First Anaesthetic & Obstetrics

I gave one anaesthetic as an undergraduate. There was an optional four-week period that you could do but everybody knew there were no exams in it, so I didn’t take that very seriously.

“I didn’t take anaesthetics very seriously… everyone knew there were no exams in it…”

When I was doing my obstetric elective in Nottingham, I got called out one evening to go on the flying squad, because a lot of women had their babies at home and they had this flying squad in case they got into trouble, and there was a woman with a retained placenta, and I found myself in this ambulance with a lady obstetric registrar, a nurse and myself. And on the way the obstetric registrar said, ‘Oh, you’ll give the anaesthetic, by the way, and I’ll tell you what to do’ and that was my training!

“‘You’ll give the anaesthetic and I’ll tell you what to do’. That was my training!”

When we got to this lady’s house, the anaesthetic was chloroform on a Schimmelbusch mask, the one and only time I gave chloroform, and the training was that I poured it on from a dropper bottle and she told me when to stop. And it was very successful, I thought it was terrific!

“A woman’s having a baby on my bus!”

Once when I was a houseman at St Pancras, a double-decker bus drew up in the front drive and the bus conductor rushed out and said, ‘A woman’s having a baby on my bus’. As a geriatric hospital, we weren’t very well equipped for this, but the night sister and I rushed out and there was this woman writhing around on that long seat … and nobody would get off because it was the last bus, and so we had to drive it to UCH and fortunately we got her there before she delivered. And then they could continue their journey home. The bus driver said, ‘This bus ain’t stopping before UCH!’

The Mayo Clinic

 I thought the anaesthetic side of paediatrics, particularly ENT work and so on, was a very interesting area. I don’t think I had thought at that time of getting a permanent job at Great Ormond Street, but I thought it would be good to do six months, and of course as soon as I got to GOS I realised that I fell in love with the place, and with giving anaesthetics to children. So at that stage it became a more serious possibility, although I didn’t think that I’d be likely to get a consultant job, because they were very few and far between.

When that possibility was beginning to arise, Bill Glover said, ‘If you really want a chance of doing this job, you really need to go abroad and learn some anaesthesia for cardiac surgery, because that’s what’s going to be needed particularly.’ He suggested that I might like to consider going to the Mayo Clinic in the States. I originally was intending to do six months of anaesthesia and six months of intensive care, but whilst I was out there I met a wonderful man called Kai Rehder, who had just set up the research department of anaesthesia, which was going to look at pulmonary physiology, and he invited me to be his first research fellow. I did six months in the lab with Kai, doing one-lung anaesthesia on human volunteers that were paid $50 a time to have an endobronchial anaesthetic… which is what they did in those days. No surgery, just the anaesthetic. And they were paid volunteers from the hospital staff, and we turned them into various positions and studied the distribution of ventilation and perfusion.

Great Ormond Street

After fifteen months at the Mayo, back at GOS, I had a couple of cardiac sessions and some general surgery, orthopaedic surgery and ENT, and the night and weekend cover also at the Queen Elizabeth Hospital on Hackney Road where quite a lot of the neonatal surgery was done. That was quite a heavy commitment because there was only one other consultant there, so again I was doing alternate nights and weekends as a consultant for ten years, and going in for all the neonates.

“I remember doing four Blalock-Hanlon operations in one night, up all night doing them”

In the early days, the paediatric cardiac surgery was a lot of palliative surgery. There were a lot of things called Blalock-Hanlon Operations for transposition of the great arteries, and these were done at very short notice to make an artificial ASD to improve the circulation between the two sides of the heart. I remember doing four of them one night, up all night doing them.

They all ended up with tracheostomies, because one of our main surgeons had developed a great interest in tracheostomy in infants and showed that it could be done safely, and there was a Great Ormond Street Tracheostomy Tube that we put in. In those days it was very unusual to leave an endotracheal tube down any length of time, so at the end of the operation the tracheostomy was done and the child was taken to the ward with a tracheostomy tube.

In the early seventies that there began to be an interest in prolonged nasotracheal intubation and there was an argument about how long you could leave them down without getting subglottic stenosis ‘cause a significant proportion of children ended up getting stenosis afterwards. Initially they were still red rubber tubes, then fairly soon changed to plastic Portex tubes, but the real factor that emerged was the size of tube. We were putting down tubes that we were accustomed to for anaesthesia, which were too big for prolonged intubation, and we began to put down slightly smaller un-cuffed tubes and always insisted on having a slight leak around them when you ventilated, and that really solved the problem of subglottic stenosis.

“A lot of children were stuck on ventilators after surgery… some were on their ventilators for years”

A lot of the children were stuck on ventilators afterwards, because as they hadn’t had corrective surgery, only palliative surgery, they often had pulmonary hypertension and higher pulmonary blood flows. Another operation that was quite commonly done was banding of the pulmonary artery. It was just a bit of string round the pulmonary artery and it was pulled until the child looked blue and then it was released a little bit. It was a very subjective operation and a lot of the children had high pulmonary blood flows and you couldn’t wean them off the ventilator. Some of them were on their ventilators for years.

And they were all on these big Engstrom ventilators. Very much to my regret, I missed an opportunity to have my name in lights because we used to wean these children from the ventilator. The regimen was to try and get them to do five minutes breathing on their own on a T-piece every hour, and then if they did that, you’d prolong it to ten minutes, fifteen minutes. There was a child there who’d been there for a couple of years and his mother said to me that she’d noticed that if she held the end of the T-piece, the open end of the bag, and increased the pressure in it, he could manage the five minutes much better. It was PEEP [Positive End-Expiratory Pressure]! And I said, ‘Oh, you shouldn’t do that’, and a few months later George Gregory described PEEP and CPAP!

Research at Great Ormond Street

I did a list with the surgeon who’d on the Everest Expedition 1953 with Hillary and Tenzing, as a locum at St Andrew’s Hospital in Bow. There were a couple of paediatricians there who were just setting up an infant lung function department at GOS with a research fellow called Tony Milner, and they said, ‘Why don’t you come and help us ‘cause you had this experience in America?’

So Tony and I focussed on the neonatal and infant side of it, measurement of lung function in the first year of life, and we built a whole-body plethysmograph, converting an old Drinker ventilator which we got out of a basement store. We began to be able to measure lung volumes in that and developed some oesophageal balloons to measure pressures. I had the access to take these measurements into the post-operative care ward because there was a lot of interest in trying to find out why these children after cardiac surgery couldn’t be weaned off the ventilator, so my joining the team opened doors to these paediatricians that they couldn’t get before.

“Looking back, you’d never be allowed to do [that research] now… we didn’t have much ethical approval in those days!”

Looking back on it, you’d never be allowed to do it now because we wheeled this Drinker ventilator into the ward and put babies inside it and measured their lung volumes – shut the lid but we didn’t have any complications. It was very safe and I had built an in-dwelling T-piece system into it so that you could still ventilate the child even when the lid was shut. But we didn’t have much in the way of ethical approval in those days!

The Portex Professor

In 1991, I was appointed Portex Professor of Paediatric Anaesthesia. At the time, the college was just moving from being a faculty of the Royal College of Surgeons to becoming a college, and Michael Rosen, then the President, appointed me as Chairman of the Fundraising Committee for the new college, because he said, ‘Ah, you come from Great Ormond Street. They’re good at raising money!’

As part of this fund-raising effort, he had a dinner and I found myself sitting next to the managing director of Portex. During the conversation we talked about my research and he seemed more interested in that than in Michael’s attempts to get money for the new college. A couple of weeks later I got an invitation to Portex, to a meeting chaired by the MD of Smiths Industries Medical Systems, the parent body, and there were a lot of important people there. He said ‘In whose department will this be? We don’t want the Portex Senior Lecturer in somebody else’s department. We’d rather have the Portex Professor.’

“You come from Great Ormond Street. They’re good at raising money!”

I was a consultant with a reasonably good research reputation, but without any extra resources just being called a professor, I was going to be rather poorly regarded, because I was suddenly going to be judged by other standards. And so I said, ‘No, you can’t appoint a professor in isolation. If you want to establish an academic department, that would be different.’ So he said, ‘Well how much would that cost? Go away and cost it.’ So I went off to the Dean and we sat down and we wrote out a costing for a professor, a couple of senior lecturers, a lecturer, a technician and a secretary. We heard nothing for three months and then just before Christmas I got a phone call and he said, ‘we’ve looked at your application. It’s about to be the 75th anniversary of Smiths Industries and we want to do something that gives our shareholders a warm glow. We’re going to fund you for ten years.’

“‘We want to do something that gives our shareholders a warm glow. We’re going to fund you for ten years”

The money went to the university and they came back and asked me if I would take it. And it was a bit difficult to say no at that point, having been involved in it! But it was just being at the right place at the right time. I stayed in that role until 2000. I was 63 by then and it was coming to the end. We’d just negotiated another five years and I thought that was a good time for somebody else to get their feet under the table and establish the relationship with the firm, and Monty Mythen took that on. He’s basically an adult anaesthetist, intensivist, but he agreed to move his office to Great Ormond Street. The department has gone from strength to strength.

Achievements and Reflections

“You got to know the parents for quite a long period of time, and they became friends”

I think the cardiac surgery gave me the most satisfaction, seeing the improvements in mortality and the ability to do corrective surgery– seeing people breathing at the end of the operation and coming off the table and not having to be on ventilators, and in parallel the development of intensive care as a more proper specialty. I did enjoy doing plastic surgery. I enjoyed lips and palates very much. I think that’s quite a satisfying area, to see the reaction of the parents after you’ve closed a cleft lip is great.

“The most satisfaction was seeing people breathing at the end of the operation and not having to be on ventilators”

Probably the most satisfying thing is the relationship with the parents actually. And that’s one of the reasons why the cardiac surgery was so satisfying, because you got to know the parents for quite a long period of time and they became friends, which of course can be incredibly tragic as well if things went wrong. I’m still in touch with the lady whose child I looked after for years, who had congenital thoracic dystrophy and she couldn’t breathe properly. We made a portable ventilator for her so that she could go out into the park and wander around. She did very well until she became a teenager and then her lungs didn’t keep up with her growth spurt and she died in mid-teens. In fact they took her home and had the whole house adapted so that she could be ventilated at home, one of the first children we had responsibility for going home on a ventilator. The husband and wife stayed up at night with her, one of them was always at her bedside 24 hours a day for about six years or something, terrific! But that was very rewarding to see that sort of commitment.

Associations

I became a founding member of the Association of Paediatric Anaesthetists in 1973, then later the secretary/treasurer and eventually became President in 1993 I think. In those days, there were hardly any specialist associations. I think the obstetric anaesthetists had been founded, there was a neurosurgical travelling club, but virtually no other association. It was thought that it would be a good idea to have some sort of group where the full-time paediatric anaesthetists in this country could meet each other, ‘cause we never met Jackson Rees and the people from Liverpool from one year to another and only knew by reputation what they were doing up there.

I was elected Vice-President of the College of Anaesthetists in 1991 and did two years. from 1991 to ’93. I enjoyed that, it was a great privilege.

And then the GMC called and I became the appointed anaesthetist on the GMC, in the days when there were over 100 members of council. In fact I’m still working for them now. It has changed enormously. I think that having 105-member council was totally dysfunctional, but there were advantages, one of which was in amongst those 105 people were three Members of Parliament, and they made a lot of difference to getting Acts of Parliament changed, particularly the performance procedures, which I became involved in.

Until 1980, about the only way you got struck off from the GMC was misconduct, and in 1980 largely as a result of this Association and its sick doctors scheme, they realised there were doctors who were a potential danger to patients because of their health, and they managed to get a change to the Medical Act to introduce the health procedures. But then in 1995 they introduced the performance procedures and to deal with doctors who were not guilty of misconduct and not sick, but whose patterns of performance were a potential danger to the patient. They set up working parties with subgroups in every specialty, and I chaired the anaesthetic working party. And that became my main area of interest within the GMC. They kept me on as an advisor, and I’m still advising one or two days a month on methods of assessment. I’m not doing anything clinical. I think you have to be quite careful when you’ve retired as long as I have.

“I was the first lay member of the Bar Council… it was fascinating to see them struggling, dragging their barristers shouting and screaming into 12 hours a year CPD”

I was the first lay member of the Bar Council. That was an appointment from the GMC because the barristers, bless them, decided that they ought to be doing something towards CPD, which they had never done before, and they wanted somebody from a group that had more experience, and so they approached the GMC. It was fascinating to see them struggling, dragging their barristers shouting and screaming into 12 hours a year of CPD.

I’m very proud to be an honorary member of this Association and to be given the John Snow Medal. I think that’s wonderful. It was an honour to be asked to do the Hewitt Lecture for the College and then to get their gold medal, which was fantastic.

And the Honorary Fellowship of the Royal College of Paediatrics and Child Health was rather special too. I did the Royal College of Surgeons’ Christmas Lecture to a whole group of school children. I gave them a talk on anaesthesia and what it’s like to be an anaesthetist. Great fun. They gave me a little medal for that.

“Great Ormond Street now has the David Hatch lecture. I thought you had to be dead to get one of those things…”

It’s also a great honour to have an eponymous lecture named after you at Great Ormond Street. They’ve now got the David Hatch Lecture, at which they give a little medal away every year. I thought you had to be dead to get one of those things but I looked in the Telegraph the other day and I wasn’t in the obituaries, so I suppose …

The Magic Circle

I wish I’d taken up magic earlier, it’s a great hobby. My wife’s very patient with me… it’s becoming a bit all-consuming!

My sister had a conjurer for a family party, and he was so bad that on the way home my wife said to me ‘You can do better than that!’ So that started me off and I went to a magic shop down the Clerkenwell Road and bought a few tricks, and they run a monthly lecture associated with the shop so I started going to that, just for my own fun really, and then I met the secretary of the Fellowship of Christian Magicians, who said, ‘Why don’t you join?’. I never knew there was one. But they do tricks with a message for school assemblies and things like that and so I got involved in that and I won the Stage Magic Competition this year, so I’m the 2014 Stage Competition winner! I’ve got a huge great cup at home!

“I’m the 2014 Stage Competition winner, I’ve got a huge great cup at home!”

Then this gentleman said to me, ‘Why don’t you have a go for the Magic Circle?’ You have to be sponsored by two members and audition and perform for ten minutes in front of other magicians, so it was a bit daunting… there are three judges marking you and only one is marking you on the technical ability with the tricks. The other two are on the entertainment value and the patter. But it’s a wonderful club to belong to and I’m now the Welfare Officer for the Magic Circle, which is a great privilege. I get in touch with all sorts of magicians that are on hard times, I now call myself Professor Whizzo and I perform for charity and raise money. I raise about £1,000 a year or so for charity.

“‘Why don’t you have a go for the Magic Circle?’”

I’ve been wondering whether I couldn’t develop a little talk to give to the anaesthetic department at Great Ormond Street about distraction therapy and the use of magic, and my only problem is that I don’t know how that squares with my oath to the Magic Circle not to give away any secrets! I think we could find a way around that!

I’ve had a very fortunate life. I think a lot of it has been serendipity. I still feel I’m a bit of a fraud really ‘cause I’ve bluffed my way through life I think. But everybody’s been very kind to me. I’ve also had a very good opportunity to write. I love writing and Ted Sumner and I wrote standard textbooks on neonatal and paediatric anaesthesia, which my colleagues at Great Ormond Street have continued. The paediatric book is now in its third edition, and so I mean we’ve been very, very fortunate and I think I’ve had a wonderful career. I look forward to living a little bit longer and doing a few other things.