As the inquest into the death of Mary Johnny continues, her doctor justified his decision not to medevac the critically ill woman to Whitehorse sooner than he did, saying that she’d been improving as expected up until her condition drastically and suddenly worsened on the sixth day of her stay in hospital in Watson Lake.

“She had a condition that I’ve seen hundreds and hundreds of times and she was responding to the normal treatment,” said Dr. Said Secerbegovic, resuming his testimony on Thursday in a Whitehorse courtroom.

Johnny, a 60-year-old Kaska woman, died on Aug. 9, 2012, a day after she was medevaced to Whitehorse General Hospital. She spent six days at the Watson Lake Community Hospital, admitted with nausea, vomiting and diarrhea.

An alcoholic who visited the hospital dozens of times before to detox, she was severely dehydrated at the time and said she last drank 10 days prior.

The inquest heard earlier this week that Johnny’s condition had been relatively stable until the early-morning hours of Aug. 8, when nurses reported she had an elevated pulse, low blood pressure and mottling on her legs, indicating poor circulation.

Secerbegovic called for a medevac at 11 a.m., about 12 hours after she took a turn for the worse and after he and the nurses spent nearly three hours stabilizing her. “I did not feel initially that she would not recover from her symptoms at the time of admission,” he said, adding that he’d seen her in a similar state before.

That was up until the “drastic and unrecoverable change” on Aug. 8.

Then he wasn’t sure she’d survive until the plane arrived from Whitehorse.

“Should at that point I have medevaced her?” Secerbegovic said.

“Perhaps I was thinking all we should do is make her comfortable. Maybe I needed an extra three hours to think about it. Perhaps I just grasped at a straw.”

The medevac team arrived in Watson Lake by 3:35 p.m., and had Johnny to Whitehorse by 7:15 p.m. She died the following morning.

As the only working doctor in the community in 2012 besides his daughter, Secerbegovic testified that he was on call ‘round-the-clock, often logging 16- and 18-hour days between the hospital and his own clinic, and working through meals.

“It’s not safe and it’s not good,” he said of the hectic schedule.

Jenny Cunningham, the lawyer representing Johnny’s mother Eva, questioned why the doctor didn’t medevac the woman to Whitehorse sooner in order to access more thorough and quicker testing available at the larger hospital.

But Secerbegovic said lab results aren’t everything – that clinical diagnoses are viable too. And Johnny had been responding to treatment, he said.

Thursday’s testimony focused in part on her cause of death. The Yukon’s chief coroner found in 2013 that Johnny died of a bowel obstruction.

The purpose of the inquest, and what the six-member jury has been tasked with, is determining the identity of the deceased and where, when, how, and by what means she died.

While it was initially thought Johnny was going through alcohol withdrawal upon her arrival at the hospital in Watson Lake, testing showed a high level of creatinine in her system, which indicates kidney trouble.

On the day she was admitted, Secerbegovic ordered a chest X-ray to rule out early pneumonia. It wasn’t taken until three days later – it wasn’t urgent, he said. Johnny received fluids through an IV, and nurses monitored her vital signs.

Secerbegovic inserted a nasogastric tube to clear gas from Johnny’s system and help her bowels relax. He suspected she had an ileus – when the normal muscle contractions of the intestines are disrupted. The tube, he said, is the treatment of choice for this condition or for an obstruction.

Johnny did well with the uncomfortable tube for a day, but then she demanded it be removed. Secerbegovic said he thought the ileus had released.

She was stomaching Jell-O and water and he felt she was improving.

He didn’t order an abdominal X-ray, which would have showed whether her bowels were obstructed.

Dr. Laurence Hollands, an internist from Langley, B.C., who testified as an expert on Thursday, said that given her “feisty disposition” and stable vital signs, it seemed Johnny was indeed on the mend.

In a report he produced for the inquest, he pinpointed a change in her condition on day four of her stay in hospital, when she was short of breath. This was the beginning of the process she died from, he said.

Her oxygen levels and blood pressure dropped. With her history – years of smoking and alcohol use – her prognosis was poor even when she first arrived at the hospital, he said.

By Aug. 7, she was experiencing multi-organ failure, Hollands said – liver disease, kidney disease and cardiorespiratory failure.

In his opinion, she most likely died from congestive heart failure or a pulmonary embolism, a blood clot that travels to the lung.

Dr. Janet Smylie, a Métis family physician and researcher at St. Michael’s Hospital in Toronto who’s worked in rural and remote First Nations communities, was called as an expert on aboriginal people’s experience with the Canadian healthcare system.

There are inherent, and sometimes unintentional, biases within that system, she said. One such stereotype is that an aboriginal person is intoxicated when he or she has different medical conditions.

In Johnny’s case, she was initially misdiagnosed with alcohol withdrawal and treated for such, despite the fact that on the afternoon of Aug. 6, she was short of breath – a symptom not consistent with withdrawal.

Her oxygen levels were low, and she was in respiratory distress. Yet she was given Ativan, a drug commonly used to treat alcohol withdrawal. And in Secerbegovic’s transfer letter for the medevac team, he wrote Johnny was experiencing delirium tremens, a severe form of alcohol withdrawal, and was confused and disoriented.

This disorientation could have been because of the lack of oxygen Johnny’s brain was receiving, Smylie said.

That Johnny had to wait 48 hours from the time her oxygen levels dropped until the medevac arrived wasn’t optimal care, she determined in a report prepared for the inquest, maintaining the initial diagnosis was due to the fact that Johnny was First Nations.

The jury also heard that Secerbegovic didn’t make detailed notes, in part because of his busy schedule and also because he knew his patients so well, he said.

One of these notes lawyers focused on was that of a do-not-resuscitate (DNR) order in Johnny’s file.

This essentially means, Secerbegovic said, “don’t take any extra measures if there doesn’t seem to be any hope of a relatively normal existence.”

He said he spoke to Johnny on her second or third day in hospital about whether he should try to restart her heart or ventilate her if she stopped breathing.

This was the first time he’d ever broached the subject with her in the 35 years she was his patient, and he did so at nurses’ requests, he said.

It’s common for nurses to inquire about this if they need direction should the patient’s condition worsen, he said.

Secerbegovic took no notes of this discussion with Johnny, though.

In fact, a DNR order wasn’t noted in her file until 2 a.m. on Aug. 8, when she’d taken a turn for the worse. That’s when a registered nurse at the hospital testified she talked to the doctor about the course of action for Johnny, who by that point wouldn’t have been capable of giving consent to such an order.

Secerbegovic said he didn’t know why he wrote in the file then.

Over the course of the week, the inquest has seen several nurses who cared for Johnny in Watson Lake testify, as well as a physician and paramedic onboard her medevac flight, the hospital’s First Nations liaison worker, and medical expert witnesses.

Eva Johnny testified Tuesday that she’d gone to see her daughter in hospital in Watson Lake and tried to convince her to go to Vancouver for medical care. She refused.

Several parties are represented at the inquest, including the Yukon Hospital Corp., the physicians involved, and the coroner, whose lawyers are questioning the witnesses.

B.C. coroner Norman Leibel is presiding.

Testimony is scheduled to wrap up today, then the jury will begin deliberations.