At the outset of this section, the following issues were identified:
This was a very complex operation, requiring, as Dr. Walter Duncan indicated, excellence in performance. Given the problems that the team had experienced up to that time, it is likely that this case was beyond the capabilities of the team in September 1994.
Despite the conclusion of the Wiseman Committee's interim report, the team clearly continued to face a number of difficulties. In this case, there were not only problems in the operating room with cannulation and a very lengthy bypass, but also conflicts over treatment that, at the very least, showed serious communication problems. Therefore, the evidence tends to suggest that Marietess should have been referred out of province.
Marietess Tena Capili's parents were not informed of Odim's experience, either with this set of defects or in general. Nor were they informed of the program's recent history. This evidence tends to suggest that Marietess's parents were not provided with sufficient information to allow them to give informed consent to the procedure.
From the evidence, it appears that the prime cause of the SVC syndrome was the suture narrowing at the cannulation sites. In their joint report, Duncan and Cornel wrote:
Unfortunately the significant obstruction at the cannulation site meant that the blood could not get from the venous pool past the surgical anastomosis to the lungs. (Underlining and bolded in the original.) Dr. Cornel and myself felt that the specimen explains the demise of this patient by demonstrating the important cannulation stenosis. (Exhibit 354, page 11)
None of the consulting witnesses who appeared before this Inquest believed that the SVC syndrome was pharmacological or drug-induced.
Cornel was asked about Odim's concern that there was pharmacological basis for the problem.
If a large dose of a vasoconstrictor substance is run directly into the lungs, yes, it can cause pulmonary, an episode of pulmonary hypertension. Whether it could be to this extent, I don't know. But it doesn't really change what I said. If the blood is not flowing through the lungs because of pulmonary hypertension, it's not flowing through the lungs. And I would then take the operation down. (Evidence, page 44,865)
Soder was also asked if adrenalin could have had the sort of effects that Marietess experienced. He replied:
It could transiently produce a profound increase in pulmonary artery pressure, but the pharmacological affects of adrenaline would last for a very short time. And after discontinuation of the adrenaline, within a few minutes, one would expect the pulmonary artery pressures to return back down promptly. It is a very short acting drug.
The Court: Back down to what?
The Witness: To the normal levels. If the theory is that the infusion of adrenaline caused pulmonary hypertension to a given level, then withdrawing the adrenaline should return the blood pressure back down to controlled levels within two to three minutes after discontinuation. (Evidence, pages 44,148-44,149)
Hudson was asked if it was wise to see if a pharmacological remedy would work. He replied that he would want to undertake a diagnostic manoeuvre, such as angiography (or the intravenous injection of dye and the taking of an X-ray to study the blood vessels). He was also asked how long it would take to see results from using a vasodilator to decrease the central venous pressure.
If you were to give a vasodilator at an appropriate dose, and I have no idea what the doses were, those drugs act rapidly. So, you would see an effect in minutes. (Evidence, page 40,010)
In discussing Marietess's post-operative care, Soder stressed that the treatment she received in the PICU was doomed to fail, since it was based on a faulty diagnosis.
This was one of the cases that Soder identified as leading to his conclusion that:
the skill and dexterity of the surgeon performing these operations were insufficient for the challenge of successfully repairing infant hearts with complex malformations. (Boldface in the original.) (Exhibit 345, page 8)
The evidence suggests that the SVC problem was surgical in nature, that the surgeon's decision to transfer Marietess out of the OR was questionable and that the treatment he supervised in the PICU could not address her underlying problems. The evidence also suggests that Swartz believed this to be the case but was unable to influence Odim or Giddins on this point.
Several of the consulting witnesses who appeared before this Inquest addressed this issue. They were generally of the view that it was inappropriate to move Marietess from the OR without first conducting further examinations as to the cause of the SVC syndrome.
Cornel testified that the increase in the left external jugular pressure meant that there was either an obstruction in the veins or an obstruction of the blood flowing into or out of the lungs. He said that either the problem with the veins had to be addressed or the repair had to be taken down and the previous shunt re-established. In either case, Cornel testified, the problem had to be addressed in the OR. He said that it would have been possible to locate the problem in the veins by attaching a needle to the end of a line connected to a pressure monitor and inserting the needle into various sites in the veins. By doing this, Odim would have been able to get pressure readings quickly.
In his report, Dr. Walter Duncan wrote that if tests had shown "compression of the anastomoses or intrinsic narrowing, urgent revision and/or decompression might have been attempted-although this would have been a high-risk undertaking." (Exhibit 20, document 363, page 10) In his testimony, he stated that tests in the OR could have identified the suture narrowing that was discovered at autopsy.
Soder testified that the team should have first looked for blockages before leaving the OR. He stated that he would have examined the sites of anastomosis where the vena cavas and pulmonary arteries had been joined. If that failed to identify the problem, he said he would then have recommended that the team take pressure readings through a needle puncture, as described by Cornel. After that, he would have attempted to reduce the pulmonary pressures, since it would appear that Marietess had some form of pulmonary hypertension.
But it is relatively, given that you can do the needle pressures, which you generally can, it makes it possible to sort this one out right in the operating room before going any further. I was surprised that this wasn't, I saw no evidence this was done.
I was surprised to find that they leaped to the conclusion that this must be pulmonary hypertension, treated [her] as such, and took [her] to the intensive care unit. (Evidence, pages 44,140-44,141)
Soder testified that the approach that Odim and Giddins employed was for the treatment of pulmonary hypertension that was caused by a medical problem and not by a mechanical or surgical problem. When asked if he would have left the operating room with the child in this condition, Soder testified:
I would have locked the door. There is no way I would have accepted a medical explanation for what I was seeing. (Evidence, pages 44,143-44,144)
In conclusion, Soder said that Marietess should not have been taken from the OR until a surgical exploration had been conducted to identify the cause of the SVC syndrome.
Hudson in his testimony suggested hunting for variations in pressures with a needle, as Cornel and Soder had both recommended.
Based on the information in the autopsy and the opinions of the consulting witnesses, it is apparent that Marietess should not have been transferred from the OR until further tests had been carried out to determine the cause of the SVC syndrome. The evidence presented to this Inquest indicates that if the proper tests had been conducted in the OR, the surgeon might very well have discovered the suture narrowing of the blood vessels. Once discovered, the narrowing could have been addressed, allowing adequate blood flow. While there would be risks to undertaking such a repair, Marietess's life depended on the cause of the SVC problems being addressed immediately.
Marietess's death was due to failure of the primary repair. While there were no problems with the connection of the vena cavas to the pulmonary arteries, the surgeon inadvertently tightened the purse string sutures to the point where they narrowed the superior vena cavas. This led to the SVC syndrome, which was ultimately fatal. This conclusion is supported by a number of witnesses. Cornel and Duncan wrote:
While the diagnosis and therapeutic plans were appropriate, the surgical outcome is explainable on an anatomical basis - namely the severe stenosis at the two venous cannulation sites. (Exhibit 354, page 11)
The evidence therefore suggests that Marietess's death was preventable.
|Current||Home - Table of Contents - Chapter 8 - Findings|
|Next||The appointment of Dr. Andrew Hamilton|
|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|