Events leading up to the day of surgery

Diagnosis

A cardiac case began with the diagnosis. A child's heart problem might be noted at any point before or after the child was born, by the mother's doctor during a prenatal examination, by the doctor attending at the birth, by the child's pediatrician or by the family doctor during a routine checkup.

Once a heart problem was discovered, in Manitoba during 1994, the child was usually referred to the Variety Children's Heart Centre at the Winnipeg Health Sciences Centre to be seen by a pediatric cardiologist.

Variety Children's Heart Centre clinics

A child who was referred to the Variety Children's Heart Centre (VCHC) by a pediatrician or family doctor would be seen at one of the centre's regular clinics. These clinics were conducted by the cardiologist, the nurse clinicians and the technicians who were assigned to the VCHC. The necessary diagnostic tests would be performed at the clinic, and parents would normally be provided with test results before they left. The nurse clinicians would both assist with the tests and provide support to the families once the test results were provided. The nurse clinicians usually reinforced the information the parents had heard from the cardiologist. If a complex problem was detected, a cardiac catheterization might then be required. Catheterization procedures are usually performed to examine, in intricate detail, the anatomy and circulation of a patient's heart. Such information is essential in advance of surgery (and other treatment).

Surgical consultation

If the cardiologist believed the patient required surgery, he would consult with the pediatric cardiac surgeon. The surgeon would usually examine the patient and determine if the heart defect required surgical intervention. The surgeon's obligation was to assess the information available about the child and determine if, in his opinion, the child's problem could be best addressed surgically and where the operation could best be done. The surgeon could refer the patient to another heart centre, if he thought that the problem was beyond the team's ability or if the specific operation could best be done elsewhere.

The surgeon was expected to consider the particular lesion, the child's condition, his own skills and the skills of the operating team, and any special needs that the operation might require in terms of equipment, environment and organization. The surgeon would advise the cardiologist of the outcome of his meeting with the parents. He would also be expected to discuss his conclusions with the parents.

The nurse clinician would attend the meeting between the surgeon and parents. Part of the nurse clinician's role was to reinforce the information the surgeon told the parents. The nurse clinician also acted as ongoing support for the parents throughout the hospitalization and would continue the relationship during follow-up at the VCHC clinic.

Cardiovascular thoracic conferences

In all cases where surgery was indicated or considered possible, the matter was referred to a weekly meeting usually held every Wednesday morning at 0700 hours and known as the Cardiovascular Thoracic Conference, or CVT conference. At the CVT conference, the cardiologist, the Variety Children's Heart Centre nurses and the surgeon discussed the case. If any interns or residents were working on the cardiology service, they too would be present. Technicians who conducted the diagnostic tests at the VCHC with the cardiologists might also attend, if their reports were being considered. The purpose of the discussion was to decide if and how to proceed with the case and consider other issues, such as whether or not the case should be scheduled (or slated) for surgery in Winnipeg. Other hospital staff, such as operating room nurses, anaesthetists and intensive care staff were not usually included in the CVT conference.

The surgeon or the cardiologist advised the referring doctor of the diagnostic findings and the decisions made in the CVT conference by letter and/or charted the information in the Patient Progress Notes portion of the hospital record (in the case of emergency operations).

Consent

Before the operation took place, the child's legal guardians needed to give their consent in writing. This would occur after a discussion that should have included a full explanation of the need for surgery and a full explanation of the risks, including complete answers to all questions asked. At the Health Sciences Centre, the responsibility to explain a surgical procedure and obtain the appropriate consent from the parents fell to the surgeon. The practice at the HSC was to have the consent form signed just before the day of surgery, although the meeting explaining the procedure might have taken place several weeks before.

Scheduling of the operation

A child scheduled for surgery might be considered as an emergency case, an urgent case or an elective case. The difference among these three descriptions would be determined by how soon the operation had to take place. Emergency cases needed to be operated on as quickly as possible, while urgent cases could endure a longer time delay. In emergency cases, often the CVT conference and the actual pre-operative assessment were combined to expedite surgery. Elective cases were planned for in advance, with a considerably longer time frame, even though they were ultimately necessary for the life of the child.

If a child was assessed with a heart defect shortly after birth, an operation might be scheduled while the newborn was still in hospital. If the operation could wait, the child would be discharged home, with follow-up in the VCHC. Infants with heart defects who were born in other hospitals would be transferred to the Children's Hospital or referred to the VCHC for assessment.

Admission to hospital

In elective cases, the family would receive a letter from the VCHC, stating the date the child was booked for surgery, when to come for admission to the hospital and other details. Along with the letter, the family would receive a pamphlet describing the surgical ward (CH3) that the child would be in and other general information.

The child would usually be admitted to the Children's Hospital at least one day before surgery. The VCHC would forward to the hospital the results of any tests done on the child on an outpatient basis as part of the pre-operative preparation. There was also a patient education record that was filled out by different nurses, starting with the VCHC nurse clinician. This record documented the steps taken to educate the parents and patient (where appropriate) about the particular heart problems and prepare the child for surgery. The nurses would explain the hospital experience to the family. They would discuss such matters as pain control and the fact that the patient would be looked after by a number of different people doing different tasks. One of the important responsibilities of the VCHC nurse was to ensure that parents understood that they could ask any questions and that they did not have to sign a consent for surgery until they felt prepared to do so.

Pre-operative conference

The pre-operative conference for each case was held on Tuesday mornings in the week before the date of surgery. The cardiologist, the surgeon, the VCHC nurse clinicians, operating room nurses, anaesthetists, intensive care doctors and nurses, perfusionists and respiratory therapists attended this meeting. Since the HSC was a teaching hospital, interns, residents, and fellows might also be present.

While the intent was that the staff who were going to be involved in the operative procedure or follow-up care of the patient attended this meeting, often, due to other commitments, someone else would attend in their place. However, it was expected that if this happened, the person attending the meeting would brief the person actually participating in the case.

The meeting involved a presentation of the cases scheduled for surgery the following week, with the diagnostic part of the presentation being made by the cardiologist and the surgeon providing information and answering questions about the operation. Any of the people in attendance asked whatever questions they needed to ask. The child's complete medical history and current status, as well as the results of medical tests, were outlined. Echocardiograms and videotapes of the cardiac catheterization that illustrated the patient's condition might be shown. The VCHC nursing staff would also present information on the child's social circumstances.

Pre-operative anaesthetic evaluation

Following the pre-operative conference, the anaesthetist would examine the patient and the patient's chart. In this examination, the anaesthetist would confirm the information provided at the conference and would examine the patient to discover if there were issues specific to the anaesthetic, such as whether or not the patient had a normal airway. Since the material presented at the conference could be several days old by that time, the anaesthetist would check to see if the child's condition had changed or if there were more up-to-date test results. If chest X-rays were not available at the pre-operative conference, the anaesthetist would attempt to view the X-rays and/or the X-ray reports.

The parents were often present during this evaluation, giving the anaesthetist an opportunity to discuss the child's medical history, the family's medical history and family issues relating to anaesthetics. The anaesthetist would explain the risks and problems of anaesthesia, what the anaesthetist would do and the drugs that might be used. At this point parents gave verbal consent. (In Canada there is generally not a separate written consent for anaesthesia, the need for an anaesthetic being covered by surgical consent.)

Following this meeting, the anaesthetist recorded any concerns and requested any additional necessary tests. An order would be placed with the pharmacy for any drugs that the anaesthetist needed to have made up ahead of time. The anaesthetist might also approach other specialists who might be dealing with the child to discuss issues that were not in the area of anaesthetic expertise.

The anaesthetist would also assign a status evaluation to the patient, which was based on the physical health of the patient. This evaluation used a classification system adopted by the American Society of Anesthesiologists (ASA), called the ASA Class. There are five classes, and adding the postscript 'E' indicates that the patient is to undergo an emergency operation. The classes range from ASA I, representing a very healthy patient, to ASA V, representing a patient who is not expected to survive 24 hours with or without surgery.

Most of the children who were the subject of this Inquest were assigned a Class III or IV. A Class III patient is one who has health problems that limit the ability to function normally. A Class IV patient has health problems that represent a constant threat to life.

Contact with the child and the family

Depending on the heart condition, the child might be living at home before surgery or might be in the hospital. Contact between the child and the child's parents and the hospital was maintained by the nurse clinicians working for the VCHC. It was their responsibility to prepare the family for both the operation and the post-operative period. Children who were not in the hospital were usually brought into hospital the day before the operation.

The nurse clinicians would also maintain contact with any child who was already in the hospital. In most cases, neonates would have been in the neonatal intensive care unit from the time of their diagnosis until the operation. Such a patient usually needed an emergency operation because of the severity of the heart condition: the heart defect was so serious that it had to be dealt with quickly or the child would die.

Preparation of the patient

It was the joint responsibility of the cardiologist, surgeon, anaesthetist and intensivist (where applicable) to ensure that a child was in optimum condition for surgery. Any one of these doctors might raise objections to proceeding with surgery if he or she thought that the child was not in optimal condition.