a separate pediatric cardiac intensive care unit.

Recruitment

Odim was half way through this clinical rotation when Chiu introduced him to Unruh at the Chicago conference. The two men spoke about the Winnipeg program for over an hour. According to Unruh, for Odim the conversation would have felt like an interview. Unruh was impressed with Odim.

He had an excellent deportment, presented himself very well, had a very impressive background, general surgery at the University of Chicago, cardiac surgery at McGill University, potential Ph.D. from that institution. And now he was at one of the foremost Children's Hospitals in the world, at Harvard. I was very impressed with him in terms of his preparation for the job and also in the way that he conducted himself during the interview. (Evidence, page 35,016)

Odim was at that point starting to look for a position as a pediatric cardiac surgeon and had job prospects in both Chicago and Buffalo, New York.

Blanchard believed that the HSC could recruit one of three types of surgeons for the pediatric cardiac post available at the Children's Hospital. One would be a surgeon who was looking to wind down his or her career, the second type would be a surgeon at the peak of his or her career and the third would be a new surgeon looking to start his or her career. He said that the first option would not be preferable for a teaching hospital, since a surgeon at this point in his or her career would not be sufficiently up to date. It was thought to be unreasonable to expect to recruit a surgeon at the peak of his or her career to a program in which the surgeon would operate on his or her own. It was believed that the best results would come from recruiting someone at the start of his or her career. Given the fact that the HSC was a teaching hospital, a new surgeon with a research background would be the first choice. Such a person, Blanchard said, would keep the HSC on the cutting edge.

Of the candidates that the HSC was interested in, one took a position with the University of British Columbia, while another candidate did not have the research background that Blanchard was looking for. As a result, the search began to focus on Odim.

Unruh said that he conceived his role in the recruiting process as that of a facilitator.

Well, a lot of this was being spearheaded by Dr. Blanchard, the chairman of the department. My process was really to assist him, and he delegated certain activities to me. (Evidence, page 35,033)

As a part of the recruiting process, Odim was brought to Winnipeg in August 1993. The visit was to allow Odim to meet with the people involved in the VCHC program and allow them to assess him. During that first visit, Odim was introduced to many of the people involved in the treatment of children with heart disease, including operating-room nurses, intensive-care staff and anaesthetists. He also met with both Collins and Giddins.

Blanchard and Unruh both told the Inquest that they expected Collins to assess Odim's clinical skills. Unruh also expected that Giddins would play a role in assessing Odim's surgical skills, although Unruh also said he did not know how Collins and Giddins had gone about assessing Odim's surgical skills. Blanchard described his conception of his role in the recruiting process in the following terms:

So that generally my role would be relating to the academic realm as the academic head because there are a lots of other people in the clinical realm that will be dealing with that, that would have closer touch with that.

Consequently my concerns about research, teaching; and then my other role is to outline carefully and clearly and completely to the individual, you know, how the organization runs and what their role is in it and what the fiscal arrangements could be. I mean that's how it works and that's what this is. (Evidence, page 36,372)

Odim's name had come up in a conversation between Collins and Dobell before the recruiting process had started. However, Collins never contacted Dobell for an assessment of Odim's skills. Collins was familiar with Dobell, having worked with him at McGill.

So I had good reason to believe that anyone who survived Tony Dobell's training program had been through a rigorous training. (Evidence, page 33,205)

Collins said he spent several hours with Odim during that first visit, and the two men had a meal at a Winnipeg restaurant. During their conversation, Collins never informed Odim that both he and Pelech would shortly be leaving the VCHC. (Pelech's replacement, Dr. Cameron Ward, was not expected to arrive until the summer of 1994.) Collins also spent a considerable amount of time with Odim when he returned for a visit in the fall.

Letters of reference

Unruh said that under the HSC's protocols, the process of obtaining and checking on references was Blanchard's responsibility, not his. As a result, he did not call Boston Children's Hospital to ask any questions about Odim's performance. Nor did Unruh ever see any of the letters of reference dealing with Odim.

Unruh said that, if he were hiring someone who would be directly responsible to him, he would contact the program director and ask how the person had performed in the residency. He thought this would be much more important than letters of reference. Unruh said he believed that Odim's clinical work in Boston was satisfactory because if it had not been, "his time there would have been cut short." (Evidence, page 37,643)

When Odim applied for the position with the HSC, he gave three references. They were from people who had been involved with Odim during his research at McGill. Blanchard and Unruh both said that they did not put as much value on letters of reference as on informal contacts with the authors of the letters. In some cases they believed a letter writer might be either overly cautious in describing a candidate's skills or overly generous. This, they felt, was less likely to happen in personal conversation.

Chiu sent Blanchard a strong reference for Odim on August 30, 1993.

He is a competent and skillful clinical surgeon, and with additional training at Boston's Children's Hospital, I suspect that he has become a capable pediatric as well as adult cardiac surgeon. Thus, I believe that potentially he could be a strong addition to your excellent team. (Exhibit 45, Document HSC 11)

Chiu continued to express support for Odim in a follow-up phone call and a second letter. In the follow-up letter he did state:

I cannot make a specific judgment regarding his clinical abilities as a pediatric cardiac surgeon, but as I stated in our telephone conversation, he has gone to Boston Children's Hospital for a clinical fellowship, and I have no doubt that he has benefited from further exposure to complex pediatric cardiac surgical cases available there. (Exhibit 45, Document HSC 23)

Mulder, the chairman of the Department of Surgery at McGill and Montreal General, sent Blanchard a letter on September 2, 1993. In it he wrote:

I would rank Jonah as a good clinical cardiovascular thoracic surgeon who wishes to carry out a combined adult and pediatric practice in an academic centre. He has the ability to carry out independent research. (Exhibit 45, Document HSC 14)

He went on to say:

He has good leadership skills and I think has all the potential to become an outstanding academic cardiovascular thoracic surgeon. (Exhibit 45, Document HSC 14)

In a second letter on November 11, 1993 (written after an offer of employment had been made to Odim), Mulder wrote:

Technically he was not as mature as some of the other residents have been but he improved on a gradual basis and at the completion of the program we all felt that he was a competent cardiothoracic surgeon. (Exhibit 45, Document HSC 28)

Mulder suggested that Blanchard contact Dr. Aldo Castaneda, Odim's supervisor in Boston. Blanchard tried, but Castaneda was out of the country. As a result, he never spoke with Castaneda or anyone else at Boston Children's.

A letter dated November 24, 1993, from Tchervenkov to Blanchard, contained the following comment.

As far as training goes, he has certainly had more than enough. As far as whether he can really be successful at today's pediatric cardiac surgery approach, that is always the question for anyone until they actually prove themselves. I have seen, what were considered excellent surgeons with excellent training in pediatric cardiac surgery bomb out. (Exhibit 245)

He concluded the letter by noting that, as a single surgeon in Winnipeg, Odim would have a rough start.

Blanchard said that he never received any indication from Chiu, Mulder, or Tchervenkov that Odim was in any need of remedial training. A review of Odim's training and experiences prior to Winnipeg led Blanchard to a simple conclusion:

Here we have a brilliant person. (Evidence, page 36,424)

Odim returned to Winnipeg in the fall for a second round of meetings with HSC staff. It was at this point that Collins informed him of his intended departure from the VCHC on October 31. It was also at this point that Odim learned that Pelech was leaving. Blanchard and Unruh had been recruiting a surgeon for a fully operational program, led by a veteran medical director and staffed with three cardiologists. In fact, the surgeon they were hiring would be coming to work at a centre that had only an acting medical director, who was also its only cardiologist.

Surprisingly, it was Odim who informed Blanchard that Collins was leaving. It was not clear when, or if, Blanchard was ever informed of Pelech's departure. Blanchard said that it was not until February 1994 that he discovered that there was only one cardiologist at the VCHC.

In September 1993, Odim and Blanchard entered into serious negotiations. Arrangements were being made to give Odim a cross-appointment to the University of Manitoba's Department of Physiology to allow him to continue with the muscle research he had started under Chiu.

Besides arranging Odim's research, Blanchard and Unruh had to devise a method that would pay Odim a competitive income of approximately $250,000 a year. They managed to do this through a special agreement with the Dean of the Faculty of Medicine, the President of the University of Manitoba, and the HSC administration. Unruh said he believed that Odim had been in a strong bargaining position and had bargained effectively.

As these discussions were taking place, Blanchard made an effort to recruit Tchervenkov to Winnipeg. He offered Tchervenkov the position of head of cardiovascular and thoracic surgery, the position that Unruh held on an acting basis. Had the hiring gone ahead, it would have placed the need to hire Odim in doubt. It also, interestingly, amounted to a change in the strategy of hiring a recent graduate, to one of hiring a surgeon in the prime of his career. Tchervenkov, however, declined the offer.

A formal offer was made to Odim on November 9, 1993 (Exhibit 45, Document HSC 25). One week later his appointment was confirmed. It was signed by Blanchard, Sutherland and the Dean of Medicine, Dr. N. Anthonisen.

The Boston references

Dr. John Mayer, Jr.,² was one of the surgeons at Boston Children's Hospital under whom Odim received his training. Mayer estimated that he would have been the attending surgeon for about a quarter of the operations that Odim was involved in while at Boston. In his testimony to this Inquest, Mayer stressed that the assessment of an individual trainee's skills is not absolute, because at that stage in their career people have a capacity to continue to grow and develop. That said, Mayer offered the following assessment of Odim's performance at Boston.

I would say in the spectrum of people that we have seen, you know, at ten residents a year, or at that time-it is almost ten years, having seen 100 cardiothoracic surgical trainees go through, I would have to say I would not have put him near the top of the group of the people that we had seen. (Evidence, pages 46,044-46,045)

Mayer said he was not entirely convinced that Odim had fully grasped some of the concepts that were being employed. From a technical standpoint, he said:

I was never that comfortable helping him do anything more than relatively simple and straight forward cases, simply because I was not comfortable with his level of technical skills. (Evidence, pages 46,045-46,046)

In the case of Norwoods, he said all he would have allowed Odim to do was open and close the chest, and it was unlikely that he would have allowed him to perform the complete cannulation process on his own.

The actual resident evaluations at Boston Children's Hospital were informal and were done by Castaneda, the program head. Mayer said he never spoke with Odim about his progress at Boston Children's Hospital, nor about the sort of institution he should consider going to after graduation.

Odim's training at Boston Children's Hospital was one of his main qualifications to justify his assumption of the job as the sole pediatric cardiac surgeon at the Variety Children's Heart Centre. Castaneda's name appears on his list of references. However, no one ever successfully contacted Castaneda or any other of the doctors under whom Odim trained in Boston.

Mayer said that if he had been contacted, he would have said that Odim "was not among the stronger candidates that we have ever seen come through our program." (Evidence, page 46,055) He said he would have rated his clinical knowledge as being from fair to good.

In his testimony, Mayer described the pediatric cardiac surgery program at Boston Children's Hospital. The centre's four surgeons perform an average of between 900 and 1,000 operations a year. There is a pediatric cardiac intensive care unit. The nurses work only on pediatric cardiac surgery, the perfusionists provide services only for pediatric cardiac patients and the anaesthetists work only on pediatric congenital heart cases. A tremendous amount of expertise and skill is focused on this one area.

Mayer was of the view that it would be very difficult for a young surgeon to move from this atmosphere to a much smaller centre, where he or she would be the senior surgeon responsible for restarting a program.

And I think to go someplace and start it up from scratch is an extraordinarily challenging undertaking.

I have been to some places where I have been asked to go and review programs in certain centres in the United States, where I think this is not an uncommon theme that, you know, people will have had some experience perhaps in one facet of the management of congenital heart disease, a cardiologist or surgeon, or one group, and think therefore they can recreate what they had in their original training centre very simply and easily. In fact, it's a fairly sizable undertaking to assemble the organization and the group of people who play on this team, who have to provide the services. And I think that this notion of the group functioning as a team is an absolutely critical aspect of optimum management of children with congenital heart disease, particularly babies. (Evidence, pages 46,061-46,062)

Before a young surgeon were to take on this responsibility, which Mayer described as "jumping off into the most complicated end of the spectrum," he said there should be a critical assessment of the centre's capabilities and the surgeon's capabilities, both as a surgeon and as a team leader.

I can tell you that having been a few places where people bit off big chunks and then had quite a bit of difficulty, that that is a common theme, that there was not an appreciation of what it really takes from the whole team perspective to be able to carry off the kinds of complicated things that have to be done. (Evidence, page 46,063)

HSC reference questionnaires

The HSC sends reference questionnaires to those persons whom a job applicant has listed as references. In the case of Odim, the questionnaires were sent to Chiu, Mulder and Tchervenkov. All three men gave Odim a positive assessment, ranking him as being very good in almost every category. Two of the three, however, rated him as being good (as opposed to very good) in his clinical competence. While it is not clear when the questionnaires were sent to the referees, they were not completed and returned until late February 1994, long after Odim had received his appointment with the HSC. The one person on the list of references provided by Odim who was not contacted was Castaneda.

It would be safe to say that Odim's recruitment and hiring was marked by flawed procedures.

No one spoke with the people who had been most recently involved in Odim's training at Boston. Considering Mayer's very lukewarm assessment of Odim's surgical skills, it is conceivable that Odim might not have been hired had that type of information been in the hands of those making the hiring decisions in Winnipeg in 1994. The failure to watch and observe Odim actually performing surgery, or to speak with anyone who had recently performed surgery with him, provided only an incomplete impression of Odim's surgical abilities and his ability to get along with other personnel in the operating room. That proved to be an extremely important issue as 1994 passed.