The May 17 memo from the anaesthetists

On May 17, Ullyot wrote a memorandum to Wiseman informing him of the decision that the anaesthetists had made. The memorandum read as follows:

MEMORANDUM

TO: Dr. Nathan Wiseman

FROM: Section of Pediatric Anesthesia

DATE: 17 May 1994

Re: Pediatric Cardiac Program

The Section of Pediatric Anesthesia has concerns regarding the perioperative morbidity and mortality of pediatric cardiac cases at Children's Hospital.

We propose an immediate review of cases to date and the implementation of a mechanism whereby the structure and function of the Pediatric Cardiac Program can be developed in a continuous manner. The process should involve surgery, cardiology, anesthesia, nursing, intensive care and perfusion personnel.

We anticipate that ongoing planning and review will ensure the development of a successful program and we would participate fully in this process.

At a meeting yesterday of all members, the Section of Pediatric Anesthesia unanimously agreed that pending the recommendations of the immediate review we suspend the provision of cardiac anesthesia for open cases as of Tuesday, May 17, 1994.

SU/jt

cc: Dr. D Craig

Dr. R. Blanchard

(Exhibit 19, Document 240)

McNeill testified that, in her mind, services were withdrawn in an effort to draw attention to the fact that the program was not being properly supervised. She testified that before the memorandum was issued, no one from Anaesthesia had formally approached Bishop, Giddins or Odim about their concerns about the program. McNeill testified that it was apparent to her at the time that Giddins did not share her concerns about the program, since he was continuing to refer complex cases to Odim. She said she did not speak to Odim because she had found it difficult to speak with him, particularly as the relations between the surgeon and the anaesthetists had deteriorated.

In retrospect, I regret that I didn't speak to Dr. Odim just on a personal level, that I didn't speak to him. But I also, in retrospect and having knowledge now that I didn't at the time, I think that my assessment of how he would have taken my remarks was accurate. I don't think that it would have been constructive. (Evidence, page 13,237)

When asked why the anaesthetists felt it was necessary to take this extraordinary step, McNeill said:

Well, I guess we didn't have confidence that there was an active process in place that was monitoring the program. There was, the program was functioning, I mean, there was cases booked for the next week. I don't remember what they were, but we came to the point where we felt that we didn't have confidence in the program and we didn't want to wait any more time and possibly have more negative outcomes. (Evidence, page 13,242)

When asked why the May 17 memorandum did not make specific mention of concerns with Odim, McNeill testified that the anaesthetists felt that to focus on the surgeon would draw attention away from the issue of proper program management.

This was an extraordinary step to have taken. One might wish to take issue with the anaesthetists taking such a unilateral action without providing more warning or lead time. Certainly the department heads who were affected by this withdrawal expressed frustration on this point. Also, it might have been appropriate to have made further approaches to Giddins, Wiseman and Odim before taking such precipitous action, particularly since operations were scheduled for that week. Finally, when the action was taken, it might have been more appropriate to have sent the memorandum directly to Blanchard and Bishop.

These things being said, it is also apparent from the evidence that the anaesthetists had real reason to be concerned. It is also apparent that they had attempted to use a variety of informal channels and had met with no progress.

Some witnesses suggested that the anaesthetists and nurses should have raised their concerns at the CVT conferences. The evidence establishes that whenever a case was presented to the CVT conference in 1994, invariably Odim would undertake to perform the operation, rather than referring any case out of province. Giddins felt that the question of whether or not a case should be referred out of province was one that the surgeon should make, and he did not make any out-of-province referrals on his own. Giddins testified that he could recall only one instance where Odim declined to perform a surgical procedure. That one exception was a child who had initially undergone surgery in Toronto. In that case, the child was returned to Toronto for follow-up surgery.

Once Giddins and Odim had discussed the need for surgery, the patient would be scheduled for an operation at a forthcoming date. Then the case would be discussed by all members of the OR team at the pre-operative conference.

Giddins said he felt that it was at these meetings that any concerns about proceeding to surgery could be raised by other members of the team. Yet these other members indicated that they felt that by the time these meetings were held, the decision to proceed to surgery had already been made by the cardiologist and surgeon. In addition, the matter had already been discussed with the family. In other words, they felt that the decision to operate was a fait accompli. That being the case, they felt there was little opportunity for them to discuss any concerns or raise any objections they might have to a particular patient going to the OR the following week. The only exception would be if there was an issue specific to their field of specialty that had not been earlier considered.

Borton testified that before mid-May 1994 she never heard any discussion at a pre-operative conference of the possibility of sending a child out of province for surgery. In her testimony, Fleming said that she had attended the pre-operative conferences for children whom she was likely to be caring for in the PICU. She testified that by the time a patient was discussed at the pre-operative conference, a decision had already been made to go forward with surgery.