October 20-the case of ER

On October 20, the pediatric cardiac surgery team was involved in inserting a pacemaker in a nine-year-old patient named ER. As an infant, ER had suffered from meningococcemia infection. As a result of this infection, it had been necessary to amputate a number of her limbs. The infection also affected her heart's conduction system.

At the pre-operative conference for this operation (which was attended by the surgeon, the cardiologist, the anaesthetist and the intensivist), there was discussion of what should be done if ER arrested before the pacemaker was inserted. It was decided that a transcutaneous pad would be placed on her chest. This would allow the team to use a precordial pacemaker to pace the heart by connecting it to the pads. The pads would make it possible to pace ER without a direct wire connection to ER's heart.

During surgery, ER went into complete heart block. According to Swartz, who was providing the anaesthetic for this operation, the block was in response to the anaesthetic agents she was using. Swartz said that this was a normal side-effect but was also a complication. ER was treated with a variety of drugs, but her heart did not respond, either to the drugs or to the chest compressions that had also been started. At that point, the team requested that the precordial pacemaker be brought from the ICU.

According to Swartz's testimony, the team was not able to properly connect the precordial pacemaker, which had been recently acquired. Swartz testified that it was her responsibility to connect the pacemaker.

A And we tried the external pacemaker, but it didn't work.

Q Why didn't it work?

A It didn't work because we didn't know-we hadn't attached her leads to the pacemaker. This was the machine that we just acquired within the last week, and we hadn't used it. It was actually in the intensive care unit, not in the OR. So we called for it to come to the operating room, in the meantime we were doing chest compressions, and Dr. Odim managed to get the pacemaker in and we didn't ultimately require the external pacer.

Q Okay. So the external pacer was the first one that you tried?

A We tried it, but we hadn't hooked it up properly.

Q And whose job was it to hook it up?

A I will say my job.

Q Okay.

A So, you know, I wasn't familiar with that pacemaker, so we hadn't put the leads on properly, so we didn't-we ultimately didn't use it and we did get, Dr. Odim did get the pacemaker in and we were able to hook up to that pacer. (Evidence, pages 16,442-16,443)

Eventually, Odim connected a different type of external pacemaker and was able to go on and implant the internal pacemaker. He testified that he was surprised that no one knew how to use the equipment.

The manuals came out. Ms. Youngson, the head nurse, didn't know how to get the machine working, neither did Dr. Swartz, I believe, who was the anaesthetist and also intensive care unit specialist.

So there was a lot of confusion, and no one really knew how to turn the machine on or to get it to function. (Evidence, pages 25,687-25,688)

Once the pacemaker was implanted, Swartz felt that the patient was properly paced from then on and that the operation was a success.

Odim testified that he had not used the machine in Winnipeg before that event.

All I know is at the pre-operative meeting, I asked whether there was a machine in existence, because many a times we will use this as backup sometimes if we are able to get it to capture. And I was told that there was a machine in existence. And I said, well, we better have that on hand for this patient, and I wanted the pads placed; and so that was done. But, what surprised me was that none of the senior personnel, or junior personnel, when we needed it, really knew how to work it. (Evidence, pages 25,688-25,689)

ER was discharged on October 25, 1994. However, she died from a cardiac arrest on July 8, 1995.

While Swartz testified that the level of communications was very good during this procedure, it is apparent that it was not very good in the period leading up to the procedure. If Odim's account was correct, it would appear that Swartz should have indicated that she was not familiar with the pacing equipment he wanted to use as a backup. In addition, if Swartz was not familiar with the equipment, she should have reviewed the use of the pacemaker before the procedure.

The situation concerning the failure to be able to use the new pacing equipment certainly speaks to the inability of the team members to address matters of communications directly at this time in the year. While there was an attempt at briefing the team involved in intra- and post-operative care, there was no follow-through in preparation for the procedure.