Pediatric subspecialties

All medical practitioners undergo training initially at medical school to become medical doctors. They then undergo a period of training in one or more teaching hospitals as a 'resident', during which they are assigned to work on various wards of the hospital. After that period of residency they can apply for a licence as a general medical practitioner or can continue training in a specific area of specialty, such as pediatrics.

Being licensed as a doctor and being recognized as a specialist are separate issues altogether. While training is generally the field of the academic community (universities and teaching hospitals), licensing is left to the various licensing authorities in each province. Recognition as a specialist in this country is the purview of the Royal College of Physicians and Surgeons of Canada.

As the specialty of pediatrics has expanded, so have the number and types of subspecialties, or more specialized areas of medical work. These include pediatric cardiology, pediatric cardiac surgery and pediatric anaesthesia.

Pediatric cardiology

Cardiology is the science of evaluating the condition of a patient's heart, identifying problems associated with it and recommending treatment for the conditions identified.

The cardiologist's most important function is the identification and diagnosis of heart defects and heart disease. These doctors stand at the front line in society's fight against heart problems, for it is their ability to identify a patient's heart condition quickly that will give rise to early intervention and successful treatment. While some heart conditions can be successfully treated without surgical intervention, it is the cardiologist who is usually the first to identify a condition that may require a heart operation. Invariably, the decision to proceed with cardiac surgery is a decision made between the patient, the family, the cardiologist and the cardiac surgeon.

If it is thought that surgery may be required, the cardiologist is expected to be able to provide a clear picture to the surgeon as to the exact state of affairs within the heart itself. For example, the functioning of valves and the location of defects, such as a hole in the wall separating the chambers of the heart, must be accurately described. This permits the surgeon to determine if surgery is, in fact, the best option and what the potential surgical issues are likely to be.

Often, in order to make a diagnosis, the pediatric cardiologist must do more than merely observe external signs, since these can sometimes indicate only that there is a problem and not what the problem is. More direct exploratory methods may have to be undertaken. Since children are usually unable to explain or describe their condition, a pediatric cardiologist's diagnostic skills emphasize the use of technology and accurate measuring devices to allow the cardiologist to form opinions and conclusions as to the cause of a child's apparent heart problem. Cardiologists now perform their tasks with the aid of modern technology unavailable to their colleagues of previous eras.

Some of the technologies available to today's cardiologist are:

• electrocardiography (the production of electrocardiograms or ECGs/EKGs, which are graphs showing the electrical impulses produced by the heart);

• echocardiography (the production of echocardiograms or ECHOs) through ultra-sound imaging; and

• cardiac catheterization, which involves inserting a long, fine tube into the femoral artery in the groin, through connecting arteries and then up and into the heart. The tubing is connected to a device that allows the cardiologist to measure the various pressures within the heart and the blood vessels surrounding it. The cardiologist may also take samples of blood for testing or inject special X-ray contrast material or dye through the tubing to obtain real-time pictures of how the heart works.

Intra-operative echocardiograms can be done in more than one way. One technique uses an external probe placed on the chest. However, it cannot be used throughout the entire operation. The other technique uses a transesophageal echocardiography probe (referred to as TEE) inserted into the esophagus. TEE provides superior images of structures in the heart without interference from the chest wall. For example, by imaging from directly behind the left atrium, TEE can produce minute detail of the mitral valve and the atrial septum. Since the probe is in the esophagus, it can produce ECHO images throughout the operation without interrupting the surgical procedure. Usually the probe is inserted by the anaesthetist and manipulated by either the anaesthetist or a cardiologist. Many cardiac anaesthetists now possess the skills to interpret the TEE.

While the HSC gained access to TEE equipment during 1994, none of the anaesthetists or cardiologists had experience with TEE.

In addition, a new field of invasive cardiology has developed in recent years. Cardiologists who have specialized in this field use technology to carry out procedures within the heart without having to cut open the patient's chest. For example, an 'invasive cardiologist' might perform a balloon atrial septostomy (as described in Chapter Two).

Pediatric cardiac surgery

Surgery is a course of treatment that involves operating on the body of the patient, and cardiac surgery involves surgery on, within and around the heart. Cardiac procedures can involve operating on blood vessels attached to the heart or on the surface of the heart, or can involve operating on the heart itself, where the walls of the heart are actually opened up. Cardiac surgical procedures are referred to as either closed or open-heart surgery.

Closed-heart surgery is that surgery in and around the heart which does not involve having to either bypass blood from the heart or stop the flow of blood to the heart. Open-heart surgery is that surgery which often, but not always, involves actually opening the walls of the heart. Open procedures are those that require that blood-flow through the heart be diverted though the heart-lung machine, because the heart itself or its major blood vessels must be opened.

Adult cardiac surgery is an area of specialty that has enjoyed wide acceptance and recognition as a medical specialty for many decades. By contrast, pediatric cardiac surgery is a relatively new area of specialization. Indeed, it has only been since the latter part of the 1950s that science and medicine have begun to address the special issues that infants and young children with cardiac anomalies presented.

Initially, persons trained as adult cardiac surgeons performed cardiac surgery on children. However, the training that an adult cardiac surgeon receives is now considered insufficient for the complex procedures performed in pediatric cardiac surgery. Specialty training programs for pediatric cardiac surgeons are now found at a number of hospitals in North America, including McGill University in Montreal, the Toronto Hospital for Sick Children and Harvard Medical School in Boston.

If a doctor wishes to specialize as a surgeon, a further period of residency in a surgical training program is required, with additional periods of training in other specific fields. For a pediatric cardiac surgeon, that would involve training initially as a general surgeon, then as a cardiothoracic surgeon, then as a cardiac surgeon, then as a pediatric cardiac surgeon. Training in this specialty can exceed ten years.

Anaesthetists

Anaesthesia is the field of medicine involving the administration of drugs that produce a loss of consciousness or sensation. Most often, anaesthetics are given for a surgical procedure but sometimes, especially in the case of children, anaesthesia may also be needed for a diagnostic procedure, such as a special X-ray examination.

Anaesthetists are doctors who have completed their medical degree and have then completed an additional residency in the study of anaesthesia and anaesthetics. This residency usually lasts a minimum of five years. In Canada, the term 'anesthesiologist' is gaining wider acceptance as the term applied to such doctors. However, as the witnesses in this Inquest used the term 'anaesthetist,' that term will be used throughout this report.

Anaesthetists have extensive knowledge of the drugs used to enable patients to undergo surgery without pain and suffering. Anaesthetists are also very knowledgeable about how the body works and the various techniques and treatments needed to maintain patients in a state whereby the necessary surgical procedures can be carried out in a safe manner. Another of the anaesthetist's responsibilities is to determine if a patient is in a condition to be safely anaesthetized and undergo an operation.

While pediatric cardiac surgery and pediatric cardiology are viewed as distinct specialties with a distinct training regimen, such is not the case with pediatric cardiac anaesthesia. There is, in fact, no separate training program for pediatric cardiac anaesthetists recognized by the Royal College of Physicians and Surgeons of Canada. Anaesthetists who specialize in pediatric cardiac anaesthesia generally have been trained in adult cardiac anaesthesia. Some may have undertaken an additional six to twelve months of training in a fellowship program in pediatric cardiac anaesthesia. Others will have developed their expertise in pediatric cardiac cases through experience, as opposed to any special training regimen. In addition, pediatric cardiac anaesthetists in Canada have developed their own ongoing medical education programs to improve their knowledge and skills.