The Pediatric Cardiac Surgery Inquest Report



The July 27 committee meeting

The committee met on July 27. Unfortunately there are no minutes available of that meeting. In many ways, this appears to be have been a pivotal meeting in the committee's history. It was at this meeting that Giddins proposed that the program was ready to resume full capacity. The committee had been in place for a little over two months. However, it had not produced any statistical review; nor was there any consensus as to whether or not the team should return to full operation.

McGilton, who attended the meeting in Youngson's place, opposed going to higher-risk cases because of concerns arising from the VM and KZ cases. She testified:

So I said that, no, as a group we do not feel comfortable in moving on-

Question: Okay.

McGilton:-to higher risk cases. And Dr. Giddins and Dr. Odim said why. So I said that even though things had been going well, that the children were doing well, things hadn't been smooth in the OR and we had concerns with that. So, again, they wanted to know what. So, I gave the example of [VM], the cannula coming out and Dr. Odim-

Question: Having to go on sucker bypass?

McGilton: And having to go on sucker bypass. And as I was talking about this, Dr. Odim said, oh, you mean when I was giving the student the explanation about the anatomy. Which to me didn't really make sense anyway, because I didn't understand what the connection was. But that was his response. And I brought that up and I brought the eustachian valve up, and Dr. Giddins got very, very angry, very upset. (Evidence, pages 10,588-10,589)

McGilton testified that she had explained how the eustachian valve had been sutured over, requiring the patient go back on bypass. According to her testimony:

And Dr. Giddins then raised his voice, got very angry and said that he could show me an anatomy book and show me how easy it would be to make that mistake, and it's a common thing to do. And basically, in so many words, you are just a nurse, what do you know? And Dr. Odim made the same kind of comment, you are not a surgeon, you are a nurse, or whatever.

I just stuck to my guns and said, well, that may well be and, yes, the children did do well, they made it through, that was true, but we just didn't feel that things had gone smoothly and we don't feel comfortable moving on. (Evidence, pages 10,589-10,590)

McGilton said she felt that Odim did not exhibit the anger that Giddins demonstrated. Instead, his comment was more along the lines of a joking statement that a nurse's comments were not worth considering.

McNeill corroborated McGilton's testimony.

But the overall reaction was not very receptive on the part of cardiology and the cardiac surgeon. They questioned her position in terms of, well, her expertise in making the criticisms that she had. And I guess it was sort of like negating her concerns on that basis. (Evidence, page 13,288)

In his testimony, Giddins said he could not recall anyone being told that their opinion lacked validity because that person was not a surgeon. Odim testified that he recalled the exchange, but said that he did not make any comments at the time. McGilton testified that at the end of the meeting, Wiseman told her she was not making things easier. Wiseman said he could not recall making the comment.

It should be noted that the suturing-over of the eustachian valve was a far from minor matter. As noted above, the anaesthetist involved in the operation had also been disturbed by the problem. It was an appropriate topic for discussion and for anyone to raise as a matter of concern.

Wiseman testified that out of deference to McGilton's objections, the decision was made not to return to full service. However, it was clear that pressure was building for a return to such service. In two weeks time, Wiseman himself recommended that the team start doing cases that were of medium risk.

McNeill said that, from her perspective, the pressure to return the program to full capacity came from a number of sources. The first was simply from the fact that there were patients in Manitoba who required pediatric cardiac surgery. There was also pressure from Cardiology and Surgery, departments that wished to see a faster return to full service. Youngson testified:

I think my sense was that there was pressure from somewhere higher up. I always felt there was other meetings going on, of course, that I wasn't a part of. You know, other meetings with department heads and so forth that were going on behind closed doors. That was just my sense, you know, I don't have any facts to back that up, I just had that feeling all the time that that was going on. (Evidence, page 8,565)

On this point, Odim testified:

Certainly at some point in evolution during the Committee there was a sense from Dr. Unruh and Dr. Blanchard of a lack of understanding of what was going on in terms of why the program was stalled so to speak.

Again, it was put to me by Dr. Unruh that the problems that you are dealing with are the same problems the previous surgeon had here so they were privy to things that I was not aware of. So they were surprised that we were stalling the program because, you know, what else is new, so to speak. I can't speak for anything beyond that, except that, you know, early on in the process they were a little perplexed by what was going on. (Evidence, pages 25,356-25,357)

This pressure continued to build and in early August led Wiseman to write an interim report that recommended a staged return to full services.



Current Home - Table of Contents - Chapter 7 - The July 27 committee meeting
Next Nurses and the Wiseman Committee
Previous The July 13 Wiseman Committee meeting
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
Table of Contents