The Pediatric Cardiac Surgery Inquest Report



The operation-March 24

The operation took place on Thursday, March 24. Jessica was to undergo a complete repair of the ventricular septal defect with a Dacron patch, suture closure of the atrial septal defect and ligation of the ligamentum arteriosus. The operating team is set out in the accompanying chart.

TABLE 6.5: Persons involved in the operation on Jessica Ulimaumi, March 24, 1994
OR team member   Persons involved
Surgeon J. Odim
Surgical assistants B.J. Hancock, I. Al-Githmi (resident)
Anaesthetists H. Reimer, H. Grocott (resident)
Scrub nurses C. Youngson, S. Scott
Circulating nurses B. Zulak, S. Scott, C. Weber
Perfusionists M. Maas, D. Smith

TABLE 6.6: Length of phases of the operation on Jessica Ulimaumi, March 24, 1994
Phase of the operation   Time taken
Induction 1 hour 12 minutes
Total bypass 8 hours 43 minutes
Aortic cross-clamp 2 hours 7 minutes
Total surgical time 13 hours 33 minutes
Total operating-room time 15 hours 5 minutes

Jessica was weaned from bypass at 1313 hours, after the initial repair. However, the operation was marked by the fact that this initial attempt to repair the VSD was unsuccessful, with evidence of a leak in the VSD patch first shown by the values for oxygen saturation in different parts of the heart. An intra-operative echocardiogram, performed at 1530 hours, demonstrated that there was a residual nonrestrictive left-to-right shunt under the right aortic valve cusp. This confirmed the suspicions that the patch closure of the VSD was incomplete. Odim had to attempt the repair a second time. The second attempt required an additional period of bypass of two hours and twenty-four minutes and an additional aortic cross-clamp time of forty-four minutes.

The total surgical time from beginning the incision to closure of the incision was thirteen hours and thirty-three minutes. Jessica was on bypass a total of six times, with a total CPB time of eight hours and forty-three minutes. She underwent aortic cross-clamping twice, for a total of two hours and seven minutes. The lengthy times were necessitated by the decision to redo the repair. In his report, Soder described the total bypass and cross-clamp times as very prolonged.

In his post-operative note Odim wrote that Jessica had a large VSD and that after the first repair, a large leak was still present. As a result, Jessica required a second period of CPB and aortic cross-clamping.

However, according to Youngson, Odim indicated that one of the problems with the repair was the type of suture that had been provided to him.

One of the comments that Dr. Odim made to me at that point in time was that if he had the right kind of suture material, this would never have happened. And I remember being very upset about that and disturbed by that comment, because I felt that he was blaming me for the fact that we had to go back and redo this repair. (Evidence, page 8,379)

There was no mention of the problems with sutures in the operative note. Also, whether Odim was correct or not in his assessment of the cause of the problem with the repair, it would appear that the time and place to have arranged for appropriate sutures was in February, when Youngson had sought his input.

Following the completion of the second corrective procedure, several unsuccessful attempts were made to wean Jessica from the bypass machine. During each attempt to wean her from the machine, Jessica's heart did not give an adequate response.

Jessica had very high pulmonary pressures that did not respond to the drugs that were administered. In addition, the anaesthetist had problems maintaining adequate ventilation of Jessica's lungs. During investigation of the problem, the endotracheal tube was dislodged from her throat. While reinserting the tube, Reimer had difficulty passing the tube below the vocal cords (Exhibit 13, page ULI 82).

A second intra-operative echocardiogram was done at 2015 hours. This showed no apparent ventricular outflow obstruction, a possible minor residual VSD shunt, a distended atria (with the right side more distended than the left) and mild to moderate tricuspid regurgitation. The lack of any obstruction focused attention on the other problems revealed by the echocardiogram. The possible VSD shunt indicated that the repair might still be incomplete. The distended atria indicated that the ventricles were struggling to pump blood. Hudson said: "The atrial distension indicates biventricular failure, right worse than left." (Exhibit 307, page 2.5) This meant that the ventricles were not capable of performing their proper function. This condition may have resulted from myocardial stunning, itself the result of the prolonged CPB and cross-clamp times.

The decision was made to transfer Jessica to the PICU and then to place her on another form of cardiopulmonary bypass, called an extra-corporeal membrane oxygenation (ECMO) machine. ECMO is a form of long-term cardiopulmonary bypass, which assists the heart in pumping and oxygenating blood. It is used in situations where a patient's heart cannot beat on its own but might recover sufficiently within a short time (up to a few days in length).

At the end of the surgical procedure, the nurses could not account for one suture needle. (This missing needle is of particular significance, since the autopsy report indicated that a needle was found near the cannulation site.) Losing a needle during the course of an operation is, surprisingly, a rather common event. During a cardiac operation, several hundred needles may be used. Cornel testified that it is not unusual for a needle to be dropped on the floor, to be lost in the drapes covering the patient, or even to get caught up in the surgeon's operating gown.

That is not to say that loss of a needle is a routine matter, for there is always cause for concern when this happens. However, the evidence established that needles are often misplaced during a lengthy operation. When a needle is lost and there is reason to suspect that it may have been inadvertently left or dropped inside a patient, a portable X-ray machine may be brought into the operating room to determine if the needle is indeed in the patient. An assessment is done to determine if it is necessary to retrieve the needle immediately or to leave it until the patient's condition has improved. As long as the surgeon is satisfied that the loss of the needle does not place the patient in jeopardy, matters will proceed normally.

In the OR, the nursing staff discovered that the needle was missing when they performed their needle count. At 2106 hours on the day of the operation, Celine Weber, the scrub nurse, filled out a general incident report form reporting a missing needle. She recorded, "Long case 0730 to 2200 hours many needles used (over 170). Surgeon notified, no X-ray done as is low priority at this time." The form was signed by Odim (Exhibit 19, Document 277B).

Odim's recollection was that, given Jessica's heavily compromised condition and the fact that there seemed to be no reason to believe that the needle was left inside her, he felt it was appropriate to send her to the PICU.

How Odim could have known that the needle was not left inside his patient is hard to determine. The evidence shows that the nurses had no idea where the needle was. If it had been inside the patient, an X-ray would probably have disclosed its location. However, while Odim should have ordered a chest X-ray in the operating room, his failure to do so does not seem to have had an impact on Jessica. There is some evidence to suggest that the needle was not left inside Jessica. Several post-operative chest X-rays were taken of her chest area in the PICU. None of them showed the presence of a needle near her heart before her death.

Thus, the OR nurses followed the proper procedure in completing an incident report about the fact that, at the end of the operation, they were unable to locate one needle. What happened to the needle that was lost during the operative procedure has never been resolved satisfactorily. The fact that the lost needle was recorded and reported to Odim was appropriate, and procedures in this regard were followed properly. The likely origin of the needle that was discovered by the autopsy will be dealt with in the discussion of the events surrounding Jessica's death.



Current Home - Table of Contents - Chapter 6 - The operation-March 24
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Previous Consent
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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