February 1994

The restart of the program

Odim took up his duties on February 14, 1994, and performed his first operation on February 28. By March he was performing very complex operations. Until May 1994, when the program was reduced in scope, it would appear that only one pediatric cardiac surgery patient was referred out of province. When compared with the way that Collins helped to ease Duncan into his role as a pediatric cardiac surgeon, this has to be seen as a very rapid start.

Three inter-related issues from this period are deserving of discussion. These are the lack of attention that was paid to team building, the cool response that was given to those nurses who sought orientation sessions to prepare themselves for working with Odim and the approach that was taken to case selection.

Team building

Operations are not performed simply by a collection of individual professionals, but by teams, which require a high degree of trust and strong communication. Teamwork improves over time, through the experience of working together. For this reason, any time there is a hiatus or a new member is introduced to the team, particularly as key a member as the surgeon, the team must undergo a process of rebuilding. As was noted in Chapter Five, the pre-surgical preparation set up at the VCHC by Duncan and Collins involved a series of meetings where team members prepared as a team for the forthcoming surgery. In addition, there were post-operative meetings that served as a forum for discussion of outcomes. Collins and Duncan had worked hard to develop a feeling of trust and open communication, as they recognized that without these, such meetings could easily turn into acrimonious encounters or simply become routine events where difficult questions were avoided and not addressed.

It is worthwhile comparing the startup of February 1994 with the sort of team building that had taken place under Collins. After de la Rocha's departure, Collins and Barwinsky had spent a number of months preparing for the restart of pediatric cardiac surgery. During this preparatory period, steps had been undertaken to ensure that proper equipment was in place, that staff were appropriately trained and that a general awareness of the program's direction and goals was developed, so that all people 'were on the same page' when pediatric cardiac surgery was recommenced. Collins had organized training sessions with nurses and throughout his tenure had met regularly with the surgeon and other medical personnel involved in the cases to assess how things were evolving. Pre-operative meetings were held at which the types of cases that were going to be scheduled for surgery were discussed and the nature of the various operative procedures was outlined. Opportunities were provided at these meetings for members who were going to participate in the program to ask questions and information was shared. Little of that occurred before Odim began to operate in 1994.

Despite the importance of understanding how a surgical team functions, little attention seems to be paid to the issue by the medical institutions that use teams. That was the case for the Pediatric Cardiac Surgery Program at the Children's Hospital in early 1994.

While Giddins was consumed by his workload, as the acting medical director for the Centre, he held a major responsibility for ensuring that the restart of the program in February 1994 took place smoothly and carefully. Odim, as the chief surgeon for the Pediatric Cardiac Surgery Program, also had a responsibility to do so, but seemed to other staff-especially the nurses-to be oblivious to its importance. The failure to ensure that the program started carefully and methodically was to come back to haunt the hospital throughout the year.

The nurses' attempts to initiate an orientation

Shortly after Odim arrived in Winnipeg, Giddins introduced him at a meeting of senior nursing staff. After that meeting, Giddins believed that Odim would arrange his own meetings with other members of the operating-room team, such as the anaesthetists and the nurses. From the evidence, it appears that Odim did eventually meet with most of the team personnel. However, the meeting with the senior nursing staff amounted to the only event approaching a formal orientation that Odim ever received.

The problems with the lack of a proper startup can best be understood in the light of efforts of members of the nursing staff to initiate a proper orientation session with Odim. Before any operations were undertaken, Odim attended a meeting with heads of each nursing department with whom he was to work. According to Donna Feser, the pediatric intensive care unit (PICU) manager, this meeting was attended by the nursing heads of that unit, the neonatal intensive care unit (NICU), nursing director Isobel Boyle and Joan Borton of the VCHC. Each of the nurses gave a description of how their units operated. Feser testified that at this meeting she informed Odim that the PICU was a closed unit. She also said that at this meeting she asked him about his approaches to post-operative care. She testified:

I was interested in what he needed from the nursing staff post-operatively, if there was anything special or anything different that we needed to know in order to look after his patients. Because, as we all know from experience, each doctor usually has preferences.

Q: Right.

A: And will have certain little things that they like to have done, or certain things in place, or certain things available to them. And I asked him, and he said really nothing, nothing special. He did point out, though, that he had information from Boston, that he had some, he had information that he would give us from Boston that detailed pre-op and post-operative care. (Evidence, pages 29,815-29,816)

Feser said that Odim eventually provided her with an academic article written by three doctors. She said this was not the sort of surgeon-specific information for which she was looking.

What I expected was information on what his expectations were pre-op, what they were post-op, and any additional information that he felt we should know in order to better look after his patients. And after looking through it, it was just another article, it really wasn't helpful. (Evidence, page 29,817)

This was to become a recurring issue for the PICU and the NICU nurses. Feser testified that Odim only visited the PICU ward itself a few days before performing his first operation, and the visit was the result of her prompting.

The NICU nurses had similar experiences with Odim. Senior NICU nurse Joan Armitage said that the staff in the NICU sent a memo to Odim requesting specific information from him about his approach to surgery. She gave this description in her testimony of the type of information that the NICU staff wanted:

My primary expectation would be that, first of all, Dr. Odim be very specific with us in terms of his philosophies, he needed to tell us that his surgeries were going to be more reparative versus our previous experience had been somewhat more palliative. Therefore, because they were more reparative the children and babies would come back to the units far more critically unstable than we had known before, that we would be dealing with a lot more delayed sternal closures, and that in general the level of our practice would just have to be stepped up just a tiny bit. (Evidence, page 29,413)

She also said she would have expected Odim to present a series of educational in-services to give the NICU nurses an insight into his approach to surgery and post-operative care. Instead, the NICU nurses also received a copy of an academic article. Armitage said it was of no value in preparing the nurses to deal with Odim's patients.

It was information that we already had had with our previous experience, so it certainly didn't tell us what Dr. Odim's approach would be. (Evidence, page 29,412)

In his testimony, Odim explained that the article had been given to him by Dr. G.W. Wernovsky, a Boston doctor under whom he had trained. Odim had asked him for something he could distribute to his new team to allow them to prepare for working with him. It was apparent from his evidence that Odim never did appreciate the lack of utility of the material he provided to the ICU staff.

The relationship between operating-room nurses and the surgeon must be one in which both have a degree of confidence in and an ability to communicate well with each other. They do not have to like each other, but they do have to be able to work well together in order to accomplish the ultimate objective-doing what is best for the patient. Surgeons must be able to assume that those items essential to the performance of the operation will be present. The nurse must be confident that-emergencies aside-there will be no expectations and demands that are not a usual or expected part of the procedure or have not been clearly communicated from the outset.

Senior pediatric operating-room surgical nurse Carol Youngson sought to arrange meetings with Odim and the OR nursing staff to discuss how he wanted things done for the surgical procedures which he was going to perform. In addition, she attempted to organize a dry run in the operating room. She was, however, largely unsuccessful in her efforts to get Odim to work with her in preparation for the initial operations.

She did manage to arrange a meeting with Odim and others, including Carol McGilton and Karin Dixon (the OR unit manager), before the restart of the program. At the meeting, Youngson had hoped to discuss Odim's surgical preferences and his equipment needs, as well as what sort of differences he might bring from his training in Boston to the Children's Hospital OR. However, instead of engaging in such a discussion, Odim simply presented the nurses with a copy of some preference cards that had been prepared for another surgeon in Boston with whom Odim had trained. He told the nurses that they could use those cards, since they represented the approaches to which he was accustomed.

Preference cards are cards or sheets of paper that outline an individual surgeon's wishes or preferences for individual surgical procedures. On each card, specific operations are identified and a brief description of the procedure is set out, along with a list of equipment that the operating-room nursing staff must prepare and have ready. The cards usually set out how equipment is to be handled and prepared. The preferences can also reflect information specific to the surgeon, such as whether a surgeon is right or left-handed, what size gloves he or she wears, whether the surgeon wishes music to be played in the OR, what type of music and so forth.

The OR nurses usually develop and maintain these cards and use them as a checklist in their preparation for a particular operation and for a particular surgeon. The cards are important tools for nurses to ensure that what goes on in the OR goes as smoothly as possible.

While preference cards were in place for the operative procedures undertaken by Duncan, Youngson had not expected Odim to have his own set of preference cards. Indeed, she viewed the meeting that she had organized as the first step towards preparing a set of cards for Odim.

Youngson soon came to the conclusion that the cards that Odim had given her were not helpful. In her testimony she said at times they gave too much detail, at other times too little. And while Odim may have trained with the surgeon for whom the cards were developed, Odim still had his own preferences, which at times varied from the information on the cards. In addition, the cards referred to equipment that was not yet at the HSC and was in some cases not readily available in Canada.

As a result, Youngson chose to use Duncan's preference cards. As Odim performed each specific procedure, Youngson and her staff would use one of Duncan's cards to prepare for the case, amend the card to take into account what Odim needed and then make up a card for Odim.

Odim demonstrated foresight in having arranged to have a set of preference cards. However, the fact that those cards did not appear to reflect his actual preferences and that he did not take the time to engage the OR nurses in a discussion of his preferences foreshadowed other problems that were to arise.

For example, Youngson asked Odim to consider doing a dry run of an operating-room procedure with the OR staff, but was rebuffed. Youngson wanted a dry run so that Odim could familiarize himself with the physical layout of the OR, where equipment went, how lines were arranged, how and where he preferred to stand and for the OR personnel to acclimatize themselves to Odim's approach. In particular, Youngson believed that the physical space and equipment in Winnipeg would not match Odim's previous experiences.

American hospitals are almost always very well equipped, at least from what I heard, always have state of the art equipment. You know, we had good equipment, but I don't know that I could call it state of the art all of the time. (Evidence, page 8,345)

Youngson testified that Odim said he did not think a dry run was necessary. He told her that he was prepared to accommodate himself to the way that the operative staff had done things under the previous surgeon and that they would not have to do things differently. If there was a need to change things, he felt that those matters could be addressed as time went on. While disappointed, in Youngson's view, it was not her place to insist that the surgeon participate in a dry run. Considering that the purpose of having one in the first place was to establish a relationship among team members, including Odim, the surgeon's refusal to participate rendered a practice session without him futile in her view.

Youngson also proposed a dry run when she met with Odim and perfusionist Chris McCudden, later in February 1994. Odim recalled that discussion and testified that he would have agreed to a practice run if McCudden and Youngson had insisted, but he recalled that McCudden was uncertain, while Youngson was not insistent that a dry run be done. McCudden recalled that Youngson had raised the matter and that neither he nor Odim saw the utility of such an exercise.

The meeting between Odim, McCudden and Youngson took place in the OR, again at Youngson's instigation. At that time, McCudden and Odim discussed issues relating to perfusion, while Youngson showed Odim the sorts of cannulas and suturing equipment used at the HSC. At that time she again attempted to determine his preferences. According to her testimony, he gave the same response that he had given when earlier asked to participate in a dry run, namely that he would simply work with the existing equipment.

The perfusion team as a whole met with Odim as well, before the restart of operations. At that meeting, Mike Maas recalled that they also offered to conduct a dry run. Odim turned the offer down, saying he believed it was not necessary.

Odim also attended one of the anaesthetists' Wednesday morning rounds, at their invitation, before the start of the surgical program. At what Dr. Ann McNeill described as a casual meeting, Odim said that he would be willing to adapt to their local methods and approaches, as well as making suggestions for changes.