Winnipeg Free Press - PRINT EDITION

New baby heart scare

Botched procedure prompts review 16 months after report on '94 deaths

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A botched heart procedure on a newborn baby at Children's Hospital in December temporarily halted a key part of the children's cardiac program.

The baby survived, but the incident has raised fears that the continuing fallout from the 1994 baby deaths tragedy may kill pediatric cardiology in Winnipeg once and for all.

The latest incident, in which a newborn's heart was pierced by a catheter, sparked a review of Winnipeg's pediatric heart program by three outside doctors who recommended immediate improvements that the hospital says have now been implemented.

The review comes only 16 months after Judge Murray Sinclair issued sweeping recommendations for change after his inquiry into the 1994 tragedy, in which 12 babies died after undergoing heart surgery.

That tragedy closed the pediatric heart surgery program in Winnipeg permanently.

Pediatric cardiologists here are allowed to continue performing diagnostic work and non-surgical interventions, such as catheterizations.

The latest review identified a lack of surgical backup available in case of mistakes, the need to recruit a more experienced pediatric cardiologist, and a failure of the program to properly report and discuss pediatric heart cases among the different departments involved in their care.

Dr. Michael Moffatt, head of pediatrics at Health Sciences Centre, said 95 per cent of the review team's 14 recommendations for improvement were implemented before cardiac catheterizations were restarted at Children's Hospital at the beginning of March.

In a heart catheterization, a thin plastic tube is inserted into the heart through a vein to open a blocked heart valve.

General surgeons are now on call whenever a child undergoes heart catheterization, and there are now regular meetings of health professionals in Winnipeg to discuss children's cardiac cases.

Health Minister Dave Chomiak said he is confident the situation has resolved itself.

"Post-Sinclair, there are a bunch of things we are doing differently," Chomiak said. "I've been advised from medical experts that there is no problem here."

In the December incident that prompted the review, the catheter slipped and pierced the baby's heart wall. The baby was stabilized in Winnipeg and then rushed to Edmonton, where the procedure was successfully completed.

Moffatt said this particular problem is a known risk and occurs in the biggest health centres with the most experienced doctors. Despite that, hospital administrators still wary over the 1994 tragedies immediately halted all such procedures and called in an external review team.

That team, in addition to making recommendations to fix the problems they found, chastised the program's administrators for being oversensitive to problems as a result of the 1994 deaths.

"It is INAPPROPRIATE (the report's emphasis) for a recognized complication of a procedure to result in suspension of services to children with congenital heart disease," the doctors wrote in their report.

Moffatt says Winnipeg's poor reputation for pediatric cardiology since the 1994 incidents is the biggest obstacle it faces.

"Nineteen-ninety-four was a disaster and we're still living with it," Moffatt said.

He said over-reaction to incidents like the one that prompted the review could drive the program into oblivion.

"If we keep stopping and starting it, we're going to drive our cardiologists away," he said. "It's not hard for them to find a job elsewhere."

The latest report makes clear that Manitoba children would be in grave danger if there is no heart program for them in Winnipeg. About 120 Manitoba children, mostly babies, are diagnosed with congenital heart defects each year, and they need a program here to diagnose and monitor their diseases.

"The report says we must have a cardiology program in Winnipeg. We'll be putting children at extreme risk if we don't," Moffatt said.

But keeping that program alive is not easy. The cardiology program's reputation and the lack of a pediatric heart surgery component have made it impossible to recruit an experienced cardiologist to oversee the program. The two pediatric cardiologists working here now have both recently completed training, and while they are skilled and respected, the lack of an experienced cardiologist still causes concern.

"I think there is some truth to that," Moffatt said.

An experienced cardiologist from India has signed an agreement to move to Winnipeg this summer, but Moffatt isn't completely certain she will come. The review team said her arrival is crucial to the future of the program.

'Mentoring role'

"With her considerable experience, both in clinical care and in political discussions, it is hoped she will provide a mentoring role," they wrote in their report.

In the meantime, the program is relying on visits from pediatric cardiologists from Edmonton to help mentor and teach the doctors here and provide relief for their busy schedules. The latest report said the program should have four pediatric cardiologists, not just two.

Winnipeg's doctors are also travelling to Edmonton with some of Manitoba's high-risk pediatric patients to gain experience by helping with the procedures there.

Both of these practices were recommendations made by the latest external review.

Liberal Leader Jon Gerrard said there are eerie similarities between some of the new recommendations and those in the Sinclair report.

"It's like looking at Sinclair all over again," Gerrard said after reading the recommendations made by the review committee.

Sinclair's report concluded that an inexperienced surgeon without proper supervision and a failure to properly communicate about the deaths as they occurred led to mistakes that ultimately cost the 12 children their lives. Lawsuits against the hospital and staff involved and an investigation by the Manitoba College of Physicians and Surgeons into the conduct of surgeon Dr. Jonah Odim are ongoing.

Not surprised

Margaret Feakes, whose grandson, Ashton, died at 15 months after having heart surgery in November 1994, said she was dismayed but not surprised by the recent events.

"Here we go again," Feakes said. "What is it going to take for the recommendations Sinclair made to be done? There seems to be no limit for these people. Is it going to take another 12 deaths?"

Gerrard said while he congratulates Chomiak and Moffatt for reacting swiftly when there was a problem, the fact that they did not make the incident or the review public concerns him.

"This raises the concern that there may be problems we don't know about" Gerrard said. "It's time to have a system that is ready to share."

Restore reputation

He added it furthers his desire to push Chomiak to implement Sinclair's recommendation to develop public records of a doctor's experience and performance.

"I want to feel comfortable that things are not being hidden," he said, adding such information would also give Manitobans greater confidence in their health-care system and perhaps eventually restore the pediatric cardiology program's reputation.

Gerrard said this particular program should immediately begin making public, on a weekly or monthly basis, the number of heart catheterizations performed on children and what the outcomes were, including complications.

Moffatt said the improvements to the cardiac program here are impressive, and include a drop in mortality from 13 cases in 1994 to three cases in 2001.

"I have complete confidence in our program," Moffatt said.

mia.rabson@freepress.mb.ca

Republished from the Winnipeg Free Press print edition April 13, 2002 $sourceSection$sourcePage

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