Gutter Blood and Sins of the Past

Its Time for a #metoo Moment in Pathology at Large

Even if painful, we must record and remember the sins of the past in order to make a better world. That’s why the “say his/ her name” call, as part of the protest against systemic US police murders of black people is so important. When a candidate for Department Headship of Pathology explained how she enabled and empowered workers take time off work –even in COVID testing facility- to join the justice protests, by managing workflow and staffing accordingly, so that turn-around time would not be impacted, many people listening alone in their offices felt tears of solidarity, vindication and hope.

Its time for a #metoo moment in Pathology at large. In Windsor in 2010, a black female pathologist was scapegoated, shamed and ruined for errors that were made by a surgeon. Few said anything. I wrote a paper about it in the Canadian Journal of Pathology , that passed rigorous peer review, documenting the injustice and collusion in the findings against her. No one did anything about it. Here I will not say her name. I justify this, because I sense she wants privacy after all she has suffered. She told me it took years for her to even think about what had happened. She planted a garden in her home and spent time there hoping for peace and solace in a square of flowers between the brick walls of homes.

Her Name was Phyllis Traynor

In Toronto in the early 1980s the Hospital for Sick Children amalgamated its cardiology and cardiac surgery wards and created a new unit. The death rate on the unit was high. Autopsies suggested digoxin toxicity but this was an error; post mortem digoxin seeps out of decomposing skeletal muscle and raises the blood level. A terrible modern day witch- hunt ensured. One nurse was charged and then exonerated. A Royal Commission under Justice Samuel Grange was held and the outcome was that the blame was turned on another nurse. That second nurse was ostracized, besmirched with suspicion but never charged; only publicly tarnished. She lost her job. She died alone and broken, to my knowledge there are no flowers on her grave. Her name was Phyllis Traynor. I reviewed the commission report. It contains all the autopsy report of most of the fetal deaths :https://archive.org/details/reportofsickkids00onta).

As a senior expert now, I can assert with near certainty that these deaths were cardiac deaths related to cardiac surgery, in very sick small children. Sick Kids was very aggressive in “innovating” such surgery. Many centers would not have done those operations. The blaming of the nurses probably saved the cardiac surgery program (other programs had to close because of high operative mortality). One very disturbing aspect of the Grange Report is its’ passage on “gutter blood”. A pathology resident had not taken venous blood, during the autopsy, for one of the index cases. He then went back to the closed body, opened it and took “gutter blood” and submitted that for digoxin levels. Without a doubt, tissue effluent would have had higher than expected digoxin levels because it is released from dying tissue where it is held in reservoir. This pathologist watched the nurses get ruined and never spoke out once; he testified at the Grange Inquest and didn’t divulge the problem. I am not naming him though I should. Its surreal to see “gutter blood” in the glossary of defined terms in the Grange Report, as though that is a normal thing in pathology. If you read the Grange Report you will see an enactment of male doctors and police (and even a Judge) dismissing, blaming and silencing female nurses in the 1980s. The series of autopsies listing digoxin as the cause of death is a stain that pathology will never expiate but must never forget. As poet Amanda Gorman said at the Biden Inauguration: “It’s the past we step into and how we repair it.”

This was not the end of the use of the lab as a vehicle of sexism. Charles Smith targeted single or poor moms as outlined in in the Goudge Report. Gideon Koren and MotherRisk also disproportionately ruined the lives of marginalized women.

Phyllis Traynor cared, with love, for the sickest and most fragile. She ended up falsely accused of the worst things possible. Say her name.

Pathology must own the sins of its past and change. Amanda Gorman stunned us in awed reverent silence, as only youth can, as she ended her poem with : When day comes, we step out of the shade, aflame and unafraid.
The new dawn blooms as we free it.
For there is always light,
if only we’re brave enough to see it.
If only we’re brave enough to be it