The Pediatric Cardiac Surgery Inquest Report



The case of VM

VM was a five-year-old child who underwent a repair of an ASD on June 27, 1994. During the course of the operation the cannula inserted into VM's inferior vena cava became dislodged and fell out.

Odim testified that while he was explaining the child's anatomy to a student, the cannula rotated out of the inferior vena cava into the open right atrium. Hancock confirmed that in the process of showing the student the patient's anatomy, Odim manipulated the cannula to expose VM's defect. With the movement, the cannula tip flipped out of the IVC. However, Hancock testified, the cannula was still attached to the atrium wall. At that point there was a considerable amount of bleeding from the vein and if the cannula was not quickly reinserted and the bleeding controlled, there was potential for a serious negative outcome.

In this situation, normal surgical practice is to initiate what is termed 'sucker bypass', whereby bypass catheters that have suction capacity are used to take blood from the operative field back to the bypass machine. These catheters are usually used in surgery to remove blood from the surgical field, and normally the blood suctioned away from the field is not returned to the bypass machine. However, when sucker bypass is initiated, the suctioned blood is returned to the bypass machine to minimize blood loss.

There is a conflict in the evidence as to whether or not Odim notified the team of the cannula coming out and also as to who instructed the perfusionists to initiate sucker bypass.

McGilton testified that Odim did not inform the team that the cannula was out. Youngson testified that she was alerted to the problem by a perfusionist, who announced that the blood flows were down. In her testimony, Youngson said that Odim may have indicated that the cannula was out. Reimer, who was the anaesthetist for the operation, said that he did not recall Odim informing the team that the cannula had come out, although he soon became aware of the event.

Youngson testified that she expected Odim to tell the perfusionists to initiate sucker bypass. According to McGilton and Youngson's testimony, Odim did not give any instruction to initiate sucker bypass. Instead, according to McGilton, Youngson gave the instruction, which McGilton repeated to Todd Koga, the perfusionist. Hinam, the anaesthetic nurse, also testified that the instruction to go on sucker bypass came from Youngson, not Odim. McGilton put the suction cannula in place to take the blood away from the operative site.

Odim, however, testified that he instructed the team to go on sucker bypass. He did not recall Youngson suggesting they go on sucker bypass. Instead he recalled her yelling that they were on sucker bypass. He took this to be a message to the perfusionists that the suction cannulas were giving the return.

Throughout this process Odim was having difficulty reinserting the cannula. After attempting unsuccessfully to reinsert the initial cannula for a number of minutes, Odim successfully recannulated the child, using a different type of cannula. Once the cannula was replaced, the team continued with the repair.

While no known damage to VM arose from this event, the incident should have been recorded. In addition, an incident report should have been filed. However, there was no record of the event in Odim's operative report; nor did any member of the OR team complete an incident report. Additionally, the VM case was not reviewed by the Wiseman Committee.

Following this operation, McGilton started to make notes about operations in which she was involved. She speculated in her notes, as Youngson did in the notes she was keeping, that it appeared that Odim was not aware of the option of going on sucker bypass in such a situation.



Current Home - Table of Contents - Chapter 7 - The case of VM
Next The June 29 committee meeting
Previous The trip to Saskatoon (June 13-14)
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