Learning from Judicial Inquests into Health Care Incidents

Today the recommendations of the Inquest into the death of Heather Brenan have been made public.
I take particular interest in this inquest as we were in the Emergency Room only a few days before Heather Brenan arrived at Seven Oaks General Hospital (SOGH).  We had front row seats to the circumstances that existed at SOGH during January of 2012.  A few weeks after our experience I wrote a letter to management at SOGH.  I received a very thoughtful and reasonable response from the Chief Medical Officer.  At the hospital's request, I consented to have my letter shared with the staff at SOGH.

Here is an except from that letter written in February of 2012.

Events of Jan 12-13, 2012

My wife was taken by ambulance to Seven Oaks General Hospital Emergency Room after she was in a car accident at about 5:30 PM, Jan 12.  The injuries she sustained were not life threatening and when she called me to let me know, she suspected she may have a broken foot.  She arrived at the ER at about 6:00 or shortly after.  I arrived at about 7:00 as I had to find child care for our two children and drive to Seven Oaks, as we live in the Lockport area.  During this time she was in extreme pain and probably had some symptoms of shock.  My wife (Susan) as previously mentioned has a Congenital Heart Condition, Hypertrophic Obstructive Cardiomyopathy (HOCM).  As part of the treatment for this she has an AICD.  This information was conveyed to emergency services personnel and to the triage nurse upon arrival at Seven Oaks.

Susan saw a physician assistant at approximately 8:30 PM.  I believe the attending physician was Dr Van Dyk although we never actually saw him/her.  X rays were taken and the diagnosis was one broken toe and one dislocated toe.  The dislocated toe was reset and the toes were taped and we were sent home with a prescription for pain medication.  We left the hospital approx 10:00 – 10:30PM.

The next morning, Jan 13^th, we received a phone call from the SOGH emergency room.  The caller stated that the Susan’s x-ray had been reviewed by a radiologist and that they wanted us back at the hospital for a CT scan and that Susan would likely be referred to an orthopaedic surgeon as the foot is broken.  We were told to come into the hospital and let the triage nurse know that Dr Abbott had requested her to come in and to let him know that she was there. We proceeded to the hospital and arrived at 11:00 AM.  We notified the triage nurse and explained why we were there.  We waited for nearly 3 ½ hours.  Once we were taken to a treatment room…we received an apology from Dr Abbott as there had been a communication error and that Susan was supposed to be brought right in and not have to wait for hours.  We were waiting so long that we nearly missed the CT scan as the staff were heading home for the day.  We did get the CT Scan, which confirmed a diagnosis of a lisfranc fracture , and after that there was significant amount of discussion about the best course of action.  We ended up leaving the hospital at about 9:00 PM.  In the end, Susan was referred to Dr Chris Graham at HSC, where she had surgery on her foot.  As I stated earlier, the outcome of our experience was a good outcome.

Concerns:

• I was very upset at the condition my wife was in when she was dropped off by emergency services at the emergency room.  She was placed into a wheelchair, and placed in a corner by herself, and ignored.  She was in so much pain that she was in tears when I arrived.  From what my wife told me she received first class treatment from the paramedics at the accident site, but when she arrived at the hospital it seemed she was forgotten about.
• On several occasions, we reminded the staff of Susan’s heart condition.  We got the reaction we usually get when we explain this condition…a blank stare.  I am convinced no one had any idea what we were talking about or had any clue what HOCM is.  For a patient such as Susan she should have been put on a monitor.  Not once did anyone inquire anything about the condition or acknowledge our concern.
• The fact that the fracture was missed in our first visit is a concern, but I view this as a medical issue that I am not qualified to comment on.  From my understanding, a Lisfranc fracture can be difficult to detect.  I was pleased that the error was caught the next day.  Obviously the procedure works; as the error was found upon review.  I would think that a typical incident report would be done when these types of issues come up.  I am confident this can be managed in house.
• The communication in the emergency room seems to have failed as the information about my wife coming back to the Emergency Room should have been conveyed to reception at Emergency and Dr Abbott notified that we were there.  We assumed this happened but it did not.  When you ask a question of Emergency Room staff you feel like you are imposing and monopolizing someone’s valuable time.  You are expected to patiently wait and not ask questions.  
• We were somewhat frustrated by our experience at Seven Oaks but in the end Susan had the surgery she required and Dr Abbott did a good job of advocating for us.  However, when Susan received her follow up at HSC, we conveyed some of our experience at Seven Oaks to the staff at HSC.  The quote from them was…”that is why they call it Seven Jokes.”  I did not really appreciate that comment.  This is an off-hand remark that really does not matter; but is this the perception that is out there?  As a leader in that facility…that would concern me.

Opportunities

• You have a dedicated and hard working staff; that is very capable.  The concerns I have stated above (if you investigate them) will likely determine a root cause of a failing of a policy or process.  People make mistakes and have errors in judgement.  It should never fall to one person alone to make a system or process work.  
• Own the Waiting Room!  The treatment process (in some form) should begin as soon as you walk in the doors of the hospital.  My feeling is that just about anything could happen in the waiting room and chances are no one would notice what was going on until it was too late.  Waiting and delays are part of the process, but people’s condition can change significantly in the hours they have to wait.  Those who are in the waiting room need to be monitored and checked occasionally.  Perhaps even talk to them.  The feeling we got was that until you actually make it into a treatment room you were not really in the hospital…you had not yet penetrated the “system.”  The way the Emergency Room is constructed you cannot see the vast majority of the waiting room from the triage desk.  Compare this to the Emergency Room at Children’s Hospital, where you can see the entire waiting room from the triage desk.  If anything happens in that waiting room…it can be seen.
• The general public does not know “hospital-speak.”  We, as patients, do not know how to access the system nor the terminology to do so.  Critical information can be misinterpreted and misunderstood.  For those of us who have spent extended periods of time in hospitals we have had to learn how to navigate the system, and it is challenging, even for those who know how the system works.  There needs to be a better way for communication to happen between patients and medical professionals.  I cannot emphasize how critical this is.  When we brought my son into emergency on Oct 2, 2008, if we had not chosen our words carefully and asked the right questions our son would have died in the waiting room.  It is because our cardiologist prepared us ahead of time, and educated us, that we were able to communicate effectively and ensure that our son was seen immediately as opposed to waiting.

My purpose in sharing this letter is this. When you consider all of the cost and time of a judicial inquest, is it not more effective to listen to patients and caregivers and learning from their feedback?  

Patients are capable of providing valuable feedback that can lead to meaningful change and do it far more quickly.  As a result of my feedback to SOGH I was asked to participate in an process review of the Emergency Department processes at SOGH.  I was able to provide candid feedback, and more importantly learn about many of the challenges faced by staff in city Emergency Rooms.  I gained a new respect for many who work in our hospital ERs but was very disheartened to learn of all the challenges and shortcomings of our health care system.

I think judicial inquests do provide valuable information and important recommendations.  My concern is that it seems like an immense amount of effort to get to information and improvement that should be readily available.  It is reasonable that with an effective incident investigation and input from all stakeholders (including patients) to improvements can be made in weeks; not the years it takes for the judicial process.  Changes need to be made quicker and more efficiently.

I was fortunate enough to be able to engage the hospital and provide feedback through my letter, and my continued relationship with the hospital.  However, I am curious what Heather Brenan would have shared with the hospital about her care at SOGH?  Unfortunately, even with a judicial inquest. that is something we will never know.

Merry Christmas 2015

Another Christmas Eve is upon us.  Many people are doing their last minute preparations for their annual celebrations.  This is a day that I will always be reminded of our Christmas at the Stollery Children's Hospital as Russell was being kept alive on a Ventricular Assist Device (Berlin Heart) and he was waiting for his heart transplant.

Christmas Day 2008
Stollery Children's Hospital  4C - ICE

Susan and I remember this Christmas very differently.  As strange as it may sound I enjoyed this time.  Russell was stable, for the most part, and all of the efforts the hospital made to make Christmas enjoyable for all of the families was enjoyed and appreciated.  Last year I saw a picture of the preparations that were made by the hospital for Christmas Day.  Child Life does a phenomenal job of putting on a very special Christmas morning.

Christmas Preparations at the Stollery
Santa's Workshop

Susan remembers this Christmas very differently.  As she describes it, she would be happy wiping this memory away forever.  At this point we were still waiting for Russell's donor heart and our patience was being tested.  The Berlin Heart had provided a capable bridge to get us to the transplant but even that was risky.  We were one clot away from a stroke or there was also the risk of bleeding due to the anti coagulation.  It was a tenuous balancing act we were performing and Susan felt every but of that pressure.

In the midst of all of that chaos, we did manage to celebrate Christmas with family.  For better or for worse it is a Christmas we will never forget.  We are also reminded how far we have come in 7 years.

Nicole and Russell - Christmas 2015

As Susan had her procedure earlier this week we were also reminded that our journey continues and is far from over.  We will enjoy every moment we have together as we think of all of the families who will be spending the holidays in the hospital.  We hope they can find joy in trying circumstances.  For all of our friends who are spending Christmas in one of our hospitals we wish you a very Merry Christmas and to all of the volunteers and hospital staff, who make a Christmas in hospital a little more enjoyable, a heart felt "Thank You"; your efforts are greatly appreciated.

The note below is for all of the fine people who help make Christmas in the hospital possible.  

'T'was the Night Before Christmas

'T'was the night before Christmas, 7 short years ago,

Where we found ourselves, far from our home. 

I remember the cold;that memorable night.

As our tiny boy, was far from all right. 

In the Stollery's care our boy stayed in good stead

His heart beat held steady with a device by his bed.

Our future uncertain, our outcome unknown

A new heart for Christmas; our impatience had grown.

Our journey had started three months before.

  His heart fell ill and could not take any more.

My 8 week old boy's heart was nearing the end.

His heart was sick and could not be mend.

ICU and hospital our new home became

A heart for a transplant became our new aim.

The days turned to weeks and our fate seemed so grim.

The watching and waiting was doing us in.

One offer, then another; not quite a right fit

Could Christmas bring that one special gift?

Christmas day came, our gift did not come

Another day gone; unanswered prayers to some.

 

One day passed and then another, an end not in sight

We doubted and fretted; would our boy win this fight?

But unknown to us the stage had been set.

In a city far away in the Pacific Northwest.

Another young boy was clinging to life.

A story filled with sorrow and unfortunate strife.

The stage was now set; a decision was made.

A call of compassion and plans were well laid

Early that morning just before the New Year

A heart had been found; joy replaced fear.

The waiting was over; a new chapter began

Our gift of new life was all part of the plan.

As I think of this time and memories so fond.

We stop and remember my son's kindred bond.

A selfless choice, by a father and mother.

A new beginning for us; an end for another.

At this time of year I remember our plight

And our special gift that ended our fight.

Our Christmas wish to one and all.

Is of joy, and peace, and thanks above all.

Merry Christmas from Donald, Susan, Nicole, and Russell

What is Hypertrophic Obstructive Cardiomyopathy (HOCM) ?

I assume some of my blog posts over the next little while may have something to do with Susan's Heart Condition.  I thought it would be a good idea to back up and explain exactly what she is dealing with.

Susan's condition is a congenital heart defect called Hypertrophic Obstructive Cardiomyopathy (HOCM).  Congenital Defects are common and effect approximately 1 in 100 babies that are born.  Congenital heart defects range greatly in severity and complexity.  Some defects may be as straight forward as a hole in the heart between the heart chambers.  Sometimes these "minor" issues resolve themselves as the child grows and require no intervention.  Other congenital defects are severe and require massive interventions.   This is why pediatric cardiology and surgical interventions can be so complicated.  The medical team can face an almost infinite amount of scenarios.  In some cases they literally have to invent new treatments or surgical procedures based on the patients need.  Nothing cookie cutter about these very complex kids.

What is HOCM?

Hypertrophic Obstructive Cardiomyopathy combines three issues with the heart.  Hypertrophy, an obstruction, and cardiomyopathy.  Here is an explanation of each issue that comprises HOCM.

Hypertrophy

TOP: Normal Heart

BOTTOM: Hypertrophic

Hypertrophy simply meaning thick.  The wall of the heart is thick and inelastic.  What you need to remember is that the heart is a pump.  The walls of the heart should be very elastic in order to function.  With HOCM the myocardium becomes thick and inelastic (as shown in the picture to the left).  Imagine a tire tube.  A tire tube is easy to form and as you inflate it with air it changes shape very easily.  That would be similar to a normal heart; very pliable and elastic.  As you picture a tire tube, contrast that with the tire the tire tube might go into.  The rubber of the tire is thick and firm.  Does it change shape as you fill it with air?  Yes...but it changes shape slowly and requires a great deal more air pressure to change the shape.  This is very similar to the HOCM heart.  Very thick walls that takes a great deal of effort and time to expand and contract.





Cardiomyopathy

A cardiomyopathy is very simply a disease that effects the muscle of the heart. In HOCM, the normally congruent alignment of the muscle cells are malformed.  The cells are out of alignment and enlarged.  This is what causes the thickening of the walls of the heart. In the diagram below you can easily see the issue when you compare normal heart muscle cells in contrast to the disarray of the cells with someone who has HOCM,  In addition to the thickness of the myocardium that this causes it also can significantly weaken the muscle.  So you are left dealing with two issues with the heart.  The thickness of the heart and also a weak heart.

The important thing to keep in mind when you consider the thickness of the wall of the heart and the inherent weakness in the muscle is that there is no treatment to correct this.  The issue is at a cellular level and no medication or surgery is going to alleviate the root cause  It is what it is.  Of course this all depends on the severity of the condition.  Many HOCM patients will utilize drug therapy and can live relatively normal lives with some restrictions.  Others are not so fortunate.

Obstruction

The third challenge that we have to contend with is the possibility of this "thick" heart creating a physical obstruction of  blood flow.  If the muscle grows in such a way that it obstructs flow or interferes with the operation of a valve this can cause other issues and symptoms.  It is safe to say this is not a good thing.  There are some treatments for an obstruction.  One treatment is the septal myectomy (shown left) that physically removes the obstruction.  The diagram shows and example of what an obstruction may look like and how a septal myectomy would be performed.  There is no pretty way to describe this.  You crack the chest, go in, and remove the obstruction with a scalpel.

This is the surgery that Susan had in 2009.  The effect she experienced was immediate.  However, Since that time, the relief that she felt has unfortunately been short lived.  She has been steadily degrading ever since.


Next Steps:

As I have described HOCM, it becomes apparent that many of the treatments are somewhat limited.  Drug therapies, surgeries, and other procedures do provide some relief.  Our referral to the Mazankowski Heart Institute in Edmonton will provide another set of eyes to look at Susan's condition and if there is any treatment that may give some relief.  There is some discussion about another septal myectomy or an ablation procedure.  At this point it would be premature to assume anything.  What we are doing right now is diagnostic and about gathering information.  Decision making will come later.

The Elephant in the Room

Many people who know our story, are aware that Russell has a heart transplant and they immediately ask the question.  Is "transplant" an option for Susan?  At this point...No.  This is part of the harsh reality of the transplant option.  Because supply of donors is so limited transplants are reserved for those with the greatest need.  In essence, you have to be extremely ill to get listed for transplant.  Not a road that anyone would choose.  We also are well aware of this journey having been through it with Russell.  There would be many hurdles to cross and different (more radical) treatments that would be considered first.  If you asked Susan if she would want a transplant, she would likely say "No." The reason being is that she knows what it takes to get there.  Not something she would want to endure.  In discussions with our Doctors, transplant has come up in the conversation but at this point it is not being considered.  This conversation would change quickly if Susan's condition were to suddenly worsen.  Then all bets are off.  As it stands right now we are trying to get information and investigate what is going on.  Possible treatments will be discussed later.

For people who have control issues; this is likely a process that they would not do well with.

Heart Catheterization - Part 2 - Susan

This is my attempt at keeping one of my blog posts under 2000 words.

A few weeks ago I described Russell's procedure for his heart catheterization.  That was quite appropriate as we will be doing something that is even new to us.  We will be doing our second heart cath in less than a month.  This time it is Susan's turn.

Last week, Susan had her 6 month appt with her cardiologist (or one of them).  When we had our appt in June...the conversation was a little more serious.  It is re-assuring to be taken seriously but it also comes with some not-so-pleasant strings attached.  In our appointment last Thursday, we also had a fairly serious discussion but this time the Dr shared his game plan with us.  We are being referred to the Toronto General Hospital where there is a clinic that specializes in HOCM (Hypertrophic Obstructive Cardiomyopathy).  This is both good and bad news.

The Good News

The Drs are taking Susan's condition very seriously.  Having minimal cardiac function and no quality of life is a big deal.  This condition is not common, so being able to work with a clinic that is experienced with the condition is a positive step.  The fact that we are able to get a heart cath in two weeks is also rather amazing given the average wait for a procedure like this.  It is good to see some action taking place.

The Bad News

Living with a chronic health condition is challenging.  Declining heart function is not pleasant.  In order to get action this quickly is a positive step but it is also an indicator of the seriousness.  In order to be seen by the clinic in Toronto we will have to go through several tests here.  Blood work, echocardiogram, and a heart catheterization.  The heart cath is by far the biggest deal as it is a surgical procedure.  Once this is done all of the data will be collected and sent to Toronto.  There are several treatment options.  One of which is open heart surgery.  That really sucks and it is something we would like to avoid.

The Frustration

Our feeling is that we are heading down a very negative path.  We went down this road with Russell and he ended up with a heart transplant.  This may be why we are somewhat jaded by this process.  We have to remind ourselves that we are on a journey with no known outcome.  Because Russell ended up with a new heart does not mean this is what will happen with Susan.  There are a lot of unknowns.  This is the reason for all of the tests and to consult with experts.  To try to figure out what is going on.  We won't know a whole lot until we get that information.

My apologies in advance to the folks at St Boniface Hospital.  I'm in no mood to play games and be patient.  I'm done.

A Letter to Christine Elliott: Ontario's First Patient Ombudsman

On Dec 10, Christine Elliott was named the first patient ombudsman of Ontario.

As a Manitoban, it would seem odd that this would matter to me.  Today, as my wife and I, sat in the Heart Failure Clinic at St Boniface Hospital (in Winnipeg) we learned that she will be referred to the Toronto General Hospital for cardiac care.  Several hurdles have to be crossed before we get there but the "game plan" will be to escalate Susan's level of care which may require open heart surgery at some point.  This would be Susan's second open heart surgery.  The state of health care in Ontario just became a real issue to us.

I have been anticipating, for some time, the announcement of this ombudsman position ever since I became aware that Ontario had announced their intent to create this new position.

The concept of an ombudsman who is only answerable to patients and to represent the interest of patients makes a lot of sense to me but will the government listen?  Will this position be able to exercise "real" authority?  These are all questions that have yet to be answered.

Anyone who has experienced the health care system has experienced the power imbalance when they are a patient.  It is not so much that there is a technological disadvantage...but health care is a monstrous bureaucracy with many layers requiring a great deal of skill to navigate.  You, as the patient or in many cases the caregiver are "out-gunned."  It is not just a matter of dealing with a doctor, nurse, HCA, or clerk.  If you have an issue, let's take a look at what you are up against:

• Regulatory Bodies
• Medical Associations
• Unions
• Health Regions
• Government Agencies
• Health Care Boards

Within these broadly described groups, there are numerous sub-groups.  All of these groups have two things in common.

1. They claim to be advocates for patients
2. Primary mandate is to represent someone (or group) other than the patient.

The point i am making is not to vilify any group.  The point I am making is that there is no one group who solely represents the interest of the patient.  This is why the concept of a patient ombudsman is an appealing idea.  The only mandate of this position is to advocate for patients, free of any influence.

Will this new position give patients a much needed voice in health care?  Honestly, I don't know.  The success of this position will depend on the scope, authority, and autonomy of the Ombudsman's Office.  The bottom line is that if this is to work the office needs real power.

From someone who sits on several boards, committees, and councils in health care I have a few suggestions that I believe many people who are involved in advocacy will agree with.

1)  Engage with Patients, Caregivers, and Patient Families

There are numerous experts within this group who have logged hundreds (if not thousands) of hours in the health care system.  This experience in invaluable.  In addition to these people being knowledgeable about the challenges of navigating the health care system but many of them bring other professional skills.  Many of the people I have encountered in my volunteer experiences, are business owners, engineers, accountants, and leaders in their own area of expertise. These people are unique, skilled, and strong voices for patients.  A skilled group of patient advisers will be an invaluable resource.  These adviser positions should have extensive experience requirements and some monetary compensation should be involved.  Many of these people have repeatedly volunteered their time in the past.  It is time we recognize the expertise these people have and offer some remuneration.   I think many people are volunteered out.

2)  There is no need to be nice.

Health Care is in critical condition (to use a medical term).  The time for a gentle nudge is over.  People in Ontario, and all across Canada, are having to contend with challenges in health care that are too numerous to mention.  Harm is being done to our population.  These are not just poor metrics we are dealing with but human beings.  Try explaining to someone who is suffering from debilitating pain and headaches that they will have to wait 6 months for an MRI.  During that 6 month wait, that person may be in constant pain and unable to work.  Where is the dignity in that?  The issues are real and they are effecting thousands of people.  It's time to get past the posturing and the BS and acknowledge a system in crisis.

3)  Health Care needs the ePatient

An ePatient is a patient who is Empowered, Engaged, Equipped, and Enabled.  These are people who own their own health care.  It is my belief that meaningful positive change in health care will come about because of ePatients.  Do you take a laptop or a notebook to your doctor appointments with several years of blood test results?  An ePatient does.  An ePatient asks questions.  Do you have your oncologist's email address?  Do you text your nurse clinician?  Do you suggest (based on your own research) an alternative beta-blocker, as opposed to what your cardiologist is recommending?  e Patients will do all of these things (and more.)  They challenge the status quo.  Until the patient starts to demand more; change will not happen.  ePatients are key to that change.  My hope is that a patient ombudsman can further empower the ePatient, by giving them a voice, and enable many more people to own their own health care.

As an empowered patient, or in my case an empowered caregiver, I have been able to assist in changing erroneous hospital policies.  I have been able to investigate incident we were involved in and resolve the problem quicker than the Minister of Health of Manitoba.  Patients working cooperatively within the health care system can make a difference.

Recommendation

My hope is that Ms Elliott becomes an effective advocate for patients and most importantly empower the patients of Ontario.  The obvious challenge for her will be transferring her leadership and skills as a lawyer and politician to understand the challenges and complexity of health care.  She is not a a Doctor or Nurse.  I am encouraged that someone who is not a medical professional was chosen for this position.  Only a person who is non-medical can identify with patients and the power imbalance they encounter within the health care system.  Best of Luck!

Russell's Heart Cath...The Aftermath

It has been a week since Russell's heart catheterization.  As expected, this day did provide us with a new experience or two.  The interesting thing about taking a young boy/toddler/infant for a procedure like this, every year, is that it is different experience every time. Because kids change so fast, how they cope with the process can be very different from one year to the next. Last Monday was no different.

Russell is a real handful during these procedures, and we expected some challenges.  Anaesthesia plays a big role in the success of this day as Russell has huge anxiety.  Everything leading up to the procedure went really well.  We had a great discussion with the anaesthesiologist at our pre-admit clinic (PAC).  I thought we had a pretty good strategy.

The Cath Lab:
Here Susan is holding Russell so they can
start his IV and apply the anaesthetic.

The procedure itself went really well.  No issues.  We get to talk to the Cardiologist and the nurse clinicians right after the procedure, so we got some instant feedback.  Lab results take a couple of weeks; but we do get some initial info from the Doctors.

Everything went sideways after the procedure, when Russell started to come out of his drug induced fog known as anaesthesia.  When anaesthesia was started he went out quickly, but he went out angry.  He came out just as angry.  When we got Russell to recovery (PACU) he was in full bore "freak out" mode.  Normally, Susan can get him calm and provide some comfort but he was having none of it.  The decision happened fairly quickly to give him a sedative.  This was somewhat expected and we were prepared because of the discussion we had with the anaesthesiologist at the PAC.  They really listened.  So a dose of midazolam was ordered up and went into Russell's IV.

With the med on board, Russell quickly settled and laid down.  Here is where we got a not-so-pleasant reminder that drugs can be helpful and can scare the living daylights out of us.  Russell flopped down on the bed and dozed off (or we thought he dozed off).  Our bedside nurse was watching him and her body language started to change a little, she busied herself with some equipment (I wasn't really paying attention).  Then the alarms started going off...alarms we were all to familiar with.  On the monitor we could see "DESAT" and "APNEA."  Then I realized what our nurse had busied herself with, she had grabbed an oxygen mask and was placing it over Russell's mouth and nose while she called for help.  There is an old rule we learned in ICU, many years ago.  "Don't freak out unless your nurse is freaking out."  Maybe saying our nurse was freaking out might have been an exaggeration but she certainly wasn't calm and she had a definite sense of urgency.  With some oxygen Russell's O2 saturation, which had nose dived and caused the alarms to go off, returned to normal.  The whole episode probably lasted less than a minute but having seen this level of urgency before  it was nothing we had ever wanted to relive.  For us, it was several moments of pure terror.  I don't know if Russell actually stopped breathing but it was an unnecessarily close call.

The rest of our day was relatively uneventful.  The usual hospital schtick.  After arriving at 8:00AM we were heading out of the door at 7:00 PM.  Our day was done.  We survived.

Here is the Important Part!

We had a situation happen in recovery that we thought was really serious and  we didn't know why it happened.  We have done 7 or 8 of these heart caths and nothing like that had ever happened.  We were left trying to interpret body language and a few cryptic comments from the staff in recovery.  No one offered an explanation.  Honestly, we were so frazzled, we didn't ask any questions we just wanted to get out of there and get home.

The first thing to understand is that hospital staff experience incidents everyday and these may seem mundane to them, but these may be horrific and traumatic to a patient or caregiver.  It doesn't matter if staff think something is routine, if you as a patient have a concern or question it deserves a thoughtful response.  This is how we (as patient, caregivers, and families) learn.  By having our concerns listened to and explained.

Russell recovering from his heart cath.
Nicole was nice enough to bring snacks

At the end of our day we were much too exhausted to think about what had happened. Over the next day Susan and I had a chance to discuss what had happened.  I decided to get in touch with our cardiologist and see if we couldn't get some info from Russell's chart.  We had some concerns.  Who ordered the midazolam and in what dose.  Did he get too much?  Given all of the meds that would have been on board from the procedure, was midazolam the right med?  These are basic questions but because we will be going through this again in a year or so we did not  want a repeat performance.

Within a few hours of me sending my email to our cardiologist, we had a comprehensive explanation of what happened.  Keep in mind that our cardiologist was not in the recovery room.  She had no idea what had happened.  In her response, she described accurately what had happened based on the notes in the chart.  The dosing she described was accurate from what we saw.  Susan actually saw the volume of med that was infused and it aligned exactly with what our cardiologist described.  The response we received was informative and seemed very consistent to what we saw at the bedside.  This proved to be a very vivid reminder of the risks we take when powerful anesthetics are used and that they don't come without side effects.  It is also a reminder why strict protocols are in place to closely monitor patients as they recover from surgery.  There are significant risks that many times we take for granted.

Just another chapter in our adventures in health care.  Would be nice to take a break but we have an appointment with Susan's Cardiologist on Thursday.  Never a dull moment.

For the Farmers of Alberta - Bill 6

I have been watching, with great interest, the events of the last few days in Alberta as the NDP government is trying to bring Alberta's farmers under the guidelines of the province's Workplace Safety & Health Legislation.  Currently Alberta farmers are exempt from WS&H regs.  

Safety is something that matters to all of us.  Should there be regs. for ensuring workplaces, including farms, are safe? I think so.  Unfortunately, there is a lot of baggage that comes with WS&H regulations.  Current legislation does not address farm safety issues for which it was never designed.

I grew up on a farm.  Had my first motor vehicle accident on the farm.  My 3 brothers are still heavily involved in agri-business.  After leaving the farm I worked in heavy industry and construction for nearly 20 years.  After becoming a Project Manager I took on a unique challenge.  I was handed the task of establishing a safety program for an upstart steel fabricator and given the specific task of getting our COR (Certificate of Recognition) accreditation.  As I learned Safety is about much more than keeping employees safe.  It can be a business advantage, a political tool, a barrier to competition, and most significantly a multi-million dollar industry.  

In understanding the implications of Bill 6, and being under the purview of WS&H regulations you have to understand that WS&H regs are far reaching and give the government a great deal of power in how a business functions on a daily basis.  There are a few basic concepts of WS&H regulation that need to be understood.

Reverse Onus.

In criminal law we are familiar with concept of "innocent until proven guilty."  Most WS&H regulations are built in the concept of "reverse onus" Health & Safety Ontario provides a good definition in their FarmSafe Plan

“In most provinces, occupational health and safety laws are based on a reverse onus principle that assumes you are responsible for the occurrence of an incident, unless you can prove you took preventative measures and actions, yet circumstances beyond your control resulted in the incident occurring”

In practical terms, as an employer, you are “guilty until proven innocent.”  It doesn’t matter that you are operating safely, you have to be able to prove you are operating safely.  This is why it is critical to document and maintain extensive records about training, safe work procedures, safety meetings etc.

Powers of Enforcement Officers

One issue that many people are surprised by is the authority an enforcement officer has.  An enforcement officer can enter a place of employment (including private property) under the jurisdiction of the act at any “reasonable” time.  Police officers do not have this authority.  A police officer would require a warrant to enter a place of business. 

There are some good reasons for officers to have this kind of authority and for the most part officers use this authority wisely.  The problem usually arises when you get an employer who is not aware and thinks they are well within their rights to tell the officer they cannot enter a private establishment.  An honest misunderstanding that can lead to a very tenuous introduction to the enforcement process.

Feeding the Monster

Safety is important.  No one argues that.  Should farms be governed by some safety legislation? Yes.

The problem with Bill 6 is that it would fall under WS&H regulations that are supposed to apply to all workplaces.  My issue is with safety legislation in general.  Extending the legislation to incorporate farms makes a bad situation worse.

Safety regs can create a paper monster.  Document…document…document!  If you can’t prove it happened; it didn’t happen.  It is unlikely that the provincial department has the resources to go out and inspect every farm.  It would be logistically impossible.  Where a farmer is likely to see an enforcement officer is if the farm had a serious incident requiring an enforcement officer to conduct an investigation.  Keep in mind that if an employee goes to a hospital and reports their injury was sustained at work.  WCB and WS&H are notified.  At this point it is too late.  If you don’t have appropriate documentation and training records etc.  Expect to be put in the crosshairs of WS&H enforcement.  Fines are a real possibility if you don’t have the resources (Lawyer) or a well-documented safety process. 

Safety legislation is challenging to work with.  The legislation is unwieldy and subject to all kinds of interpretation and misinterpretation.  The situation is so bad that when I have tried to engage officials from WS&H about an interpretation the response I got was “what do you think?” and the officer refused to give any advice.  The point being that the dept is scared of providing any specific advice for fear of being held accountable in the event of an accident.  If the WS&H officers are reluctant to provide advice how do you think employers feel as they have to make decisions everyday about what is safe and not safe.

The process is so broken that in the event of an accident there is really nothing an employer can do to defend their actions.  After an accident occurred on one of our jobsites I had a lengthy discussion with a WS&H officer.  As a result of the accident the officer was writing up several improvement orders related to alleged violations of the Act.  I reviewed the orders and the apparent violations.  One issue was improper training.  I responded by providing a safe work procedure and a training record for that employee.  The officer responded by saying “the training is obviously not sufficient.”  The officer used the fact that the incident occurred, that the training was not sufficient, and the employer is at fault.  No consideration is given to the fact that the employee may have made an error or had a lapse in judgement.  It is the employer’s fault.

Safety legislation has no doubt made workplaces safer.  This does not mean it doesn’t need to be improved.  My biggest criticism about current safety practices is where we have forgotten that this is about making workplaces safer not how much paperwork you can generate to justify your existence.

Safety and Unions

One of the most powerful tools a union has is safety.  Ask someone who is experienced in labour relations how a union is certified in many situations safety plays a role in certification.  Here is a common scenario:

There is a serious accident in a workplace.  An astute union rep, aware of the situation, will attempt to make contact with employees within that business or many times the employees themselves may talk to a friend or relative who is in a union.  In some form contact is made.  A union rep will try to sell the employee on all the benefits of the collective bargaining process and how, with union representation, they could address safety issues at their place of employment.  After a serious accident, many employees can feel shaken and vulnerable.  The union option can be very appealing.  This is the beginning of a union drive.  There is a vigorous process for certification but once the notice of certification is issued in a workplace it is usually too late for an employer to react.  There are very stringent rules that an employer must follow during this process.  If an employer sends a notice to employees or has a staff meeting explaining the company’s position, this can be deemed employer interference and can have serious repercussions.  In Manitoba, which has the strongest pro-union legislation in the country, employer interference can result in immediate certification.  No vote. The union is in.  It is for this reason that safety can be a very compelling issue in the certification process. 

Is there a real possibility that farm labour on the typical family farm unionize?  I don’t think it is likely without significant changes to labour legislation.  Unions are driven by member dues.  I don’t see a union actively pursuing small operators.  There just isn’t enough incentive for them to expend the effort for one or two members.  If there is a way for a union to sign up large numbers of farm workers, that would be a much different scenario.  Something to keep an eye on in future labour legislation.

Employers vs Employees

It’s getting very tough to be an employer these days.  I respect anyone who takes the risk and puts their own capital on the line and starts their own business.  I’ve worked for entrepreneurs and have a great deal of respect for them. 

One of the biggest challenges any business, especially new businesses, has is attempting to be a responsible and sought after employer.  There are good employers and poor employers just like there are good employees and poor employees.  Unfortunately, legislation and especially safety legislation doesn’t make this distinction.  With the power imbalance that employer have with an employee there is a considerable amount of legislation that tries to balance the employer – employee relationship. 

Unfortunately, in many cases regulatory bodies favour employees as opposed to employers.  If an employee says they were fired for raising a safety concern and files a complaint with the Safety and Health division, without any clear documentation that states otherwise; WS&H will rule in favour of the employee and issue an order to pay compensation or reinstate the employee.  The employee does not need to provide any documentation to support their claim.

Most employers will chose not to appeal decisions like this because the cost it would take to appeal is usually cost prohibitive.  If they have to pay the former employee a nominal amount to address the issue that is many times the best business decision for the employer.  The cost to appeal a decision like this could cost the employer $10-15000 in legal fees and administration costs.  Many employers feel they don’t have much choice.

In short, a disgruntled former employee can cause a great deal of harm to an employer if they have ill intent and know how to work the system.  Employers need to really understand what they are doing when they decide to terminate the employment relationship.  When employees raise safety issues, they must take them seriously.  Not managing your human resources effectively can be very costly.

Safety on the Farm

Probably one of my biggest influences when it came to safety was probably my Dad.  After 20 years working in industry I’ve constantly drawn upon my experience learned, on the farm, before I ever entered the workforce.  Farms can be very dangerous places.  I still recall my Dad warning me about power take offs and the dangers of augers.  I recall Dad giving me heck for parking equipment the wrong way.  There was a right and a wrong way of doing everything.  The hazards on the farm can be unforgiving.  We had a neighbour who died as a result of mishandling a farm chemical.  Farm equipment is large and extremely powerful.  The farm yard can be a flurry of activity in the busy seasons fraught with many potential hazards.

What many safety professionals forget is that employers are not in the safety business.  I can hear the shrieks of horror as safety geeks would indignantly argue that point.  The bottom line is that farmers or any business need to produce and sell a product and hopefully make a profit.  Farmers have to farm.  I view safety as something that should encompass anything we do.  When you say good bye to someone you might say “drive safe.”  Safety is something that should be a component of everything we do.  Safety is not the goal its how we get there.  No one gets up in the morning and has a burning desire to “do safety.”  Unless you are a safety geek.  Safety on the farm or anywhere else is about building it into how you get work done.  That is really important when developing safety procedures, regulations, or legislation.  It’s about getting things done…safely.

Given the complexities of the farm and the fact that most farmers are not fluent in safety legislation and interpretation, there is a tremendous need to consult with farm groups and farmers themselves as to how to make farms safer.  I think it is completely reasonable to draft legislation that is unique to farms and farm families.  This could be a tremendous opportunity for the Alberta government but unfortunately they seem to have adopted the one size fits all approach.

Bottom Line

We all want farms to be safe places to live and work.  That is the issue.  Family farms involve work and how farm families live their lives.  A farm is not a stand-alone building stuck in the middle of an industrial park.  It is not a conventional place of work.  Employment and Safety legislation should address this unique work environment not attempt to shoe horn farms to fit into “one size fits all” legislation. 

I take no issue with farms falling under safety legislation.  However, there is a significant opportunity for government to engage farmers in the process.  Safety rules that apply to farms should be developed with farmers and for the benefit of farmers.  Farmers are by nature problem solvers.  If farmers do not embrace safety regulations the result will be a long standing enforcement issue.  We want farms to be safe; we want farmers and their families to be safe.  The best safety tool for someone working the farm is their mind.  The last thing we want is that mind devising ways of circumventing safety rules.  We want farmers focusing on their work.  Buy in from the farm community is key to the success of any legislation.  Unfortunately the Alberta has completely missed the boat on any goodwill they might have received from the farm community.

For the sake of safety the government has some “fence mending” to do. 

Donald Lepp, CHRP