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Cynthia Blackjack

Nurses testify at inquest into woman’s death (Revised)

Wednesday, the third day of the inquiry into Cynthia Blackjack’s death, saw testimony from two nurses who were present at the Carmacks health centre on the day of her passing in 2013.

By Gabrielle Plonka on January 23, 2020

Wednesday, the third day of the inquiry into Cynthia Blackjack’s death, saw testimony from two nurses who were present at the Carmacks health centre on the day of her passing in 2013.

The inquest is taking place at the Kwanlin Dün Cultural Centre in Whitehorse after having heard testimony in Carmacks on Monday and Tuesday.

Deb Crosby and Theresa Ogilvie were the managing nurse and auxiliary nurse on call respectively.

They were questioned by counsels representing the territorial government, the Yukon coroner, the Little Salmon-Carmacks First Nation and the Council of Yukon First Nations (CYFN).

“There isn’t anything I would have done differently,” Crosby told counsel.

The 29-year-old Blackjack died Nov. 7, 2013 while being medevaced to Whitehorse.

She had contacted the health centre by phone several times in the days previous, complaining of dental pain.

The day before she died, she visited the centre with abdominal pain.

She was given morphine and was advised to find her own ride to Whitehorse General Hospital.

The following day, Blackjack returned to the Carmacks health centre by ambulance, and staff immediately chose to medevac her.

She suffered cardiac arrest mid-transport and died minutes before the plane landed in Whitehorse. The likely cause of her death was ruled as multi-organ failure caused by hyper-acute liver failure.

The inquest is seeking to prove whether Blackjack’s death could be attributed to systemic malpractice affecting First Nations patients.

Crosby worked at the Carmacks health centre from 2007 to 2014. She refuted the idea that racial profiling affected treatment given to First Nations patients.

She told counsels she worked to acquaint herself with First Nations considerations. During her time in Carmacks, she said, she attended General Assemblies, potlatches and workshops hosted by the Little Salmon-Carmacks First Nation. She also worked with First Nation staff and elders.

At the prompting of Susan Roothman, the counsel representing Little Salmon-Carmacks, Crosby added that she was aware of residential schools and the impact of intergenerational trauma.

She said she spoke with elders to learn of their experiences with residential schools in communities.

Crosby said she has been trained in trauma-informed care and “absolutely” saw Blackjack as a vulnerable person.

“Cynthia did have challenges: Cynthia had challenges with addictions, Cynthia had challenges around trauma when she was young, socertainly all of the things that I learned (about trauma-informed care) would have come into play.”

Roothman asked Crosby how her cultural background, as a non-Indigenous person, affects her ability to treat First Nations patients.

As a member of the LGBTQ2S+ community, Crosby said, she has experienced discrimination.

She also worked extensively with marginalized populations early in her career.

“I had no bias and no stereotypes,” Crosby said. “I know what it’s like to be biased against.

“My very first nursing job was at the Royal Alexandra Hospital (in Edmonton) working with marginalized people.

“I wound up doing a lot of work around sexual assault and domestic violence because I wanted to provide care to people who are marginalized. So I can very clearly say that I, personally, have no bias. My children were raised with no bias.

“I don’t make assumptions. I see what I see.”

Counsels questioned notations made in Blackjack’s file the week she died.

On Nov. 6, Blackjack is described as “very dramatic during assessment. Difficult to determine symptoms.”

The note is signed Matt Lewis, a full-time Carmacks nurse at the time.

Roothman questioned whether the use of the term “dramatic” might inspire medical staff to overlook dangerous symptoms.

Crosby responded that “dramatic” is a term used by nurses to describe a patient who is “expressing things over and above what, perhaps, might be there.”

She said she did not have a problem with Lewis using the term, and nurses’ job is to report what they see, to the best of their ability.

CYFN counsel Gregg Rafter later questioned the phrase “on a recent bender,” mentioned in the same notation as the term “dramatic.”

Crosby told counsel the use of the term “bender” would likely have been Blackjack’s words.

There was discussion of how much a community nurse is able to control a patient’s care without infringing on privacy or overstepping boundaries.

Roothman suggested that, in First Nations culture, issues of health involve the entire family.

She questioned whether Crosby should have contacted Blackjack’s mother or grandmother regarding her recurring health concerns.

Crosby said that in adhering to the nurse’s code of ethics, she could not contact family without the patient’s explicit permission. She noted that she thought of Blackjack as a very private person.

She added that in providing care for Blackjack’s recurring dental issues, dentist appointments were made for her by Carmacks staff.

On several occasions, Blackjack did not show up for her appointment.

As a medical practitioner, Crosby said, it was outside her capacity to direct Blackjack further.

“Patients have the right to live at risk, as long as they understand the implications,” Crosby said.

On Nov. 6, Blackjack was instructed to find a ride to Whitehorse General Hospital, and to return to the health centre if she could not find one.

Crosby said this is common practice in Carmacks because there is only one ambulance, and dispatching it to Whitehorse would remove it from the community for four or more hours.

Generally, if a patient is able to go safely by private vehicle, he or she is instructed to do so.

When Blackjack left the Carmacks health centre on Nov. 6, Crosby said, she understood that a ride had been secured for her.

“Ultimately, I need to think about the community as a whole … you’re always thinking of the worst-case scenario,” she said.

Comments (9)

Up 8 Down 6

Cheyenne Lacoste on Jan 27, 2020 at 5:53 pm

@JMurphy
Yes I am fully aware that the Sarah Steele building offers counselling services. I myself sought counselling a few years back and it took a year for me to get “assigned” a counsellor.
So yes it’s free but If someone is in critical need a year would be hard to go through in my opinion.
These services are available in Whitehorse however, what about the communities? Mayo, Old Crow, Watson lake and Carmacks where Cynthia was from..
Individuals who want to recover need the help and support of many.
It is a big territory and if the Sarah Steele building is servicing the entirety of it, people may not get the care they need & want in a timely fashion.

Up 11 Down 2

YukonMax on Jan 27, 2020 at 5:07 pm

Carmacks is so close to Whitehorse, it makes no sense to send out a medevac. The protocoles adhered to in order to activate a medevac can take a long time. After the E.M.S. authorizes the medevac, Alkan Air has to get the call, prep the aircraft, wait fo the E.M.S. to arrive, load the plane with equipment all, and all. She would have been in Whitehorse by the time that plane arrived in Carmacks.
I know, I was suffering a heart attack for 4 hours before the plane got to Faro. I could have driven myself faster.

Up 34 Down 7

JMurphy on Jan 26, 2020 at 2:35 pm

Cheyenne Lacoste,
Free counseling is available at the Sarah Steele building. You have to go in and sign up, they will then assign an intake. Once you've completed your intake you will be assigned a counselor, you can have several appointments per week if you'd like, all covered, doesn't cost a thing. These wonderful counselors can then get you set up with a psychiatrist AND psychologist, once again, zero cost. So where....where can anyone find a counselor in the Yukon without having to pay $150/hour? Whitehorse. Sarah Steele Building. (867) 456-3838
And here's the wonderful part, it's right in the same building as DETOX. Imagine that, bountiful resources available to those who seek. What a strange concept.

Up 66 Down 7

Salt on Jan 24, 2020 at 10:24 pm

JC, someone from her community obviously. Family? Friends? Why is the government being presented as the only choice here? Do people bare any responsibility for themselves and their family/community or should we just expect the bureaucratic blob of government to mother us cradle to grave?

Up 17 Down 17

JC on Jan 24, 2020 at 4:53 pm

Annette Peters, who could have driven her?

Up 33 Down 8

Max Mack on Jan 24, 2020 at 11:40 am

I wonder if the political underpinnings of this so-called inquest effectively means this will be a show trial with a predictable outcome.

Up 49 Down 3

SheepChaser on Jan 24, 2020 at 10:51 am

Really have to appreciate the detailed reporting by the Star here. Well done. Our nationally subsidized broadcaster could learn a thing or two.

Up 23 Down 39

Annette Peters on Jan 24, 2020 at 4:49 am

They could have driven her.

Up 74 Down 7

Cheyenne Lacoste on Jan 23, 2020 at 6:32 pm

Nurses can not fix things like
“Multi organ failure” which causes “hyper acute liver failure”
It doesn’t matter how many notes the nurses could have taken.
Cynthias case is unfortunately not a rarity. One of my friends roommates drank himself to death.
Between the span of three days he went from “normal” to yellow and dead.
It’s a terrible thing to see.. how many more people do we have to lose to get to root of the problem here.
Alcoholism is a deadly disease and should be treated as such.
Education/ treatment/ counseling/ sober housing there are plenty of resources that should be available.
Where? Where can anyone find a counselor in Yukon? Unless you're willing to shell out $150+ /hour.
I feel for everyone involved but it seems like the bigger issues need to be addressed.

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