April 13 - the case of CSM

CSM was born on January 15, 1993. Shortly after birth, she was diagnosed with Down's syndrome and a complete AV canal defect. On June 3, 1993, she underwent a palliative banding of her pulmonary artery. (In this procedure a band is placed around the artery to reduce the excess flow of blood through the artery.) After that, she had had frequent bouts of pneumonia, with recurrent wheezing and increasing fatigue on activity.

On April 13, 1994, CSM underwent a procedure where the band was removed from the pulmonary artery and other repairs to her heart were carried out. She underwent CPB for five hours and fifteen minutes and had a cross-clamp time of two hours and fifty-eight minutes.

Her chest was left open for 16 days in the PICU and she required a temporary pacemaker. CSM had problems with her mitral valve, resulting in mitral regurgitation (blood flowing the wrong way through the mitral valve). She also had problems with congestive heart failure and recurrent infections. There were difficulties in weaning her from the ventilator, and she had a prolonged need for inotropic support. She spent 62 days in the PICU and was discharged on June 26, 1994. These times represent a lengthy period of bypass and a lengthy stay in the PICU. Odim agreed that her lengthy bypass time, in addition to the long cross-clamp time, might have hindered her recovery.

While in the PICU, CSM also suffered from junctional ectopic tachycardia (JET), an abnormal heart rhythm with a very rapid heart rate. This condition can be fatal if not properly controlled. There were differences of opinion among the doctors as to how this condition should be treated. This conflict revealed that Odim had not yet understood the protocols regarding the ordering of medications in the PICU.

According to Kesselman, Giddins, after discussions with Odim and Kesselman, suggested that the JET be treated with propafenone, a drug not widely used at the HSC. Odim wanted to use another drug, Pronestyl (also known as procainamide).

Propafenone was not immediately available in Winnipeg. The testimony presented to this Inquest differs as to the way in which events then unfolded. According to Kesselman, propafenone was acquired, but did not prove effective. At that point CSM was treated with Pronestyl, as Odim had suggested. According to Odim's testimony, his orders were overruled by the PICU doctors, who administered Pronestyl only when he put his "fist down".

My recommendation to use a particular drug was not followed for a 24 to 36 hour period while the patient was simply getting worse and worse to the point that I had to at the end of one of our preoperative conferences, after I had come back to discover that nothing had been done, talk to the team.

The intensive care doctor at the time felt that in her experience a certain drug was better but that drug was not in the hospital and I said well, if you don't have the drug and we have Pronestyl in the hospital why are you not giving this child this drug who we may lose while you are waiting to get this experimental drug from Ottawa. I was overruled. They got the drug from Ottawa the next day and give it enterally or through an NG tube, so they gave a drug that's supposed to be given intravenously for a condition, they were giving it through the GI tract and at a subminimal dose.

At that point, I simply had to put my fist down, the Pronestyl was given and within 24 hours the child turned around. So that's an example of a reluctance to-because of turf issues, to follow the lead of the surgeon. (Evidence, pages 26,402-26,403)

It should be noted that propafenone was administered in the manner prescribed by Giddins.

The testimony of Dr. Fiona Fleming, the intensivist caring for CSM during this period, differed from Odim's. When Fleming took over treatment on Sunday, April 17, the HSC staff were not aware of the fact that propafenone was not easily acquired. Fleming testified that when she examined CSM the next day, she discovered that earlier that same morning Odim had written an order calling for treatment with Pronestyl. She testified that she consulted with both Odim and Giddins about Odim's order. The conclusion of this consultation was an understanding that CSM would be treated with propafenone. Fleming said it was not a unilateral decision on the part of the ICU doctors, but rather the result of a discussion between herself, Odim and Giddins. She also testified that all orders written on the charts had to be signed by the ICU staff intensivist. When the propafenone arrived and failed to bring about an improvement, Fleming testified, after a further consultation with Odim and Giddins, a decision was made to use Pronestyl.

In commenting on Odim's description of the event, Fleming testified that she did not believe the issue was one of turf but one of communication.

That my understanding was the course of action had been agreed upon, and that Dr. Odim had decided he wanted something different, which in retrospect turns out to be the correct drug, but it was left on the chart, with no telephone call to myself, no conversation to my resident, and I don't know whether he or Dr. Giddins discussed it between themselves. But certainly when I discussed it with Dr. Giddins later that morning, he said, no, we are going to use propafenone. (Evidence, pages 35,996-35,997)

As Fleming noted, it appears that the drug that Odim wished to use in treating CSM was more effective. However, it also appears that he had not familiarized himself with the PICU protocols. It also appears that he did acquiesce to the use of propafenone which, according to Fleming, was the drug preferred by Giddins.

Odim testified that it was only after this case that he came to understand that he could not write medication orders for the patients in the PICU. While he said that this concept was new to him, evidence from Feser suggests that this had been brought to his attention in February at their initial meeting and again at a meeting on March 22. At this second meeting, it appears that Feser had spent a considerable amount of time discussing this issue. Either Odim wilfully refused to adapt to the PICU practices or he simply did not pay attention to important information that the nursing staff presented to him. Neither possible explanation speaks well for him.

On April 18, the PICU senior team leaders held a meeting. According to notes taken at the meeting by Feser, one of the issues discussed was that of Odim's attempts to prescribe medication to patients in the PICU. According to Feser, there were a number of problems that arose out of Odim's apparent lack of regard for the PICU protocol. In some instances, Odim would speak to the PICU nurses in the morning to discuss how a patient had done overnight. During these conversations, he would tell the nurse to change some aspect of the patient's medication. However, the nurses were not supposed to make any changes to a patient's medication that had not been ordered by an intensivist or an ICU resident. In addition, Odim would give orders directly to nurses at the bedside. Feser testified:

In fact, you know, by this time he is also, he is getting annoyed because he is asking, like why wasn't this done, because I had asked for this to be done. Where he is not really, he may have mentioned it to the bedside nurse or asked it, but he has not relayed that in full detail to the resident or the intensivist. So we are wondering, what are we supposed to be doing? Are we going to maybe change what we have been doing in the past? (Evidence, pages 29,989-29,990)

This problem continued throughout the year.