The decision to operate
Dr. Cameron Ward examined Erica on October 1 and found her to have palpable but weak pulses in her arms and legs and an enlarged liver. These findings indicated poor blood flow from the heart to the body and congestive heart failure. In his testimony, Ward described Erica as "catastrophically unwell by that stage." (Evidence of Dr. Ward, page 70) He concluded that the only treatment would be a type of Norwood procedure.
Ward treated Erica with prostaglandin to keep her ductus arteriosus open. He inserted an endotracheal tube and instituted mechanical (artificial) ventilation. He also treated her with a diuretic, Lasix, to keep her lungs clear of fluid.
Erica's heart, which had only one working ventricle, faced a number of very difficult challenges if it was to get oxygenated blood to all the parts of her body. The coarctation and the transposition created numerous problems, in terms of pressures and blood flow. To help the function of her single ventricle, Erica was given dopamine, a drug that improves the heart muscle's ability to pump. However, the tasks that her heart was required to undertake actually weakened or compromised it. As a result, she required ever-increasing doses of dopamine.
As noted in Chapter Two, there are only three options for a child with the problems that Erica faced: 1) a heart transplant, 2) a Norwood procedure as the first step in a series of staged repairs, or 3) comfort care until the child's heart fails. In Canada, transplants for patients like Erica were quite uncommon at that time.
This would be the second Norwood-type procedure that the team performed in 1994. Giddins testified that, while Erica was smaller than Daniel Terziski, who had undergone the first Norwood-type procedure, the fact that the team was "that much more integrated would potentially be in her favour." (Evidence, page 4,048) Giddins's view that the team was "that much more integrated" seems out of touch in the face of the evidence, which suggests a deepening rift existed between Odim and the anaesthetists as well as between Odim and the nurses.
Giddins testified that he approved of the decision to undertake the Norwood. He saw no reason to canvass the team members to see if they felt the program was ready to handle this case. Considering the issue of case selection that the anaesthetists had raised during the Wiseman Committee process, and the tensions within the team, this also seems to have been a particularly unwise decision.
Ward spoke to Erica's parents that evening. He testified that he told them that, unless Erica underwent a Norwood repair, she would die. He also indicated that a Norwood itself was an extremely risky procedure that would leave Erica functioning with half a heart. According to Judith Bichel, Ward told them that Erica only had a 30 per cent chance of surviving surgery, adding that the surgeon would probably give the family better odds. In his testimony, Ward said that he could not recall any consideration being given to transferring Erica out of province. He testified:
I don't think that transporting this child would have been a great option anyway. Transporting any sick neonates to another centre when they're requiring intensive care is always to the patient's detriment, and the only question is whether the detriment of that patient overcomes any-any potential benefit that you get from moving to the other centre for the surgery and/or post-operative care. (Evidence of Dr. Ward, page 78)
Ward was also asked about if he had doubts about whether or not the team should be undertaking this operation in Winnipeg.
What was my view? I guess that at that stage I was new to the program. I didn't really have a perspective at that stage as to whether I thought the surgery should or should not be performed there. My own honest opinion was that this child would likely die wherever it was operated on. (Evidence of Dr. Ward, page 79)
Odim saw Erica that evening at 2250 hours and concluded that a type of Norwood procedure was required.
On Sunday Odim spoke with Erica's parents about her condition and diagnosis. He was asked what he told the parents.
I presented those options to the Bichel family, and presented the options in Canada, really being doing nothing or a Norwood operation. And at the time the child had just been resuscitated, and the general consensus, as was my consensus, was that this was going to be a very high risk venture, even more so than usual because of the requirement for resuscitation and drug therapy. (Evidence, page 25,649)
Judith Bichel testified that Odim had explained the repair and its risks to her and her husband. He told them that Erica's chances of survival were fifty-fifty. She said that when her husband had asked if Odim had performed this procedure before, Odim had told them he had not, but that he had assisted in such operations. Why he did not tell them of his experience with the Norwood procedure in the Terziski case is open to speculation. Judith Bichel said that they were not told of any alternatives to this type of procedure; nor was a transfer to another centre suggested.
Odim testified that he could not recall if he spoke with the Bichel family about his own experience with Norwood procedures. Odim was asked if it was standard procedure to discuss either his experience with a lesion or the institution's experience with the lesion with parents.
It was not-it varied case to case, it wasn't a standard procedure to talk about my particular experience or the number of cases that I had done. It came up from time to time with certain families who queried, but it wasn't a standard approach.
Q: Again, the way it came up was if they asked, is that correct?
A: Usually, yes.
Q: Was there any discussion about the possibility of doing this surgery in another centre?
A: Not that I can recall.
Q: Okay. So you don't recall considering that option?
A: No, I don't. (Evidence, pages 25,653-25,654)
It was pointed out to Odim that the decision to undertake this very risky procedure was being taken less than a week after he had sent Blanchard a letter indicating his dissatisfaction with the program. He was asked if there was not a contradiction between the feelings expressed in the letter and the decision to undertake a Norwood.
Certainly the members of the team throughout the year had discussed issues of Norwood operations. It was discussed during the Wiseman committee, and there really wasn't any indication that team members felt that we should not be embarking upon offering this as a last ditch effort for families.
So at the time this procedure was contemplated, certainly the general consensus was this child was too sick to go anywhere. And secondly, if anything were to be done, it would probably have to be done here in Winnipeg. And the families were presented that option, or this family was presented that option, albeit very risky. (Evidence, page 25,655)
Cornel was asked if he thought that it would have been possible to transport Erica to another centre. He replied:
I can't really comment on the first day, but after that she was, all the time she was in hospital I think she was being managed pretty well, and I think she was deteriorating constantly. I don't think she could have, honestly. (Evidence, page 44,874)
When asked if it would have been difficult to transfer Erica, Dr. Walter Duncan testified:
Yes, I think transfer would have been quite hazardous. Again, you can argue it may not be as hazardous as performing surgery. I think that some centres in Canada would not do this type of surgery, given the information. (Evidence, page 41,446)
In a surgical note that he made at the time, Odim wrote that he reviewed all of the options including non-surgical and palliative. He also wrote:
As this is not a true HLHS [hypoplastic left heart syndrome] she falls into a more favourable category of child undergoing the stage one Norwood procedure en-route to a Fontan. The risks and attendant post-operative problems have been discussed with the family in detail. They seem to understand and give their verbal and written consent for operation. (Exhibit 3, page BIC 36)
Odim was questioned about his comments that Erica was in a more favourable category, particularly in light of his statement that hers was a very high-risk case.
[H]er single ventricle was a left ventricle as opposed to a right ventricle in true anatomic hypoplasia of the left side of the heart. And the experience and data seems to indicate that if you have a single ventricle, many a times the left ventricle seems to perform a little better, because it is more programmed embryonically and genetically to do the high pressure systemic work, as opposed to the right ventricle which has a different shape and a different genetic program, just to do pulmonary work. (Evidence, page 25,652)
Odim indicated he had planned for a period of treatment and then surgery on Tuesday morning. The hope was that controlled ventilation, prostaglandin and dopamine would stabilize Erica. However, the evidence shows that she was never in stable condition before surgery.
After the operation, Odim wrote a note to Erica's doctor, Dr. Matthew Lazar. In the letter, Odim wondered if an earlier repair would have made a difference in the outcome (Exhibit 3, pages BIC 21-22). However, none of the witnesses to this Inquest were critical of the decision to attempt to stabilize Erica's condition before surgery.
|Current||Home - Table of Contents - Chapter 8 - The decision to operate|
|Previous||Background and diagnosis|
|Section 1||Chapter 1 - Introduction to the Issues|
|Chapter 2 - Pediatric Cardiac Issues|
|Chapter 3 - The Diagnosis of Pediatric Heart Defects and their Surgical Treatment|
|Chapter 4 - The Health Sciences Centre|
|Section 2||Chapter 5 - Pediatric Cardiac Surgery in Winnipeg 1950-1993|
|Chapter 6 - The Restart of Pediatric Cardiac Surgery in 1994
January 1, 1994 to May 17, 1994
|Chapter 7 - The Slowdown; May 17 to September 1994|
|Chapter 8 - Events Leading to the Suspension of the Program
September 7, 1994 to December 23, 1994
|Chapter 9 - 1995 - The Aftermath of the Shutdown
January to March, 1995
|Section 3||Chapter 10 - Findings and Recommendations|
|Appendix 1 - Glossary of terms used in this report|
|Appendix 2 - Parties to the Proceedings and counsel|
|Appendix 3 - List of witnesses and dates of testimony|