Pre-operative condition

While there was little disagreement with the decision to operate on Gary in March, questions have arisen as to whether or not he was in fact healthy enough to undergo surgery. Some of the consulting witnesses who assessed this case raised concerns about whether or not Gary Caribou was suffering from an infection at the time of his operation. If this was the case, then it may not have been appropriate to operate. Cornel, for example, stated that Gary's preoperative status was possibly compromised by an undiagnosed chest infection.

As early as November 1993, it had been noted that Gary was experiencing wheezing throughout both lungs. From the end of December, he had suffered through two bouts of fever while in Lynn Lake and had been treated with antibiotics, although tests had not indicated that there was an infection.

On February 28, when he was readmitted to the HSC, extensive wheezing was again noted, along with moderately severe subcostal and intercostal in-drawing. Subcostal and intercostal in-drawing are indications that a patient is having difficulty breathing. The first seven ribs are attached to the breastbone by costal or rib cartilages. Subcostal means under the rib and intercostal means between the ribs. These terms together describe the situation in which a person's breathing is so difficult that the skin below or between the ribs is sucked in each time the patient takes a breath. Thus, Gary's breathing difficulties were worse than they had been in December.

Gary's liver was also enlarged. This was a sign that he may have had heart failure or he may have had lung congestion from a lung problem that was not related to his heart problem. The enlarged liver could also indicate that, because of the very fast rate at which Gary was breathing, his lungs had become overinflated and were pressing down on his liver.

There was ongoing discussion among Gary's doctors as to whether or not Gary suffered from a lung problem that was primarily due to his heart problem, or if he had a lung problem that was primarily due to reactive airways disease.

Because of the varying opinions as to the cause of Gary's breathing difficulties, there were also differing views as to how this condition should be treated. McNeill testified that there was a question as to whether or not to increase Gary's diuretics. She said that Giddins was of the view that it would make no major difference to Gary's condition, since the primary problem was significant reactive airways disease.

However, the Pediatric Service did, on occasion treat Gary with extra doses of diuretics as needed to cope with his heart failure. In addition, respirologists had concluded that Gary did not have an acute viral infective process but suggested that something more be done to improve his heart condition, which could be in the form of more or different medication. Odim, Giddins and McNeill also concluded that there was no infection but that Gary's breathing problems could not be addressed until his cardiac problems had been dealt with by surgery. McNeill also testified:

What I am saying is the respirologist, the cardiologist and myself all believed that his respiratory status was a combination of primary respiratory reactive airways disease, with a contribution from his cardiac condition. (Evidence, page 13,072)

Gary's breathing problems and the doctors' differences of opinion continued right up until surgery. On March 1, Giddins examined Gary and heard wheezing. He noted that Gary's chest X-ray showed over-inflated lungs, with mild enlargement of the heart. He wrote that the X-ray suggested "signs of more chronic respiratory nature than pulmonary edema." (Exhibit 5, page CAR 81)

Pulmonary edema, or fluid in the lungs, occurs when the heart is in failure. In this condition, blood backs up in the lungs and fluid from the blood passes into the tissues of the lungs. Giddins suggested discontinuing the digoxin and then the Lasix, a diuretic. This drug helps the body get rid of excess fluid and treats pulmonary edema. Giddins indicated that the obstructive airways required treatment. He also suggested doing a test to rule out cystic fibrosis, and consulting with the Respirology Service.

On March 2, the digoxin was discontinued, but the Lasix was still given twice a day and sometimes an extra dose was required. The report from the chest X-ray taken that day suggested "the findings may be the result of pulmonary edema." (Exhibit 5, page CAR 109)

On March 3, despite being treated with Ventolin, a bronchodilator, Gary had increased respiratory distress. He had decreased air entry in both lungs, with increased wheezing and took longer than normal when exhaling (a sign of increased respiratory difficulty). He had gained 278 grams in three days and 108 grams overnight. (This rapid weight gain was considered a sign of fluid retention.)

At 1445 hours the senior pediatric service resident wrote, "RSV [Respiratory Syncytial Virus test] negative but may have underlying lung disease (obstructive)." (Exhibit 5, page CAR 49) This assessment suggested that Gary's current respiratory status was likely the result of his heart problems and possibly related to discontinuing the digoxin. At the time, Gary was given an extra dose of Lasix.

Later that day, Dr. Salvador, a cardiology resident, saw Gary and determined that his current respiratory distress was not due to sudden heart failure but was the result of either a respiratory infection or his having had a viral infection. Salvador maintained it was too soon after stopping digoxin (24 hours) for Gary's problem to be heart failure. Salvador suggested that Gary not be given any digoxin that day. He added that if the next day it appeared that heart failure was exacerbating the chest condition, Gary should then be treated with digoxin. The results of a chest X-ray taken that day indicated a slight worsening of the pulmonary edema.

On March 4, Giddins wrote in the chart that there was no need for digoxin and commented that there was certainly significant shunting (from the VSD). Dr. K. Bergen noted that although there was still significant wheezing present that day, a change to another bronchodilator, called vaponephrine, had made a significant improvement in Gary's chest. The antibiotic, which had been started in Lynn Lake, was stopped. During this time Gary also continued to have occasional regurgitation and/or vomiting with coughing spells. The tests for cystic fibrosis and RSV infection were negative.

From then until the evening of March 8, Gary's condition remained relatively stable. However his weight increased 400 grams from March 7 to March 8 and an extra dose of Lasix was given in the morning of March 8. Bergen noted, "Lasix in extra doses have [sic] also been used to decrease wheezing secondary to CHF [congestive heart failure] identified by large increase in weight." (Exhibit 5, page CAR 58)

On March 10, a respirologist examined Gary and found he had wheezing when breathing, along with mild in-drawing. His weight had also increased. The same specialist noted that Gary had respiratory symptoms related to his cardiovascular status, but these symptoms were responding to vaponephrine. He also suggested increasing the diuretics and restarting digoxin. It was noted later that day that Gary had an occasional discharge from his nose.

That same afternoon, McNeill saw Gary in order to conduct an anaesthetic assessment. She noted that he was wheezing. He looked distressed, had flaring of his nostrils and in-drawing. (All of these were signs of difficulty with breathing.) McNeill reviewed Gary's test results and concluded that his borderline congestive heart failure was still not being controlled completely. She questioned whether or not his diuretic therapy should be increased pre-operatively. She suggested that post-operatively Gary would likely have poor ventricular function, with increased pulmonary vascular resistance, and that there was an increased risk of respiratory complications. McNeill also noted that she would reassess his clinical status pre-operatively.

When questioned, she said that she returned to reassess Gary but did not record her findings in the chart. She agreed that she should have done so. She said Gary's condition continued to vary and that no single treatment seemed to be able to correct the situation (Evidence, pages 13,084-13,085).

By that evening, Gary was in moderate respiratory distress, with a fair amount of wheezing. Another dose of Lasix was given, as well as vaponephrine, which improved his air entry.

Wheezing was noted again on March 11 and March 14, along with a large amount of nasal discharge, just before surgery. However, no further tests were conducted to see if Gary had a lung infection. Several expert witnesses commented on the decision to operate without checking further for a lung infection. Cornel stated:

The cause of the wheezing was not clear and if there was serious concerns that this was an infectious origin I feel that more viral studies were indicated. I believe this baby's respiratory problems placed him in a higher risk group for surgery. (Exhibit 353, page 11)

It is worth noting here that Gary's mother had not been told that there was any increase in his risk level from his respiratory problems.

A pre-operative infection is a source of potential danger for any patient. In its directions to parents of its patients, the Variety Children's Heart Centre specifically warns parents to watch their child for infections and colds before surgery and to advise medical staff of any such problem on admission. The importance of guarding against colds and other infections has to do with the child's ability to deal with the impact of open-heart surgery, particularly on lung function. There is also a concern that a child with an infection could pass that infection on to other children in the PICU.

In his testimony, Cornel stated that it was his practice to postpone surgery in the face of an active viral infection.

I am concerned that we should not operate if we don't have to when there is a remedial problem in front of us. So a suggestion of a viral infection makes me back off. And a suggestion can be a running nose, a cough, a fever that is unexplained, or a fever at all.

I like all these symptoms to be clear, because if a child seems to have something mild that is going away, we do not know, without a little time, if that's a precursor to a more serious illness that is coming, or the tail end of something that has just gone. Therefore, I will usually postpone surgery if there is any suspicion of an infection. (Evidence, pages 44,688-44,689)

Dr. Robert Hudson¹ said that Gary "was still not in optimal condition at the time of surgery." (Exhibit 307, page 1.13) He said that with appropriate therapy it would have been possible to improve his condition. "Therefore, regardless of the etiology of his respiratory distress, he was taken to the OR without optimal treatment of his cardiac and/or pulmonary problems." (Exhibit 307, page 1.14) He wrote in conclusion that "in my opinion, this patient's cardiorespiratory problems were not optimally treated before surgery. This is a basic standard of care in elective situations." (Exhibit 307, page 1.15)

These experts seemed to be suggesting that as a result of his VSD, Gary was in congestive heart failure, and likely had an underlying infection lurking in his lungs. That infection they felt required treatment, or at the very least, further exploration.

Odim and Giddins, on the other hand, indicated that they were of the view that Gary was not suffering from a chest or any other type of infection at the time of the operation. Giddins pointed to the fact that Gary did not have a fever at any time after his admission until the operation and that elevated temperatures were inevitably present whenever there was an infection. Giddins acknowledged that tests for infection were not ordered before the operation but that such tests were not routinely ordered pre-operatively.

Odim similarly said that he saw no signs of an infection and that he felt Gary was in the best condition they could get him in before the operation. Giddins, as well, thought that Gary was not going to get any better and that the longer they waited, the worse his condition was likely to become.

McNeill testified that after speaking with the respirologists and cardiologists, she was satisfied that they had done the best they could to get Gary in the best possible condition for surgery. She did not believe that anything else could have been done pre-operatively to improve his intra-operative or post-operative cardiac function. She agreed with Giddins's assessment that his cardiac lesion was the key problem contributing to his pre-operative status and to his cardiac problems post-operatively. In her testimony, McNeill said that she did not believe that more aggressive treatment would have made any difference in Gary's condition pre-operatively. When asked if ensuring a child was in optimal condition for surgery was a shared responsibility, McNeill testified:

It's a shared responsibility. Between, well, the anaesthetist and whatever medical person is involved, so in these cases, a cardiologist or respirologist, if there are other consultants involved, and the surgeon also has a responsibility that surgical related issues are controlled or treated or dealt with properly. (Evidence, pages 13,795 - 13,797)

When asked if she were unable to resolve the concerns she had about a child's preoperative condition, whose decision it was as to whether or not to give the anaesthetic, McNeill testified:

Well, I mean, the bottom line is that if you do not feel that you can-to give an anaesthetic to any child for any reason, medical, social, technical, whatever, it's our final responsibility or our final judgment to withhold the anaesthetic. (Evidence, page 12,930)

In Gary's case, McNeill spoke to both Giddins and the Respirology Service before making her decision to go ahead with the anaesthetic. She testified:

So having those views expressed to me, I decided that we would go ahead, accept that his lungs were not dry, and we would perhaps have problems peri-operatively with his respiratory function because of that. Also knowing that his cardiac function was not totally normal because of the lesion that he had, and that we may have post-operative difficulties with contractility given his pre-existing, or pre-operative cardiac function, plus what we were going to be doing to him.

So that would be my assessment of going in, that he was at increased risk for both respiratory and cardiac dysfunction post-operatively. (Evidence, pages 13,098 - 13,099)