Issues for the Variety Heart Centre

There were a number of ongoing issues that Collins attempted to have addressed, during his tenure as director of the Variety Children's Heart Centre.

Operating rooms

The operating room that was used for pediatric cardiac surgery had space, ventilation and temperature-control problems. While improvements were made, the state of the operating room was never deemed to be satisfactory. Despite the improvements, Theatre 2 was judged to be small by witnesses who appeared before this Inquest. The theatre was cramped because of all the specialized operating room equipment required, such as the perfusion pumps, and the greater number of team members necessary. In addition, problems with temperature control frequently led to fluctuating operating room temperatures. This made it more difficult to control a patient's temperature, always a critical issue in pediatric anaesthesia.

The VCHC offices

Pediatric cardiology had originally been housed in the basement of the Children's Hospital, and much of its equipment dated back to the early 1960s. The VCHC was eventually housed on the main floor of the HSC's Community Services Building, which is across William Avenue from the Children's Hospital building. By the time Collins left, he testified, the VCHC was the best-equipped centre in the country.

However, the state of medical technology was always evolving, particularly in the field of cardiac services. In order to maintain its status as a state-of-the-art facility, it was important for the centre to be able to make regular equipment and technological purchases. This was a constant challenge for the centre.

The medical fee schedule

Medical fees paid to physicians in Manitoba are paid in accordance with a fee schedule negotiated from time to time by the Manitoba Medical Association (MMA) and the Province of Manitoba.

The MMA fee schedule in place during Duncan's and Collins's tenure did not, in their opinion, reflect the development of the specialty of pediatric cardiac surgery. When the fee schedule had originally been set, pediatric cardiac surgery was a limited field, particularly when compared with adult cardiac surgery. As a result, fees paid to surgeons for pediatric cardiac procedures were generally lower than were those for adult procedures.

Additionally, even where the fees for each procedure were comparable, because the number of pediatric cases in Manitoba was considerably lower than the number of adult cases an adult surgeon could perform, the potential income for a pediatric cardiac surgical specialist was far lower than that for an adult surgical specialist. Duncan made far less money performing a pediatric cardiac operation of considerable complexity than he did for assisting at a simpler adult procedure for which he had no post-operative responsibility. The lack of resolution of this issue eventually contributed to Duncan's decision to leave Manitoba in 1993.

Relations with adult surgery and the hospital administration

Because he was the only pediatric cardiac surgeon in the city (other than Barwinsky, who still did not perform any cases of complexity nor cases involving neonates), Duncan not only did all of the cardiac procedures, but also all of the follow-up care required of a surgeon.

The evidence also established that Duncan not only provided the post-surgical care that was normally expected of a surgeon, but also took special interest in his cardiac patients. He often spent the night in the intensive care unit at the bedside of his patients, after he had spent the previous day in the operating room performing surgery on them. This was the case even when a child spent several days recovering.

Collins believed that, because the adult cardiac surgery program was much larger than the Pediatric Cardiac Surgery Program, the concerns of the pediatric program tended to be ignored. For example, Duncan provided coverage services for adult cardiac surgery, while adult cardiac surgery did not provide a similar service for pediatric cases. When Parrott left the hospital in 1991, Duncan was called upon to carry an adult caseload, as well as his regular pediatric cases. As a result Duncan found himself on call-for literally 24 hours a day, seven days a week-for two different programs.

Duncan, in particular, believed that the pediatric cardiac program was largely ignored by both the university and the hospital administration.

This issue was part of a broader conflict between the HSC's adult and pediatric services. One of the steps taken to address this was the creation of the position of head of pediatric surgery. Dr. Mervin Letts initially held this position during this period and was replaced by Dr. Nathan Wiseman. As head of pediatric surgery, Letts served as head of a committee of pediatric surgeons. The purpose of the creation of this committee was to provide a voice to allow pediatric surgeons more input into the institution.

Assistance for Duncan

Duncan, as noted above, was under considerable pressure. His status as the sole pediatric cardiac surgeon in Winnipeg and the lack of a local pediatric cardiac training program often left him in the position of not having the same surgeon assist him from case to case.

The importance of the surgical assistant was made clear to the Inquest by Dr. Garry Cornel¹, a consulting witness to this Inquest. He said:

I think familiarity is perhaps the most important requirement, so getting used to somebody and working together is tremendously valuable. At times in the past, in Newfoundland, I had to work with different assistants very often, and I found that very unsatisfactory, and was able to recruit a full time assistant.

In Ottawa now we have a residency training program, so there is a senior cardiac surgery resident present for all cases, and often there are two staff people for each case as well. If it is an unusual case that I especially want Dr. Weerasena to familiarize himself with, one or other of us will be first assistant, depending on who is actually doing the surgery, and the resident will be there as the second assistant. At other times I will have the resident assist Dr. Weerasena, and I may stand and look over his shoulder, and vice versa. (Evidence, pages 44,631-44,632)

Cornel added that being a trained cardiac surgeon was a significant factor in an assistant:

In a complex case, and especially if things have gone wrong, somebody with experience may provide an idea of another way to try, or another way to do things, and that can be of great help.

The assistant that I have had for the past ten years in Newfoundland is still there, we still work together, and it is a wonderfully satisfactory arrangement. He is just a marvellous assistant, he knows what I am going to do before I even think about it, and so that's equally satisfactory. But we-you know, for a new very complex case, I would prefer to have Dr. Weerasena to help me. (Evidence, page 44,633)

The HSC was seeking an adult cardiac surgeon who could also assist in pediatric cardiac surgery. However, it was not able to recruit such a surgeon during Duncan's tenure. For Duncan, this became a source of some frustration. A partial solution was formulated when Dr. B. J. Hancock, who had been one of Duncan's most consistent assistants, decided to seek specialty training as a pediatric general surgeon and intensivist. She left for her training with the thought in mind that she would eventually return to Winnipeg, in part to be a pediatric cardiac surgical assistant, in addition to becoming a pediatric general surgeon.

Lack of cases

Duncan's frustrations were expressed in a letter of July 28, 1989, to Bishop (Exhibit 17, Doc 92). In this letter Duncan complained that he was not performing enough pediatric cardiac operations to maintain and further develop his skills. After Parrott left in 1991, Duncan began performing adult operations, but there were difficulties in scheduling these operations.

The number of anaesthetists

According to Collins, the HSC had an embarrassment of riches when it came to pediatric anaesthetists, since there were six to seven qualified pediatric anaesthetists. The problem was that he felt there were not enough pediatric cardiac operations to allow them to maintain their skills. He testified:

The problem in it all is when you come to open heart surgery and running pumps, it requires practice. And I don't know what pumps a year are, but maybe it is six pumps a month, and if you have got six anaesthetists, that's one pump each a month, and you are beginning to get into a situation where maintenance of skills can be questioned. (Evidence, page 33,079)

Duncan believed that there should be a limit on the number of anaesthetists who were involved in pediatric cardiac surgery. This was meant to ensure a high level of skills and teamwork. Duncan wrote of this "I cannot have a trusting relationship with individuals who I see only eight or ten times a year in the OR." (Evidence, page 23,601) This issue was never resolved before his departure.

Intensive care

Collins would have preferred to have all open-heart cases, no matter what their age, go to the PICU. Because there were more NICU nurses and neonatologists than there were PICU nurses and intensivists, he worried that the NICU staff did not have sufficient exposure to pediatric cardiac surgery cases. However, the neonatologists opposed this proposal. It also was not physically possible to send all the open-heart cases to the PICU in the early years of the program, since the PICU was smaller than the NICU and had older equipment. However, by 1993, the PICU had been upgraded substantially, having expanded into a larger space with newer equipment, to become a state-of-the-art facility. This issue of two intensive care units was also not resolved before Duncan's departure.