Examination - in - cheif of Dr. Anne K. Dzus (Called by the Crown)
COURT
RECONVENED
THE COURT: Who do we have here, Mr.
Kirkham?
MR. KIRKHAM: Dr. Dzus.
COURT CLERK: Could you raise your right
hand and state your full name, please.
THE WITNESS: Anne Kathleen Dzus.
testifies as follows,
MR. KIRKHAM EXAMINATION - IN CHIEF:
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practise currently in the province?
surgery?
College of Physicians and Surgeons in 1986 and
subsequent to that I spent a year in the States
subspecializing in pediatric orthopaedics.
20
subspecializing in pediatric orthopaedics as well,
the area in question in layman's terms would be
what?
who takes care of bones and joints and
muscles, so fractures, curvatures of the spine,
hips, joints that dislocate. I have subspecialized
to try to limit my practise to mainly children.
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you put it to mainly children, what percentage of
your practise then would deal with children?
adults when they're involved in trauma.
and residency, did you come into contact with Tracy
Latimer?
40
was a resident working with Dr. Wedge who was my
predecessor in this area, he's now in Toronto, and
we did surgery on Tracy at that time. I - - I
personally don't recall it but looking at the
charts I realize I was involved in her care then.
Subsequent to that, when I started my own practise
I first saw Tracy in 1989.
recall, I guess, the nature of the visit?
50
Children's Centre where we see lots of children
like Tracy with multiple handicaps and she came to
what we call the orthpaedic clinic there for me to
assess her along with other members of the team
including the physiotherapists.
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cerebral palsy and this is a lifelong affliction.
She had on of the worst forms of cerebral palsy in
that she was totally body involved. Her total body
was involved from her head right down to her toes
so all four limbs, her brain, her back, everything
was involved so she was as severe as they - - in the
classification that we have for cerebral palsy.
guess, is it progressive in terms of getting worse
or is the extent of the affliction that one has at
a certain age, for instance, sort of youth -
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one time insult to the brain that causes the
original damage and if you look at the brain as the
computer of the body it's been damaged and so the
signals going to the body are abnormal but the
disease itself can change or the manifestations of
the disease can change as the children grow.
me, changing as they grow, can you illustrate what
you mean?
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90
100
per cent of them will develop a scoliosis over
time. A scoliosis is an abnormal curvature and
rotation in the back so in simple terms if we look
at a normal back it has a normal hunch at the top
and a normal sway at the bottom when you look at it
from the side but if you look at it from front to
back it should be virtually straight. The children
that develop a scoliosis becomes C shaped and 70,
75 per cent of totally involved spastic
quadraparetic children like Tracy was will develop
this scoliosis. Not all of them do but the
majority of them will develop it and Tracy was one
of that that had it. Plus a similar percentage, 75
percent I think is the number that's quoted, of
the totally involved, totally dependent children,
will also develop a subluxated or dislocated hip
over their lifetime. The hip is originally normal
and in joint but because of the muscle imbalance,
the abnormal signals that are coming to the - - from
the brain to the muscles, the hip over time will
dislocate.
In 1989 when you examined Tray - -
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Records from the clinics.
MR. BRAYFORD: I have no objection.
THE COURT: Yes.
THE WITNESS: Okay. I saw her March in
1989.
in March of 1989, at that time was she displaying
the scoliosis that you've referred to?
scoliosis was measuring 50 degrees, five zero,
which is a significant scoliosis, like significant
curve.
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displacement?
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you're looking at it from the back, the spine
curves like this. The pelvis is joined to the
spine and the pelvis can become oblique. Instead
of being level with the seat or the floor it
becomes sideways and she was developing that
already. That can add to the problems of the hips
and we note that we - - that she was developing the
windswept deformity and the pelvic obliquity and
we were worried about the range of motions of
her hips at that time.
addressing those concerns?
to try to balance some of those muscles around her
pelvis in order to prevent that pelvis obliquity,
the hips, from possibly progressing on to
Dislocation.
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February of 1990 where she had multiple soft tissue
releases, lengthenings of various muscles in her
lower extremities, to try to balance the stronger
muscles against the muscles that were not
functioning as well.
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if - - to simplify things, if we - - if you've got
an elbow that wants to bend all the time, the
muscles in this side are a lot - - I won't say
stronger but are receiving more signals from the
brain to bend, bend, bend compared to the ones
that are saying to extend so what we can do is
weaken the muscles by either lengthening the
tendon or actually sometimes even cutting the
tendon completely or cutting the tendon where it
joins to the muscle just to allow that muscle to
lengthen and gain more range and allow the muscles
on the other side to have a better chance of
functioning so that's what we mean when we say we
balance the muscles.
benefit from that?
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she - - she appeared to be much more symmetrical
after that. We were able to get her leg into a
neutral position whereas before we couldn't so at
that point we thought we were - - we were - - we were
happy with how things go. A January 1991 note
saying she has done well from the releases and I
was happy with how she was looking at that point in
time. She still had her scoliosis and that was a
concern.
tissue release, was there any planned action or
course being taken regarding the scoliosis?
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flexible but is still worrisome and we planned to
see her again in about six to mine months with
another x-ray of her back.
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was now 11 years and four months. We commented
that her pelvic obliquity, the angle of her pelvis,
was much improved but despite of that her right hip
is now more - - I won't say more dislocated,
subluxated which means partially out of joint, so
despite the muscle balancing , her hip was
continuing to go on its merry route of trying to
dislocate and this is quite common in children with
cerebral palsy. Despite you doing everything that
you know how, sometimes the hip is just destined to
go out of joint.
on surgery for the scoliosis?
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degrees. It was - - we felt it was still flexible.
When you lifted her up and let her be suspended the
rib hump that was with it would decrease and the
amount of curvature would decrease and because it
had progressed from 50 degrees to now 67 degrees,
that is a significant increase and the worrisome
part is that if you do nothing about this back once
they've reached - - the curves have reached this
magnitude they will continue to increase, okay, and
they can increase quite rapidly and - - and
unrelenting to the point
that the rib cages will press on the pelvis and
those then can become quite painful. It's much
easier on the surgeon and on the patient and on
everybody involved with the care if we operate
when the curves are still relatively flexible and
are smaller numbers, now, this is still a big
number, rather than waiting till this curve gets to
90 or 100 degrees.
220
surgery from your point of view as the physician?
230
Tracy's curvature. When we saw her now in August
and admitted her for the surgery her curve had
increased still more and was up to around 73
degrees so even in the few months from waiting to
get into surgery to the time of surgery the curve
had increased. At surgery we got it down to
around 15 degrees by putting in stainless steel
rods and multiple wires to put the back straight
and to fuse it in that position. This is major
surgery.
refer to the rods and that, is that the standard
medical way of dealing with the scoliosis?
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tolerate braces, cannot - - need to get up quickly
after surgery so you have to have very strong
implants, this is one of the best ways to deal with
it as it is a very, very strong method of fixing
the spine.
the results?
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lost around three litres of blood and that was
replaced. Her results were good. She was home
about six days after - - she went home, was
discharged, on the sixth post op. day which is very
good. Most of the children with this magnitude of
surgery go home at about a week to two weeks
afterwards so Tracy came through it very, very
well. Not to say that it wasn't easy on her but
compared to other people she - - I was happy with
how she did. The complications rate for this
particular surgery is very high. Tracy was lucky
and had no complications that were of significance.
She had some post operative
vomiting and she did have some seizures after
surgery but Tracy has a long history of seizures
so this was not totally unexpected.
To put the magnitude of
surgery in perspective, if you have a scale of one
to 100 where one is the removal of a mole or a wart
and 100 is a heart transplant, scoliosis surgery on a
a normal adolescent would probably rank 70.
scoliosis on somebody with totally involved
cerebral palsy would rank in the order of 90 in
magnitude. So it is significant surgery.
of followup?
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think, November second, and I saw her September
sixth - just - - that doesn't make sense. She was
-- August 27th, she was discharged, September
second, 1992, and I saw her September 16th which is
about two weeks which is my standard followup post
operatively. I see most of the children I operate
on two weeks after surgery.
she was not vomiting anymore and was sleeping
quite well through the night. She was sitting
easily in her chair and the plan was to have her
going back to school within the next few days.
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very straight and we were able to move both hips
through an almost full range of motion though she
was a little tentative about putting her right hip
flat but this has always been her troublesome hip.
and the x-rays at that time were quite
satisfactory.
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310
two months from then. Again, she was still
improving. She was able to sit for unlimited
periods of time and that's an important thing to
note because the children that have severe
scoliosis with the total body involvement will
find sitting very, very difficult. They'll sit
for a few hours and then make it known, by
whatever way they can communicate, that they are
uncomfortable and need to be adjusted and moved
and that so one of the goals of surgery is to
increase their sitting ability and sitting time
and so it appears that that had happened. We were
- - she was sleeping better at night but we were
still concerned about her right hip. Her range of
motion of her hip was improving but she was
uncomfortable when we moved her hip at that time.
already talking right hip surgery but we were
wanting to wait for her to be fully recovered from
this major spinal surgery before we undertook her
hip surgery.
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Wanting her to be fully recovered - -
330
require three litres of blood, that's more than
somebody Tracy's size would have had circulating in
her own body plus we - - the rods are there to hold
the spine straight but the body itself has to fuse
the spine. That means repairing and throwing - - or
laying down bone as a broken bone would heal to
allow that spine to fuse and that does take six
months to one year on average so the worrisome
thing about doing another major surgery in a short
period of time is that her body would not tolerate
it
when, doctor?
340
time was pain in her right hip. She had not really
changed much from her November visit but
her pain was a big concern. She was still having
seizures. There was severe spasticity. Basically
unchanged. The right hip was dislocated and we
were concerned about it. Reconstructive surgery or
the hip was again discussed with family and we
decided to wait the full year as originally planned
and we scheduled tem to see - - I scheduled - - was
scheduled to see her again in the fall of '93.
February how did she appear then?
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that she was recovering quite nicely from that and
doing well.
her in the fall of '93, that would have been the
next time you saw her?
preparation for surgery regarding the hip?
360
that I saw her in February her next
appointment would be scheduled for the fall of 1993
and we had already discussed the possibility on
several occasions of addressing the hip problem at
her - - at a year from her back surgery.
visitations to you from February until the fall?
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summer of '93 having my third baby so - - so I had
other people taking care of my practise at that
time plus their - - Tracy was taken care of by a
whole team including her family doctor and the
people at Kinsmen Children's Centre so if there
would have been a problem I would have hoped that
that would have been communicated that way.
Tracy?
and how Tracy was at that time?
380
is how painful Tracy was. She had changed
substantially from the visit in the spring to this
visit now. She was lying on the examining table
when I came into the room. Her mother was holding
her right leg in a fixed flexed position with her
knee inn the air and any time you tried to move that
leg Tracy expressed pain and her way of expressing
pain was to cry out.
time, particularly regarding - -
390
without causing more pain. We - - we got her left
hip - - it actually had a nice range of motion and
was not a problem but her left hip range of motion
was excellent, had some spasm but not enough to
worry about but every time we tried to move the
right hip she was very resistant. Resistant to
any change of position and we basically got no
range at all because it was too painful for her.
problem
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410
little concerned because she no longer would lie on
her right side so she was always lying on her - - on
her left side and there was concern that her skin
on the left side as starting to break down. She
- - as far as her general health had been the
comments from mother was that she's actually done
very well with respect to her back and didn't have
any colds or sicknesses over the winter and that
again is another important statement because when
children get severely deformed in their back and
are now having difficulty sitting they also have
more difficulty swallowing and clearing
secretions, eating becomes a problem and these
things can all end up in the lungs and cause
problems there so it looked like we had been
helpful in one way in keeping her upright and that
she was healthier in her chest area.
420
then at the end of your examination on the 12th?
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440
450
decrease the amount of pain that Tracy was having
In her hip and there are many options that you have
though none of the options are totally satisfactory
but they're e only options we have when the hip
becomes dislocated and painful. The two options
that we discussed were do a major hip
reconstruction if the hip was reconstructable i.e.
the articular cartilage, the cartilage on the joint
surface was in still healthy enough shape that we
could put it back inside the socket so if this is
the head and this is the socket, we have to put the
two back together because right now it's sitting
out here. When the head in children with
spasticity, head of the femur or the ball of the
ball and socket joint sits out of the femur - -
out of the socket too long, the joint capsule and
the muscles that are overlying it will rub out
here and change the shape of the head or of the
ball part and also erode or wear away all the
articular cartilage and that articular cartilage is
what's important to allow the ball and the socket
to move freely within each other. If that's worn
away and you put the hip back in joint you're
literally putting an arthritic hip back together
and it's doomed to continue to be painful. So the
option is, if the head is worn away, is then to
reset that part of the head and cover it with the
overlying capsule and muscle and then just leave it
as a flail joint with no ball for a ball and socket
joint and that's called a resection arthroplasty
and those two options were discussed. They're
again major surgery and the results can be
unpredictable but we know that with a resection
arthroplasty the goal is to make them pain free and
in the majority of children it is successful in
decreasing their pain.
460
November. That's correct.
470
12th of October to the fourth of November. That's
literally two or three weeks but because of the
amount of pain Tracy was in I had a cancellation on
the fourth and I thought it was only fair that we
try to get this done as soon as possible for her.
We had originally scheduled her to be admitted the
day prior to surgery. However, there was a concern
that Tracy had lost a lot of weight over the summer
so in consultation with the doctors
at the Kinsmen Children's Centre we changed her
admission date to one day prior to that so that she
could be investigated for this weight loss and
nutritional status.
480
on the 12th was there anything that would have,
medically speaking, prevented the surgery from
going ahead at that point?
when she was admitted for this workup that if we
found something, i.e. that her nutritional status
was so bad or her blood level was so low that she
would not survive the surgery then we would have
cancelled it again and got that aspect taken care
of.
490
surviving the surgery, what was your opinion on the
12th of October when you saw her as to whether she
would have survived surgery?
too painful to do nothing so we had to make her in
an optimum shape so that we could treat her pain.
that point as far as the surgery?
500
operating on somebody with Tracy's magnitude of
disease in that she's lost weight, she's had
seizures, the anaesthesia part is difficult,
there's a chance of increased seizures after
surgery and the pain control after surgery is also
a big factor.
performed the back surgery.
surgery.
510
the years with Tracy and the examinations, who did
you end up dealing with from the family, I suppose?
we'd had but mostly with the mother. I remember
that most specifically the last visit only mother
was there but I know that I dealt with the father
as well.
520
witness that I had understood was coming tomorrow
and as a result there's questions that I'd like to
talk about with both - - both with the witness and
with my clients before I ask her any questions. If
we can break for the noon hour until two then,
please, my Lord.
him speaking to the witness?
him speaking with the doctor.
530
THE COURT: We'll adjourn until two
o'clock:
COURT ADJOURNED UNTIL 2:00 P.M.
COURT RECONVENED
dealing with Tracy specifically, over her lifetime
from infancy until the time of her death, was her
quality of life improving during that period of
time? I guess quality of life is a pretty abstract
concept but what was happening to her life?
540
550
560
have the ability to communicate like we communicate
so you had to rely on actions and facial
expressions to try to understand what she was
thinking or if she was even capable of thinking.
We think she was. I knew that in her younger years
she would smile in communication, I cannot
honestly recall her smiling at me. I know that
after her spinal surgery her sitting became easier
so maybe that's one aspect of the quality of life
that you can say improved her. Her breathing
became easier in that she wasn't as congested and
she did not vomit as much so that quality of life
improved but now instead of being a flexible person
that can move side to side, forward and back, we
have somebody who is literally very stiff from the
top of her spine right down to the pelvis so she
has lacked - - she now lacks that mobility so that
takes away some of that quality of life, plus the
fact that she has lost weight in the summer prior
to her death and that she was in severe pain from
what we believe was her hip I would say that her
quality of life in the last year of life was
deteriorating.
through Tracy's life, are they treating the
cerebral palsy? Are they going to cure the
cerebral palsy?
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580
orthopaedic surgery, it's important that you make
sure that the caregivers and the parents know that
when you operate on a child with cerebral palsy,
after you've done your operation the child still
has cerebral palsy. We are only addressing the
symptoms of the problem. The problem is stemming
from an abnormal brain and the signals that it's
giving to the body so she will still have cerebral
palsy. It will still be as severe as it was prior
to surgery but hopefully we have changed that
person to the better to make sitting, lying,
eating, moving easier.
cerebral palsy, for instance dealing with the first
surgery that you were involved in from 1985, are
you able to predict all of the ramifications of the
surgery in advance of it?
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600
palsy, and this would include adults, is that
they're spring loaded so if we had the example of
the arm always wanting to be bent, when you and I
go to extend our arm, the muscles up here slowly
relax while the muscles back here tighten up to
give us controlled extension of the elbow. These
people have a lot of stimulus to this muscle
holding it flexed. They may also have a similar
amount of stimulus to this wanting to extend it but
we can't say that because these guys are stronger
and when we release this we may end up like that.
Another way to describe it is spring loaded so when
we release one spring the opposite spring may take
over and some of the children end up with the
opposite deformity of where they started out.
back to 1985, were there some unexpected effects
from that surgery?
did happen on her right hip where before it tended
to be held close to the body. After muscles were
released it tended to spring out to the side.
610
Would that surgery have been done that same way if
the ultimate effect had been anticipated, had been
known to going to occur?
for the surgeon that did. The - - the effect of
that leg going out to the side should have been a
protective effect to hold the hip in joint so some
people would not have necessarily considered that
result a total failure. It just made it more
difficult to seat her.
620
intervention was to treat one issue and ultimately
it - - it had some detrimental effect, too. That
would be fair?
detrimental in the long run or whether that kept
her right hip in - - in joint a little bit longer.
it's impossible to know. It did make seating and
caring for her at that point in time more
difficult.
contemplated in October when you met with Tracy's
mom Laura, can you anticipate the future for us?
Would we be able to say with some degree of
certainty this is it, we've now - - now solved her
medical problem and this will be the last surgery
she has?
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650
That would happen. We know that she had lost
weight, that we had one hip that dislocated. The
chances of her other hip dislocating are always
present and always there. Some will not - - some
children who we follow along for a long time that
we think are dong fine will dislocate their hips
in their teenage years. Because of her weight loss
if that continued for whatever reason, I expect
that there may be more surgical intervention
- - there may have been more surgical intervention
in the form of a gastrostomy feeding tube or
another method of giving her nutrition that would
bypass the mouth and swallowing mechanism.
be able to swallow on her own in the normal
fashion. She would be force fed or - -
have different connotations - -
660
extent that Tracy had, affected all of her muscles
from - - she had a squint, i.e. one eye went
sideways. That's from the brain damage to the head
affecting the eye muscles, the swallowing muscles,
the cough muscles, every muscle there so she did
not swallow like the rest of us so feeding was a
difficult situation.
670
reasons for the, if I can put it, the immediacy of
the operation being that it was, you know, going to
occur in November much sooner that what it had
normally been scheduled and - - just the fact
that the operation was occurring at all was pain
management and I guess one of the things that would
be going through my mind at least is the ability to
manage the pain in other ways through, for
instance, the use of drugs and why or why not is
that an option?
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drugs would mean using fairly powerful drugs. She
already was on anticonvulsant, antiepileptic
medications to control her seizures. Combining
drugs can have side effects. One can add onto the
other. She already in the past was having
difficulty with swallowing. We know that she had
difficulty clearing some secretions from her lungs,
nose and that and these children can gag on their
own secretions. If you depress, by using strong
drugs, some of these very primitive reflexes then
you put her at risk for aspirating, getting the
contents of stomach food into her lungs and ending
up aspirating pneumonia, ending up very sick,
depressing the respiratory function that, already
- -
killers to try to control pain in that way in
actual fact might well quite conceivably kill her.
controlled environment, solution but not long term.
700
the necessities of that is probably pretty much
giving up on trying to treat her as a normal child
as far as feeding her goes. That - - if you were
going to use that kind of pain management you'd
pretty well have to feed her by means of tubes or
something.
Guess I'd really appreciate sort of some fairly
conclusive opinions on these. Would you ever have
expected Tracy's ability to, for instance,
speak, would ever, develop?
710
her limbs so that she could move them in a
meaningful manner such that she might be able to
sit up on her own, that kind of thing, as opposed
to being propped up? Was that a likelihood?
720
all aspects of care from feeding to diapering to
getting sat up in a chair. With answer to your
first question about communications I should say
that there have been some children, though not as
severely affected as Tracy, that have the ability
to understand but not vocalize and some of them
have been given a computer to talk with and have
gained the ability to communicate that way.
Whether Tracy would have had that ability or not, I
cannot answer that. I suspect, given the seizure
activity that she had, it is an indication that her
brain damage was severe.
730
cerebral palsy at birth as Tracy was, how many of
them would you expect to have been alive say by - -
by the age that - - that Tracy was? How many would
you expect to still be alive at her age?
740
referring to a study that came out of the Mayo
Clinic in Rochester where they looked at the
survival of children with cerebral palsy and
when they specifically looked at the totally
involved child, total body involvement, about 50
per cent of them had died or 50 per cent of them
had survived to their tenth birthday.
if we looked at the options that were presented to
you at the time I understand - -
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weren't in a position to know exactly what you were
going to do. Is that right?
was going to be performed on her hip joint?
760
x-ray with the flattening part of the ball, I
suspect that the capsule, the lining of the joint,
because of the constant motion and spasticity of
her muscles probably had worn away the articular
cartilage and we are now talking about a salvage
procedure which in simple terms means taking away
the damaged part and covering the end of the bone
with muscles and hoping that would be enough to
take away the painful part of her hip joint.
talking about sawing off the ball part of the - -
770
and about the top quarter of the - - femur bone.
the thigh bone.
no suggestion that that leg's being worked on in
any way that it's going to be used in the
conventional sense for - -
780
interventions that were your options at that stage,
what kind of effect was this having on - - that you
could observe - - on Tracy's mom Laura when you were
discussing the options? How was she - -
790
basically for years suggesting that there would be
hip surgery but most of the time we were talking
about a reconstructive procedure to put the hip in
place and this was the first time that I suggested
that maybe this hip was now too far gone, that if
we got in there and found that the - - the head, the
ball part, was totally eroded that it would only
cause more pain to put it in, back in joint. This
- - this was upsetting to her.
examine the child perhaps the way you might like to
on the day was - - was hampered by the difficulty
in say flexing or moving the child's
limbs because of the pain the child was in.
800
at any time because we take them into a very
artificial situation, we put them on a - - from
their chair onto a cold examining table. They will
often get more spastic just because of the strange
environment and then we come in and try to move
them and they, in normal situations without pain,
become even difficult to examine. Tracy was
exceedingly difficult to examine because of her
pain.
Tracy's pain?
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820
difficult to manage for the same reasons we've
talked about before. We do have ways and means of
putting what we call epidural catheters where we
freeze the bottom half of their body for a period
of time but that is only good while they're in the
hospital. The children still have to go somewhere,
either home or to another institution to recover
and that is not the end of the pain.
very low body weight after the previous surgery a
year earlier. What kind of a recovery period might
be expected for this hip surgery?
future?
830
with cerebral palsy. There's no cure for cerebral
palsy. We're treating symptoms only so we have - -
we may have alleviated some of the symptoms in her
right hip but it's still not a normal hip so,
therefore, it's still at risk for causing trouble
of different sorts down the road plus I cannot
honestly tell you what was going to happen to her
right hip down the road either, or pardon me, to
her left hip down the road.
840
manage pain medically.
long as possible and to keep her quality of life as
best it can be.
the effect of not being able to keep it so that the
child can be positioned upright for parts of the
day? What - - what's the effect of not being
able to do that?
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year before. With time the curves that are as big
as Tracy's relentlessly progress even as adults and
some of them get more that 100 degrees. It becomes
impossible to sit for any prolonged length of time.
You end up making custom made chairs to fit the
body in the deformed shape that the body is in and
even that doesn't always work to keep the child
upright. When they're no longer upright you're
talking about positioning in bed. Positioning in
bed has its problems with bed sores, trouble
clearing the chest cavity, recurrent pneumonias,
respiratory tract infections. There is problems
with feeding somebody when they're lying down, they
can't swallow and Tracy had difficulty swallowing
already. There is problems with the pain from the
curve itself and pressure from the ribs on the
pelvis. There's problems with pressure sore and
personal hygiene, taking care of these children and
young adults.
870
make sure I'm clear on this, you spoke about 73
degrees so in other words rather that the back
being straight up and down, it would be as though
one was tipped perpendicular to the ground
sideways.
would tip you sideways so 70 degrees is when you're
looking from front to back or back to front,
literally C shaped.
880
the pelvis to tilt - - tilt the pelvis.
890
this point, in looking at the - - the care or the
treatment that Tracy had been given, how would you
describe the manner in which her parents had cared
for her through her lifetime based on what you
could observe?
cared for. I - - I think she came from a very
caring, loving environment that looked out for
Tracy.
her best interests at heart?
MR.
BRAYFORD: Thank you very much, Dr.
Dzus.
