Case selection

During the period that Collins was the head of pediatric cardiology at the HSC, pediatric cardiac surgery was carried out by three different surgeons: de la Rocha, Barwinsky and Duncan. Collins ended de la Rocha's Winnipeg career because he was not satisfied with de la Rocha's surgical results. Flowing from his experience with de la Rocha, Collins was careful to ensure that the program never again took on cases that were beyond the skill level of the attending surgeon. This meant, if necessary, erring on the side of caution and sending children out of province.

While the HSC was attempting from the outset of Collins's arrival to establish itself as a heart centre capable of treating any and all patients referred to it, in very few years did the program actually do all possible cases. From its inception, the pediatric cardiac surgery program at the Children's Hospital regularly referred patients to other heart centres in the country, including Saskatoon, Edmonton, Vancouver and Toronto.

While it was always understood that cases could be referred out of province, there also seems to have been an inclination not to refer cases away unless there was a good reason for doing so. What those reasons were seem to have hinged on the question of whether or not the surgeon felt capable (or felt the team was capable) of performing the operation in question. According to Collins, he essentially left the question for Duncan to decide, although Collins seemed not to have been too shy about expressing his view as to whether or not a particular case should be done in Winnipeg.

One would have thought that when a new surgeon arrived in Winnipeg, the entire question of which cases would be done here and which would be sent out of province would be revisited. There is some evidence that this was the case. Odim gave this description of the approach that he and Giddins had agreed upon.

The plan was essentially we would slate the elective cases and we would get a chance to meet families, and then we would tackle the emergencies as they came. So that the program would start up by vetting the elective cases on the slate, meeting with the families, reviewing the data, and booking them. And of course during this period, we would take whatever emergencies came through, like any other service. (Evidence, page 23,948)

Odim said this did not mean they would operate on each emergency, but that they would review it. The only cardiac lesion that Odim said that they expected to have to transfer out (or have an outside surgeon come in to address) was Transposition of the Great Vessels.

Despite Odim's view that this was "understood", there appears to have been remarkably little discussion of this approach with anyone other than Odim and Giddins. None of the anaesthetists could recall Odim or Giddins discussing the matter of case selection with them before operations resumed. The same could be said of the nursing staff, the perfusionists and staff in the ICU. If there was an agreement on the matter of case selection, then the agreement appears to have included only Odim and Giddins.

At the same time, other staff involved in the program said they 'assumed' that the cases the surgeon would be undertaking at the outset would involve only the simplest of lesions. There seemed to be a consensus that the program should and would start off by doing only those cases that presented the lowest risk for morbidity and mortality. However, problems arose when more complex cases were undertaken more quickly than some involved in the program felt was appropriate.

While Odim said the plan was to start with the simpler elective cases, the complexity of the cases being done by the program quickly escalated. Within a month, Odim was performing operations that he described as cases of moderate complexity (the Caribou, Ulimaumi, and Goyal cases, all to be discussed in this chapter). Rather than sending any patients out of province initially, the more complex cases appear to have been simply deferred until later in the program. The problem with deferring pediatric cardiac patients, however, is that eventually-and in some cases sooner than others-the condition of the child will become more critical. In his testimony, Odim said the Caribou and Ulimaumi cases were dealt with because they had become urgent.

At least one member of the VCHC staff was surprised with the lack of formal discussion about the approach that was going to be taken to restarting the program. Nurse clinician Borton testified:

I thought that we would all sit down and find out what his experience had been in terms of slating procedures. I thought we would decide to do simple to complex cases, in that order. I thought he would want to know what we had done before in terms of pre-operatively, and what our routines were. (Evidence, page 18,121)

This did not take place. Within the first four months, Odim had undertaken a first-stage Norwood reconstruction, a particularly difficult procedure. The decision to offer this operation was undertaken by Odim and Giddins without any prior discussion with the neonatologists or the anaesthetists (or any other member of the surgical team).

Given that both Odim and Giddins were new to their positions in 1994 and quite inexperienced, their department heads-Bishop and Blanchard-ought to have ensured that there was a better plan in place, which would restart the program in a staged manner. There does not appear to have been any such instruction or planning.