March 7 - The case of DR -
the first open-heart case
DR was born on August 23, 1981. When she was nine years old, she was diagnosed with an atrial septal defect and was referred to the Variety Children's Heart Centre for evaluation. On March 7, 1994, DR underwent an operation to close the ASD.
Odim operated on DR one week after performing his first surgical procedure in Winnipeg. This was the first open-heart case he performed in Winnipeg. It was during this procedure that a number of events arose that caused concern for some members of the operating team. The three issues that arose were Odim's lack of familiarity with the OR setup, his problems with cannulation and his treatment of nurses.
Odim's lack of familiarity with the OR setup
In preparing to go on bypass, the surgeon must connect the patient to the cardiopulmonary bypass machine through a series of lines. In Winnipeg the surgeon, after connecting one end of each of the lines to the patient, generally handed most of the lines to a scrub nurse, who handed them to the perfusionist, telling him what each was for. In turn the perfusionist connected the lines to the appropriate bypass machine ports. Because of the cramped nature of the operating room, the surgeon handed some lines directly to the perfusionist, who was generally situated behind the surgeon.
During this operation Youngson concluded, to her surprise, that Odim was having considerable difficulty with the mechanics of the process.
It was just that Dr. Odim didn't seem to know how this all went. And at that point in time, what went through my mind was, this guy has never done this before. And I thought, no, that can't be true, he has come from Boston and Montreal, he has done all of these cases, he must have had lots of experience. But that was the thing that popped into my mind at that point in time. (Evidence, pages 8,359-8,360)
Nurse Carol McGilton also described Odim as having trouble with the lines.
Youngson felt it necessary to assist Odim by, in effect, giving him direction, while McGilton (who was the second scrub nurse) performed a number of tasks that would normally have been undertaken by Youngson.
He was very polite about it, he thanked me, he seemed appreciative-I won't say impressed by my knowledge, he seemed to acknowledge that I knew what I was doing and sort of went with what I said. I felt kind of odd, I think it was the first time in my experience that I ever told a cardiac surgeon what to do. You know, they don't take to that very well in most instances, so I was a little uncomfortable. (Evidence, page 8,362)
Odim testified that he did not have problems placing the lines but rather asked for guidance from Youngson and chief perfusionist Michael Maas because he was unfamiliar with the setup in the operating theatre. He said that he was trying to modify his approach to the actual physical setup of the OR. He also denied he was confused about how to connect the lines.
In her testimony, Hancock did not agree that Odim seemed not to know where the lines went. She felt that the setup in every OR was different and, since they were a new team, they had to work out all the steps of where things should go. She did not seem to feel that there was anything unusual about the time it took in this case for the lines to be sorted out.
Youngson agreed that Odim did seem to be trying to adapt himself to procedures that were established by his predecessor, Duncan. However, she felt that placement of the lines could have best been reviewed in a dry run, rather than while an operation was actually proceeding and the patient was lying on the operating table with an open chest. There is merit to this view.
Odim's problems with cannulation
Once the lines were in place, the surgeon would perform the task of cannulation. There are different approaches to cannulation. The Winnipeg OR nurses were familiar with the technique that Dr. Kim Duncan had used. In that method, the surgeon placed a clamp on the part of the blood vessel intended as the cannulation site. After cutting a small hole in the clamped portion of the vessel, the surgeon would then slowly release the clamp and insert the cannula into the hole in the vessel.
In the alternative "stab-and-go" technique, the surgeon, without making use of a clamp, would open a hole in the blood vessel with a scalpel and then immediately insert the cannula. This method calls for speed and efficiency. Hesitation or fumbling with the cannula can increase the risk of blood loss.
Youngson, who had never seen the stab-and-go method used on pediatric patients, offered a clamp to Odim when it came time to cannulate. Odim declined to use it, saying he would use the stab-and-go method.
OR staff, such as Youngson, McGilton and McNeill, felt that Odim was not particularly proficient at this form of cannulation. (Even when he used a clamp, which he did later in the year, they thought that he was not proficient at cannulation.) McGilton wondered during the DR case if Odim was nervous or was simply not used to the HSC equipment. Dave Smith, who was one of the perfusionists, noted with respect to other cases the difficulty that Odim had with cannulation, but concluded that Odim was just rusty.
After noting Odim's difficulty with cannulation, Dr. Ann McNeill was sufficiently concerned to mention it to her anaesthetic colleagues. She felt that, as a fully trained cardiac surgeon, Odim should have been quite familiar with cannulation, and that it should have been second nature to him. She felt that before going into surgery, Odim should have taken steps to familiarize himself with the line procedures that were used in the Children's Hospital, as well as the cannulas that were available.
Hancock, however, did not agree with the criticisms levelled at Odim's cannulation technique. She felt that Odim did know how to cannulate adequately, although she did notice that he sometimes cut the purse-string sutures that were designed to hold the cannula in place and would have to put in new ones. Some of his cannulations were difficult, she said, but she did not believe that Odim's cannulation technique compromised patient safety. She did, however, concede that he needed to improve in this area. She said that if she had had a serious concern with Odim's cannulating techniques, she would have discussed her concerns with him.
Odim said he used the stab-and-go method only for cannulation of bigger children and adults. He said he did so because their aortas can be somewhat calcified and the use of a clamp can crack the calcium and send debris into the bloodstream (and possibly up to the brain). For babies and small children, he said, he always used a clamp to cannulate. Dr. Heinz Reimer (an anaesthetist who worked on several of Odim's cases) and Hancock both recalled that Odim did not start using the clamp technique until halfway through the year. Odim disagreed with that recollection.
While Odim also disputed the evidence of those who expressed concern about his cannulation abilities, he did say that before the DR case, he had last cannulated a child in Boston three months earlier, in December 1993. He acknowledged that he had been doing predominantly clinical research during the last six months of his training in Boston. As a result, he had cannulated only once or twice a month during that period. He disagreed, however, with the suggestion that he was rusty at cannulating.
OR staff at the Children's Hospital had been used to Duncan's method of cannulation, which involved the use of a clamp. Odim's use of a different technique cannot be questioned on the basis that the technique might have been inappropriate. The question of what approach to use to cannulate a child is clearly one best left to the individual surgeon. However, it does seem that there were questions about Odim's mastery of the technique that he did employ.
The issue of Odim's cannulation technique and whether or not he was proficient in it was raised again and again during the course of the proceedings, particularly with regard to several of the 12 patients whose cases were investigated. Poor cannulation can lead to significant blood loss, which is very serious in young children, who have small volumes of blood. Many of the children whose cases are discussed in this report suffered from a variety of blood-loss related problems.
In addition, problems with cannulation can lead to interrupted procedures if cannulas have to be reinserted. Any lengthening of the time of a procedure increases the risk of complications to the child. Finally, if cannulas are not properly inserted, there can also be problems with blood flow to and from the bypass machine, which can create a variety of additional problems for the surgical team to address.
The OR staff at the Children's Hospital of Winnipeg were unprepared for Odim's particular approach to surgery in general and were unimpressed with his cannulation ability in particular. These facts undoubtedly were significant contributors to the lack of confidence that team members quickly developed in their new surgeon.
Odim's treatment of nurses
Odim's dealings with nurses were to prove problematic throughout 1994. During the course of the year, he and a number of nurses developed antagonistic relationships. The antagonism generally related to differences in opinion about medical issues. However, the relationships also concerned more personal matters. Witnesses testified that, shortly after the restart of the program, Odim made a number of comments that were sexist and of a sexual nature to some of the nurses. Those comments were unprofessional and offensive and, in the context of the hospital setting, demeaning to the nursing profession. Much of what was said during the course of those conversations was heard in camera, and is not worthy of repetition. While Odim testified that he had no recollection of having made these comments, the specificity of the recollections of the numerous witnesses who overheard them, and the vagueness of Odim's denials, all combine to bring about the conclusion that Odim made the remarks as alleged.
Odim also came to resent the way he felt the nurses, and Youngson in particular, tended to compare him with Duncan. This led him to make a number of sarcastic and inappropriate comments about the relationship between the nurses and his predecessor. When operations were not proceeding smoothly, Youngson testified that Odim would turn to her and say he was sure that this was not the way that Duncan would have handled the case.
On another occasion, in an obvious reference to Duncan, Odim sarcastically asked Youngson, in front of other members of the operating team, if she had heard from her "beloved" recently. Odim's comments could have done little but create a distrustful and negative atmosphere between him and the nurses. Other remarks made by Odim later during the year also contributed to this atmosphere.