The Pediatric Cardiac Surgery Inquest Report



Nursing concerns

On May 19, 1994, the OR nurses met to prepare their list of concerns for the committee. Present were Carol Youngson, Carol McGilton, Celine Weber, Susan Scott, Beatrice Zulak and Irene Hinam.

It is to be noted that nurses from the PICU, the NICU and the VCHC did not participate in this process. Given the manner in which the committee was structured, it is understandable that the operating-room nurses did not include nurses from other units in this process.

The nurses prepared a two-page list of nursing concerns, which was submitted to the committee. They broke these concerns down into three categories: communication, morale and confusion regarding roles.



Under the heading of communication, the nurses spoke of how they had attempted to arrange a meeting with Odim before the first operation to discuss the equipment he would need. They said that Odim left them with the impression that he was familiar with the equipment they had in stock and would work with the existing equipment. After examining documents Odim had given them that described specific surgical procedures, the nurses had concluded that except for a number of special sutures (which they had placed on order), they had the necessary equipment.

This impression changed with the first pump cases. The nurses concluded that the cannulas were not what Odim was used to working with, after he made several negative comments about the equipment. In response, the nurses provided him with catalogues from which to order cannulas. However, he said he did not have the time to go through them. This had left the nurses at a loss as to how to deal with this issue.



Under the heading of morale, the nurses said they fully supported the withdrawal of anaesthetic services. They indicated it had been very demoralizing to lose so many children in a short period of time. They did not state in their document that the deaths of the children had brought about a loss of confidence in the program-however, that should have been apparent from the statement.


Role confusion

Under the heading 'Confusion Regarding Roles,' the nurses stated that it was stressful to have Odim asking the scrub nurse about the set-up of cannulas and pump lines, a matter not usually within their purview. To resolve this, the nurses arranged to have a perfusionist stand at the head of the table when the cannulas were being placed. It was noted that this problem could have been worked out in advance with a dry run (Exhibit 20, Document 278 P).



Current Home - Table of Contents - Chapter 7 - Nursing concerns
Next Anaesthetic concerns
Previous Preparing for the process
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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