This is Professor Piaffe were being interviewed by Derek Hockaday, 21st of November 18 up here, I think you were elected to the chair in 91.
And how long had you been in Oxford before that, Derek? I came on the 5th of January, 1970.
Right. And I came for one year to do research in intensive care because I was fed up of running an intensive care unit in Geneva using cookie recipes.
And I thought I should train in research and then be able to work in intensive care and develop some things, not simply apply cooking recipes.
And I very much enjoyed the work in Oxford on the intensive care unit and in
the department and realise that one year wouldn't give me research training.
It wouldn't be credible. So I had to do something like a day field.
So I registered for a day fill and spend the next two and a half years doing my day field.
And that was experimental hemodynamics.
We use the canine model with fairly sophisticated means of measurements to look at the effect of anaesthetics on the heart.
At the time, not all that much was known of these mechanisms.
So I did that with somebody who became very well-known, Sedrick Chris Roberts,
who later became president of the Royal College of Anaesthetist and Professor in Bristol.
And that's what I did. And because Cedric Chris Roberts went to Bristol, when I finished my degree, there was a job to do.
There were researchers to pick up and continue to help with the higher degree.
So from being a student, I suddenly was supervisor of several researchers in the same field of cardiac dynamics.
And by the time I had my first real interaction with the clinical school,
being a clinical lecturer appointed under the old Nuffield benefaction rules,
and this continued to US clinical lecturer, then university lecturer,
and eventually in seventy six, I became Reider in the department whose department and you join me.
That was the department with Alex Campton Smith as the Neville depart as the Nuffield Professor of Anaesthetics.
And of course the reason is that in those days, intensive care, particularly the respiration unit at the Churchill,
were very much as the adult intensive care, fairly limited as I did in Germany,
run by anaesthetist, because these these were the ways in the early 70s and even later,
the majority of staff in intensive care were anaesthetist and therefore belong to a department of anaesthetics.
And if you wanted to do research in this field, you would join anaesthetics.
And this is what happened and why I was in the department and had a succession of jobs, including in nineteen ninety 1991.
And the Fed chair. Yes. And but now the base of the department is worth the Churchill I associate with
respiration and fatness and so and was also the department where it ended as it were,
in that building just by the Radcliffe Infirmary. I mean it's in the regular infirmary but you know, it was joined on by a funny corridor.
Yeah. The respiration unit was run jointly by Alex Consensuses and John Spaulding.
Yeah, that was John's body. And my research should or could have been in the respiration unit on tetanus.
This is the work that Cedric Chris Roberts and John Kerr,
plus two research fellows from New Zealand and Australia, we are neurologist had done but in total in 1970.
To understand it, there was no case for nine months, so no possibility of doing any study.
And even then, the case in August 1970 was Rosada.
Tetanus.
We didn't study anyway, but the whole thing had disintegrated and indeed there were no longer tetanus patients admitted to the respiration unit.
So I had to convert. And that's why I did experiments that were mostly on the effect of anaesthetics on the heart and its performance just to go back.
No polio, no tetanus. A bit of Gambhir, Barry.
Yes, there was guayabera.
And this is one condition I was particularly interested in, because in Geneva I looked after patients with Jabbari and one of the patients.
A fateful day of the week when I was on call, had a cardiac arrest at about nine o'clock,
a second cardiac arrest at about 11 o'clock, and it said one at 12:00 noon.
And I must admit that I got a little concerned about that.
And this is the first patient ever to have been given a temporary pacemaker and it worked for the next three weeks.
You are on enough pace or not pace.
It was the first time in Ajilon Barry the autonomic dysfunction had been on the
side of cardiac arrest or severe bradycardia and had been treated by insertion,
insertion of a temporary pacemaker that were fairly old fashioned but worked.
And my interest continued.
And a few years ago, and a few years later, there was a case report of a review by the Mayo Clinic, and they had treated 30 patients with pacemakers.
But mine was still the first case ever. And they quoted from The Lancet the first case, that uncertainty and it had become routine to say,
Guillain Barre, you monitor ECG because it may be absolutely fine.
And one day a problem occurs and that's it.
It could be the end of the patient and it really was. But the pacemaker saved the day.
What was the title of your thesis that was totally different.
It was essentially the effect of carbon dioxide on the heart and the circulation, systemic pulmonary.
And that was part of the studies we wanted to do on what can happen during anaesthesia.
Hyper carb. If you hyperventilate hyperkalemia, if patients are breathing spontaneously, what are the effects on the heart and the circulation?
Looking at contractility as well, we really wanted to know exactly the pathophysiology of the physiology of hypo and hyperkalemia.
Yeah, we did the same later with hypoxia and we branched a lot into the effect of anaesthetic
agents because the effect on cardiac performance was fairly often misunderstood.
People thought that halothane cause hypertension by vasodilation dilatation because the veins became
more obvious that when you look at it in an experimental model and do those response curves,
you realise that the reduction in cardiac output is due to contractility of the myocardium falling over failure.
So this is the sort of work that got me interested.
And also in those days, and you may remember those days, it was so received wisdom to stop antihypertensive agents before surgery.
That was the received wisdom. We didn't believe it was other than anecdotal evidence.
And we said Sediq prescribe. It started and I joined when had studied one or two patients.
We decided to do data and hemodynamic studies of patients in whom we had permission
from the Ethics Committee to maintain their treatment and we would compare them.
And it wasn't randomised because it couldn't be randomised.
We compared them with people who were severely hypertensive but were on a new medication and this is what was recommended.
Leave them alone. So those on treatment, we maintain it, not on treatment we left alone.
And what happened?
Is that we could see with documented evidence of cardiac output, vascular resistance or the hemodynamics you could measure in patients,
we could demonstrate that certainly those maintained on treatment, if anything,
were slightly more stable, but certainly not at risk of cardiovascular collapse.
And that was the received wisdom.
These drugs antihypertensive Agents Koo's interfere with the control of the circulation and that caused cardiovascular collapse.
But it had never been documented. So we did document that and then we did more.
We decided one class of drug becoming very frequently used in hypertension, beta blockers.
Now, beta blockers were taboo in anaesthesia. Absolutely not under no circumstances.
And we thought, gee whiz, why is it?
And we started studies where we either gave an intravenous beta blocker before
anaesthesia or an oral beta blockers for three days before anaesthesia and surgery.
And all we could see is that these patients were much more stable, no detriment,
good cardiac function, good cardiac output, absolutely fine, but more stable.
And that made really people think treatment of hypertension should be maintained.
And that is even true of beta blockers. And so it was a complete revolution.
And it it went to some extremes because in those days, a hypertensive allergist in London,
Richard, is you probably knew him, was very keen on propranolol,
does then most use beta blocker and you was treating hypertensive patients with up to two grams a day, 40 milligrams, two cups a day.
And we saw that is pushing our luck because we had some hypertensive patients on two grams of fat and we thought this is pushing our luck,
but are we going to stop? We didn't think it was a good idea.
So let's document what is happening. And yes, that is true.
A heart rate, surprise, surprise.
But that withstood the whole anaesthetic process from induction, intraoperative phase recovery without any signs that the circulation was failing.
So it caused a complete U-turn in the way of thinking.
And that got me really interested. But you were asking my relationship with sort of university.
So, number one, I became a fellow of the college. Yes.
As a reader, roughly. When in seventy six, 76, 76.
That is when I said a piece of it went to Bristol.
I was elected to the fellowship at Worcester.
And in those days I was already starting to teach medical students.
Now, whatever the arrangements were, I cannot remember.
But there was a sort of anaesthetic module of some kind and I was teaching and that has been the case ever since.
And I was teaching medical students this morning and yesterday.
Right. So it's a few years later. I think it's about 42 years later.
I'm still teaching medical students and I I never stopped, but it was becoming more formal as years went by.
But the last 30 years, they were a specialist study module, probably about 20, 30 years and afterwards on these modules.
But I was already teaching the previous scheme for quite a while.
So that was my role within the medical school.
I was teaching medical students within the faculty more than medical school supervising research fellow.
I was doing a higher degree myself or jointly with pharmacology.
We had a lot of different students jointly with Derek, one of the lecture later Reede in pharmacology, and that was very productive.
What was the name, sir? Derek there. All right. Very well.
We really did a lot of work and the students like that because they were doing part of their work in his lab on cells.
And part in my lab on the canine model, so there was a good spectrum of studies done with the scene and that resulted in the higher degree.
Yes, that was that was fun. That was another part of my activity, was supervising teaching medical students.
And this is at the university where the teaching trainees in anaesthetics.
Yes. I mean, in a sense, it all with the university. But just to go back to your higher degree, who we are.
Did you enjoy your. Yes. Yeah.
Who were the examiners? They worry, quite honestly,
I've completely forgotten that presumably it was a pretty good thesis because then you were promoted to be look after the others, don't you?
Oh, yes, no. Things went very well. And I say there was there were a few corrections, as always, and that was that was done.
Now, I was just thinking, you know, when I was a clinical student,
when Game seven and Unanesthetized one or two patients oneself, would that ever happen nowadays with a qualified student?
No, no help. And what they enjoy most medical students, when I often I teach them at the end of their attachment to anaesthetics.
And what they enjoy most is they gain confidence in sticking needles in veins that maintain airways, which is important.
And a good many do a fair amount of intubation. Right.
And they love that. They love that. But.
Anaesthetic itself, Zelzal and the Halpern's see, I don't I cannot guarantee, but I very much doubt that they would do more than that.
But to intubate and Zengerle is that that's what we hear again and again.
They find the attachment to anaesthetics quite unique because and maybe I'm wrong,
but they have a greater opportunity in the theatre to be one to one with a consultant.
That is nobody else. That's what they enjoy that they enjoy that a lot.
They get a lot of teaching. And we have a form of teaching tutorials with groups of eight of turns, only six, seven, eight.
And I think they have now 14 topics. So it's a fair amount of standardised teaching so that they will have covered.
For example, this morning I did fluid balance.
Yesterday, I talked about cardiac problems in surgical patients and also I talk about acid base balance.
But no, that's very interesting because in a sense,
that pathophysiology when you teach them which anaesthetic agent is the right one for which operation.
No, that's I don't talk about never. Does anybody talk about.
Oh, yes. Oh, yes. They have tutorials on regional anaesthesia, the principle of general anaesthesia and pain relief, pain management.
They have a day of emergencies in the simulator and they absolutely love it.
That is for them. It's fantastic. And so they generally are very, very happy days when somebody is talking about blood transfusion and pitfalls.
And so it's it's a fairly well balanced programme and airway management, of course.
So they do intubate in theatre,
but they also have a session on airway management so that they learn more about different types of equipment that may come across.
So they enjoy what they are doing with us. Were you involved with the pain clinic at all?
Not really know. Very little. And it was before an acute pain management was organised.
We have a team now, acute pain management,
and the pain management was as such was really Henry Makuei and at the Churchill or before Dr Lloyd Addington, John Lewis.
And then he came to the John and to the Churchill,
and it was the first chronic pain management unit having Bense that was unique so they could
do interventions and people could stay overnight if that was justified by the intervention.
And that was a great novelty. So there is still a group doing mostly chronic pain.
There is a group doing acute pain and it's it has grown considerably.
And now there's a great deal more integration between those who do mostly chronic chronic pain and those who do acute pain.
They are much more joined up. But the acute pain management team is much more recent.
It took a long time. We were I think we were a good deal behind other centres having an acute pain team,
which has made an enormous difference to what you can or can do on the ward.
You couldn't not have an epidural without a pain team available and checking that everything is working and is all right, you couldn't do it.
How many advanced students would you have, you know, reading, working for degrees that was for or generally,
I would say three years, three, four is too much shows too many when the year is in a sense.
Yeah exactly. So you have one finishing one starting one maybe in the middle.
But it's seldom being more than that though.
There have been times with more with people are coming from abroad to do just one year and not necessarily a higher degree.
But they were sort of then joining somebody was working on a higher degree so they would benefit and help.
So is the numbers. But I don't think I ever had four.
I saw from the nineteen thirties and a physicist in Germany, Krebs had the story and.
He had the slogan, If I can understand why these students, none of them are any good.
I mean, it does. And I said, move that first.
I mean, do you find that they're introducing nobody's students?
Well, they're doing what they're told. Oh, no, they do. They do introduce nobody said do develop.
And we had several examples of the students who managed to refine the approach to problems of hemodynamics and extend Scilab,
develop new technologies and make them work.
And one, for example, at the time the canine model was becoming far too expensive,
came from France and developed a rabbit model that quite honestly, I we discussed what he could do, how it could be done.
But it got the model going at was that and he did this higher degree in Lille is university and he's now head of department at many years grades.
And he did very well. But he really made the model stick and we did a lot of interesting studies and it worked.
And another one, uh, developed a long kind of preparation that's not as original.
But we didn't have it and it got it off the ground and it worked.
So, yes, students do contribute a lot. It is the land of what I call the heartland preparation,
let me know it's it's heart just for her is right, but it for some of the things we wanted to do.
It serves a purpose as well. And so that's why we used it.
And the last day feel I supervised, I formerly supervised.
Did the work on using the land and off. Do you work or talk to Peter in Merton?
Peter not Sinclair. But it's a name like that.
He's a professor of cardiology and he's interested in nitric oxide and beta blockers because the question would be,
does anaesthesia affect nitric oxide levels? I cannot answer that in a scientific manner because it's not an area I have necessarily a research much,
but it's quite possible because he's working on that.
So you should talk to him. Really, the interaction of nitric oxide with beta blockers?
Yeah, that's yes. It's I'm not aware of that.
And he runs the Burden Saunderson Institute in Physiology, Deepak, you know that.
Yeah. And Peter, I've forgotten his name just for a minute, anyhow.
Now, did your views of the university change as you went to being a to a professor, a retired professor?
Yes, what I don't think it's my view changed it, the university changed profoundly because when I came,
there were still the benefaction and the NAAFI benefaction hired people.
Lecture's that was my post was and does not feel benefaction.
This was absorbed with within the general board because clearly the benefaction could not support it in its own everleigh,
a vastly expanded medical school that wasn't possible, but for a long period,
and it was still true in 1992 1990 that were established posts in departments and the description,
the particular of the chair indicated what staff was established and therefore if people moved, they could be replaced.
And that was not questioned in 1990, 1991.
And the chair had a budget and the chair also had for the new incumbent,
a sum of money available to the new head of department to develop something if he or she wanted it.
And that was really extremely helpful. And it helped me in a way, because until I retired,
it would have been very difficult to remove posts from the department because that would have been a breach of contract.
And but now that has disappeared in my understanding is that doesn't exist anymore.
Established post, don't I believe I may be wrong but don't exist in the ways I did.
And my understanding, again, is that most of the researchers have to fund at least a substantial part of their salary out of grants.
So the number of established posts that was reasonably large as decreased was a number of people doing research has increased,
but it has increased on the strength of grants.
And again, in the field of grants, views have changed.
When I submitted grants to MRC, a British Heart Foundation, for example,
it was assumed that the department was offering the new researchers on the grant project or programme would offer support is technical,
secretarial and otherwise. No, it's not right.
All these costs have to be costed in the grant, even the heating and the lighting.
Yeah, right. Okay, I believe so. And so it has changed completely.
And therefore now is the sums involved in grants have been increased enormously because it's not only the fellow salary,
but all the ancillary support, because the funding is different.
Instead of coming centrally from the university to the department to have the corps that was regarded as essential in the 80s 90s,
you wouldn't get a grant if you didn't have the support for a study that was just now.
It's different. You have to cost everything. And so the grants, I cannot remember what sort of figure it is,
but I think it's probably sixty or seventy percent of at least 50 percent more because of overheads that has to be there.
So you have to spend as head of a department, has to spend all of his time writing grants.
I'm sure a lot more because I believe but I'm no longer head of department.
But I believe that things have changed mostly along those lines.
The support that existed and was implied is no longer employed.
You have to compete. You have to justify and you have essentially to find the funding that has changed.
Quite dramatic. No, anaesthetists wouldn't function without surgeons, so relationships with surgeons were very important.
Yeah, now I must admit that I have been extraordinarily fortunate because in 1974,
Peter Morris was appointed Nuffield professor of surgery and Alex Campton Smith in his wisdom.
So we have a new Nuffield professor of surgery.
We should offer support for his clinical activities and the support us in under two headings.
One is weekly operating list.
It would be run by Zionistic department, but was added before.
Wouldn't it always have been? Not sure, because I don't think Àlex was much involved with Professor Alyson's no operate,
whether it be an NHS anaesthetist separate from the department or the anaesthetists in the department.
All in all, it was always integrated. But I mean, somebody must have been anaesthetising rather than whenever you can't operate.
I don't know that it was before my time.
He was he was no longer I think he may still be alive when I came, but the first three years it was higher, my higher degree in the lab.
So I didn't know. When Peter Morris started, Alex decided we should run this list.
And I was doing it essentially from day one and have done it all the way throughout his career when he stood down in 2001.
And there was something more to it with.
And we also, as Cedric Roberts, Alan Noge myself took charge of anaesthesia for renal transplant when Peter started a real transplant programme.
And we did the first cert, which took quite a while in those days.
So we established a routine, what could be done successfully, repeated successfully.
And that was another interaction. But what was most important is that Peter Morris relied to a significant extent on me in the preoperative assessment
of these vascular patients who by definition have coronary artery disease and goodness knows what diabetes is alive.
And so I was much more involved in the preop assessment then.
I was involved in giving the anaesthetic and then I was involved on ICU because all the
abdominal aortic aneurysm repairs went to ICU and that was one of the ICU consultive.
So I would see them essentially Tuesday, Wednesday in theatre.
I would look in Thursday morning on ICU and Friday was my day on ICU.
So from 1979, certainly I had this really rule of pay of active physician.
As soon as the leave open,
I started to be involved regularly on Friday with ICU at the John Rateliff and this was really perioperative medicine before the word was invented.
And of course, the reason it worked and I think for me it worked extremely well.
I hope it worked for my patients is that before coming to Oxford had done nine years of what we call in Switzerland internal medicine.
I was in there fully trained physician. Right.
Okay, I did having done three years of this or two and a half in medical intensive care, but I had done nine years of medicine.
So doing that using the sort of skill I had acquired there,
plus limited anaesthetic skills because I didn't have the sort of normal training anaesthetics,
but being involved in intensive care, it worked extremely well.
And I did that with Peter certainly from 79 until 2001.
We were doing I was doing on Tuesday I would run with the vascular surgeons.
And so that was pretty unique. And I enjoyed that because it was in a way, patients I was anaesthetising were really also my patients.
And with Peter, we really conceived our work like.
They were our patient was very, you know, terrific and for a number of years, in the early days of surgery of the abdominal aorta,
we were opening not only the aorta, but sort of carving later a change, but there was often bleeding.
At 10:00 on a Wednesday evening, I would go to surgeon Latif, see the patient on ICU.
And from time to time, I would call Peter and say, look, Peter, I'm unhappy with your patient.
There is, I think, a degree of bleeding, which is a bit worrying, is I've booked a theatre and you would come and operate.
So it was a sort of collaboration we established. And I think it was it was really very interesting and important.
And one thing I will never forget, a senior registrar in surgery wasn't quite sure what I was doing, doing the wardrobe.
We with this anaesthetist come into the ward round once and and commenting.
That was strange. And so he was quite upset about it.
And one morning before the ward and Peter came and said, You remember do you remember this private patient of mine we discussed two weeks ago?
What do you think we should do? And the penny dropped a lot.
And maybe maybe there was some things of collaboration that was maybe not all that usual.
But for me, it was fantastic. And it continued not only with Peter, but the other vascular surgeons.
We really formed a team with David Tibs. No, David was we we I never anaesthetize for him.
And he was not all that active anymore.
And but Valerie Good was anaesthetising for him, for example.
But no, it was really more the academic team with Linda Hunt's.
Yes. And others. And really it was the group doing their vascular training and they were doing mostly which Peter Morris.
So I knew them very well. And I really enjoyed working as part of a team and doing palliative medicine before it was invented more generally.
Were there ever any, as it were, systemic problems between the surgeons and many suggests?
I'll tell you, I'm thinking about that. There was a chap I knew who he did medicine and got his membership and then he got bored with that.
He was the sort of bloke who got bored. He was highly intelligent and he got bored.
And then he took to surgery and was doing very well in that. And as a sort of senior registrar, he said, I can't stand it waiting around,
you know, and for the anaesthetist to arrive at night, there's no work to come in.
I think I will take the Fifth Amendment. No, I think it does happen.
But on the whole, I think people start to realise that anaesthesia is not always as simple as all that,
and that on occasion things take longer than they could, is that there is something going wrong and you couldn't necessarily predict it.
Now, whether people are late arriving, that is a matter I'm not going to comment on because I had a strict rule,
I would say at least was due to start at eight thirty.
I did not leave and I would be in Zionistic room at quarter to quarter to eight so that the lines
would be in and we would really have the patient on the table within five minutes of eight thirty.
So it was never an issue.
But in a way I had the luxury of doing one full day a week since the days I was in the lab of running the department own ICU.
So for me, coming home that way, it was no problem.
And I had always seen my patients the night before because that is when we were doing The Woodlands so I would know them.
So everything was prepared and coming at quarter to eight.
On the whole, we could start on time. Now, you must have had to work with the nurses very closely.
And how did they feed you? Because that must be very important.
Yeah, they are. And we were lucky in the department to have lots of very well trained anaesthetic nurses and they were excellent, but we trained them.
And that was, I think, started by John Lloyd Wright, I'm pretty sure.
And so there was a training scheme and I found that they were really very, very,
very good and got really full support and that is on occasion absolutely essential.
When the chips are down, you need to have somebody competent and prepared to walk the extra mile.
And that was never a question. And it's this is something which is not university, but maybe a hospital.
There was a flexibility in working that may or may not exist anymore.
But for example, if the list was difficult,
nobody would bat an eyelid and you would finish at seven o'clock in the evening is when we were still at Zerai and Peter Morris was doing carotids.
That was seventy four. Seventy nine, OK.
He and I were only carotids were only done if Peter and I were in town and on occasion there were problems
because they were operations to be done and there was no space on the Wednesday list or the says there is data.
So we would book a theatre for Saturday morning and do a couple of cat cartoons on a Saturday morning.
And that was in the operating theatre.
Does the theatre sister, but does the anaesthetist have a designated nurse?
The same. Yeah, yes. Yeah. And he said, oh yes.
I said it's one days and then I you the nursing must've been very important.
Oh that is absolutely essential.
And again we were lucky to have very, very, very good nurses on ICU.
Very good, very competent. And that makes life possible.
But of course in those days, ICU was a lot smaller, did not live.
There was the potential for 12 or 14 beds in practise.
Very often we had only. Six beds open because we didn't have the nursing staff, not enough,
but gradually we opened and then an extra unit was built so that now we have 18 beds, if I'm not mistaken.
So it's much bigger, but it was small, two units with 12 beds total, but 12 when seldom.
And you can still get the serve because you hear about stuff, nursing shortages.
But is there a problem now? No, I hear on the grapevine that certainly at the Churchill they've had problems with,
uh, nurses going back to where they spend and they have great difficulties.
And that's what I've heard from the church.
Well, of course, now is a full fledged ICU and under what is called a post-operative acute care unit next to it.
And that is where I think they have problems in having enough staff,
because some people go and I think it's the political situation is such that they don't feel safe in staying.
So they some go home. Have you seen real changes in fluid balance management, asset base management in your career?
Oh, yes. And I will tell you, because that is right in your field of interest.
When I first got involved with managing patients with diabetic ketoacidosis, that is in 1960,
the received wisdom was to give fluids, but also to give 100 units an IV and 100 units.
And that that was the received wisdom that I think it has changed a little since.
But am I right in saying that it's really an Oxford change?
Absolutely. Insulin in a drip as opposed to, you know, reinjected.
The real Oxford thing is a small dose. Yes. No regular smoulders.
Yeah. Rather, a few people were giving it intravenous before that either blank for the name of the guy was a research fellow.
Did develop this technique of having insulin in the deep Albertus George Albert is is OK, I'll tell you about that.
That's George Albert IV. And that for me it's a great it was a great novelty.
I must admit that between 60 and 69 we had we used to do this a bit.
Yes. But a hundred units I, I was standard practise.
And what about Lactaid? Do you ever give Lactaid intravenous sodium Lactaid.
No, no. Because way back way way back when used to give people used to give like they know what was
done and shown later not to be the best thing was to use bicarbonate in diabetic ketoacidosis.
And we know it's not necessarily the best thing unless unless academia is such that the patient perish unless you give it.
And we had one case, a determinative to whom I gave more by carbonates and I'd given to all of the other patients and she survived.
But it was the most fierce diabetic ketoacidosis I've ever seen.
And every time we decided, no,
we should stop by carbonate apage at six point eight would start to go down and it becomes I'm fairly laid back, but it's a bit frightening.
And the potassium is difficult to do now. But I'm fascinated because what when with that have been that you were looking after a diabetic cagers.
That equation is that someone who needed surgery done as I was in Geneva sorry, in Geneva, then I was involved with medical intensive care.
He was nineteen sixty one. Yeah. But then you were talking about giving a lot of bicarbonate with that in Oxford that this patient was.
Yes. Was nothing to do with surgery. She was on ICU on a fateful Friday where I was the ICU concerned.
And roughly what, at what date was that because I thought the physicians would have been doing that.
We see that as well if they were up in arms. I did that.
We are given by cabinet. No good for you. I mean, I'd thought the physicians.
Looking after the patient on their own would rather than I don't know, with this one,
she was admitted she was intubated because she had AIDS, right, because of the super acute Accademia.
She had developed AIDS. She was hypoxic, ventilated on ICU, took her three days to get a.
I've never seen a case like that. And I don't wish to see you there.
And I mean, it's a silly question in a way.
Would you say there was much difference between nursing in Geneva and in Oxford or about the same?
The difference is that our small intensive care unit in Geneva had essentially 10 beds and there were relatively few nurses,
but they were doing that for years and they were absolutely superb.
Now, when I came in 1970, we had it was Nuffield three.
There were four beds and there were more there were more nurses, but in between 70 and 74,
75, I wasn't much involved with that until we opened ICU and the tower block.
Before that, I wasn't much involved, but they were very good.
But I think the ones I have been working with had been all working very for a very long period, say 10 years when I was in charge.
They'd been working for 10 years. But I've I can't really compare because I wasn't much involved with Nuffield three.
John Lloyd was running it that when we moved to the John leave in 79, which is a long time later, there were very, very good.
And in the tower block as well, they were very good. But that was less I was helping them mostly to help when the consultant couldn't do the wards.
And so I would go in and help. But it's only after 79 that I was involved regularly every week.
So then all this time, your writing papers? Yeah.
Giving lectures? Yes. To London committees. Yes.
So how did your faith go ahead and did you work in the evenings writing your papers?
Yes. Yes, I think it is you you should ask and she would tell you and to be entirely correct, I never told Andy that I was going to retire.
And she doesn't know yet. She doesn't really know.
And so mum's the word.
No, don't don't spill the beans. No, I've yes.
You had I had to work in the evenings and the Saturday and but what I must admit I also enjoyed
is to be involved on the national scene as a member of Council of the College of Anaesthetists,
because that gave me a different perspective on, uh, Anastasiya Countrywide.
And also I was much involved being on the university representative on the Oxford Anti Trust Board, um,
when we became a trust, I was one of the non-executive director right from the start for seven years or so.
Yeah. And that was very interesting. At the same time, I was on Council of the College,
so my activity on intensive care decreased because I couldn't do everything runs the department council of the College Trust Board,
and that was a bit much. So I distance myself from intensive care and that was much less needed because there were more people.
So they didn't need early on. They were full and they needed to be free on Friday to have had a break during the week.
And that is what I provided is a break during the week.
That Wednesday, we are more consultants. It wasn't really terribly helpful, but it was helpful for me to get the Friday.
It was, it seems the I mean, taking the university and the NHS together.
How much of the number of anaesthetists increased over you during your time?
When I came in nineteen seventy. They were searchin consultant anaesthetist.
Now I hesitate, but the number is probably one hundred and twenty.
Probably they're going to give and take a few.
So almost tenfold, almost tenfold. That happened everywhere.
Yeah. Oh, yes. I mean, take cardiology the same when I came, there were four cardiologists for the whole region.
And when they were on the trust board, there wasn't much conflict between the trust and the university.
No, I don't I don't think there was no good. I don't think there was.
But certainly once I had served my time, Ken Fleming became the non-executive director, replacing me.
And I think I don't think there was conflict, but maybe it was a bit more assertive of university role in the trust.
So I think he did an awful lot of good.
I think he was very good at what I did was to make sure that things were running properly in a new newly developed trust as much as I could,
that it wouldn't interfere with teaching and research.
But I think can push things a bit more forward, including some change of the name.
Yes. Which I think was is a good idea.
Right. And you think that helped change the name? I think he did.
And I think it was. It was. But at the time I was there, it would have been impossible.
David Weatherall and tried. Right. And after all, he carried a lot of weight.
So who would have stopped him, as it were? I don't know.
I think in general, in general, I think a lot of NHS consultants were not keen to see the university taking a greater role.
But that's what what my perception is, which may or may not be correct.
But my successor, after I stood down from the chair, the next person to be head of department was right behind me, you remember?
I do, because the chair should have been refilled a appointment.
An election was made and the person took 18 months to finally say, no, I'm not coming.
And then you can imagine that those who had gone out of their way to get this appointment or this election working were a bit miffed.
Yeah, to say the least. So there was a bit more time before an election was made.
And then was Irene Tracy as professor of Anaesthetics Science and Henry Makuei of Professor of clinical anaesthesia or clinical anaesthetics.
So they were to two people. Now, I don't know how they have perceived university and running a department,
but I think Irene must have been fairly successful and likely to become head of the Department of Neurosciences Clinical Neurosciences.
So if she must have liked this stories if and Henry, I don't know, because we we didn't discuss that really.
And we only stayed as young as three years instead of I think it was sort of five years would have been reasonable.
But I think after three years, she decided to turn down from the chair and.
Now, what happened, I asked you that I should have asked you,
what would you what other aspects of what you've done and interactions with the Oxford that you like to mention that I haven't asked about yet.
What really interested me the most in terms of interaction is that Alex Clinton's speech was really wanting a NHS university
department to work as a unit so great that you wanted the academic department and the NHS department to work together.
That's absolutely Pickering. Pickering wanted that. Yeah. And that was also my view, very good to us.
There was maybe a little less of that while Keith Sykes was in the chair, but it wasn't a split.
But maybe the interaction was a bit less. And I was very keen to have profound interaction between academic staff and NHS.
And it had to be a department, just one department that I thought was very, very, very well.
And in a way, I had also some views about appointment to consultants, because, of course,
as head of department, you were automatically a member of all appointment committees for consultants.
And my view was that there is a range of talents we need in the department and amongst the people we appoint.
We should on occasion say we are not interested in how many papers they may have written, but do they have a skill they can impart and teach?
And I was very aware of this need of diversity.
So in a large department, not everybody has to be academically interested.
But what is essential is that those who are appointed contribute something
unique or more or less unique and therefore will contribute to the teaching,
the training of trainees in anaesthetics, because afterwards that's what we have to do.
And I thought that was very important to accept that you shouldn't simply look at the CV and say, oh, this guy hasn't published much.
I'm not going to shortlist. You really should say now what has he done?
And you discover when you read more, this guy is really an expert at regional anaesthesia.
You know, we need such expertise because we want these skills to be passed on.
And that was my view. And on appointment committees,
I would I would really try to make sure that we maintain a wide range of subspecialty interest to impart to the future trainees.
And I think it has served and I think see an example of the integration.
Shortly after I was elected to the chair, there was a big hoo ha because some lists had been cancelled and there was a big discussion.
And what the chairman of the department,
because a clinical department always had a consultant chairman and there was a consultant committee for really the running of the department,
the chairman of the department.
The first thing he did was to say, look, we are going to create a small group to try to progress this problem because there is a problem.
We have to deal with it. And the first thing he did was to ask me to join, which was, I think,
an indication that consultants appreciated the idea of having a unified department where we would all pull our weight in in a different way,
but we would pull our weight and put it in the same direction. That was good.
And if they want to and they just could still do research.
Yeah, yeah, yeah. Me. Did you have any what used to be good and B appointments that say seven NHS four.
Oh yes. Oh yes it has. This has. But there were really as many university sessions.
It was mostly a day. Right. But yes we've had that, we, we had them and.
Yeah. And they were used. That's been true and that you'd like to say.
Yeah, what I have to say is that I've immensely enjoyed being in Oxford in this very exciting environment because it is.
And you've seen yourself. We were at the time developments took place or at a very fast rate.
And some of the developments were pretty unique. So be there, I think is was fantastic.
And the reason I'm still teaching and doing I still have an office in the department and I go every day is that when I was in the chair,
I really received a lot of support from my consultant colleagues because you kind of do a resume and never,
ever did anybody questions the fact that I was on college council and therefore couldn't do my Wednesday at least once a month or whatever.
And in a way, I enjoyed teaching and I enjoyed doing research.
I enjoy mentoring or supervising research fellows.
And I could see no reason to stop. And at the same time, it's sort of payback to the department.
You've given me a lot of support now. I give a bit of support in in teaching and continuing to contribute directly to the department,
mostly teaching medical students, but also teaching our trainees.
I had a session two weeks ago. I have one session tomorrow and on Friday of those are the trainees taking the exam.
And I'm taking an active role in mock vivo exams for trainees.
And I do that regularly and I enjoy it. And in a way, it's also I feel it's sort of payback.
I've got a lot of support now. Time has come to do it.
I've been an examiner at the college, so I've seen the real thing.
So it's useful for me to be involved and it's useful for those who run it to have me involved and talking and saying, oh, we could do this or that.
And it's I enjoy that. That's very valuable and enjoy that immensely.
I enjoy that absolutely immensely. And today I was teaching and after my teaching I went to a small meeting.
It's exactly 10 years ago that in the department,
the simulation centre started that it has broadened enormously and into a lot of simulation, but also other courses on leadership.
And so, like, it's been a huge success.
And the person who runs it, Helen Hiyam was my research fellow, attracted her from London and she worked with me not on simulation,
but cardiovascular and cardiovascular research, and then became a consultant and took that on the road.
And the impact of this simulation centre on the job, not leave academic and clinical, is just amazing because all the students go through that.
Most of the trainees, you know, especially spend time on the simulator and lots of people to take part in leadership and leadership courses.
And this afternoon, they are they have discussions on different aspects, which is quite amazing what they're what they are going to discuss.
So as I was simulation,
there are courses on human factors and patient safety leadership that is under the Oxford Centre for Simulation led by Alan Home.
And I must admit that I made two really fantastic appointments.
I was lucky, Duncan Young and Helen, and these are the ones that have done the most in the department, know lots of others.
I've done very well. But elsewhere, a number of heads of departments that have done very well.
But and I trained them and that's great.
But in a way, in Oxford, those are the two appointments that have made a difference to the way things are done.
And Helen is a case in point and I really enjoy.
Seeing how she has developed that she she is brilliant.
So that is the sort of things that have been very interesting and supportive of in in a small way.
And, yeah, I I've enjoyed the why we came for one year and now we are quite a long time.
Where did you live? One year. So the first year.
Where did you live. Oh we rented a house on the Amazon road and after a few years we decided to buy.
So we bought a house on Headly Way right by the bus stop.
And while we were there and it was fine and this house came on the market and we bought it 25 years ago.
So we've never moved on three sides of a triangle and all within walking distance of the journey,
which I moved to, you know, when I was working with Peter Morris.
It was fantastic because he clearly accepted that as I was near and I wanted to do it, I could see the patients.
And you relied on me to say, I smell a rat.
There is something wrong. So he really felt I could I could help and spot problems in his patients.
And it was great to to have work with a superb surgeon.
And he's a superb dancer. He really have a lot of time.
And we worked together for such a long time and felt that really we were a team.
And that was I mean, all the time as a physician must have helped tremendously.
Yeah. Because he you wanted me to to see patients that that was that was never a question.
You wanted me to do as much. And I was also helped in a way, because in Geneva I was doing intensive care,
but I created the care section and therefore I done more along the line of cardiology than other people in internal medicine would have done.
And in a way, I think I spoke probably a bit more the same language,
which helped a lot with this vascular patient, cardiac problems, people like Colleen ForFour, Oliver Omron.
I could knock on their door and they knew that if I knocked on their door is that I really needed a second opinion or investigations.
It was not just to cover myself. It was it.
It really did matter. And I needed their views as to whether really.
Yes, you are right. This is a problem. But I think treating the problem may cause more harm than good, which I couldn't always be sure of.
And that was really also fantastic to be involved directly with cardiologist any any time, day or night.
I could get one to see a patient. And Brian Cribben also collaborated with but mostly Oliver Ormerod and calling for far.
And it was easy access because I had the background of having run in the day.
We couldn't do very much, but still on my I infarctions spoke to me, so to speak, and it was great to have this collaboration.
And what is amusing in a way, he said over the past several years now there is a multidisciplinary team
meeting for patients having kidney pancreas transplant and it is the cardiology
aspect of it and have been co-opted to it because the way we investigate these patients is the way we investigated the abdominal aortic aneurysm.
And that was. Done by Oliver Cromwell and myself in the 80s, and we use the same scheme and it has served us very well and they wanted me to join.
So I go in there and we discuss three, four or five pages and see all the angles.
And that makes life really interesting and rewarding.
Do you still use exercise judgement? They are used yet, but for these patients, it's mostly myocardial cinematography.
Yes. And also exercise. Yes. And the cardiopulmonary exercise test, which is now used a lot.
And fortunately,
and it's really extremely helpful because the new ways in which EKG's are recorded and data analysed makes it easier to spot myocardial ischaemia.
Early on, I was concerned that it wasn't very good at that.
So an exercise test, which would be useful purely Ziggs exchange with limited DCG didn't appeal to me very much,
but now it's done far better and it's maybe it will replace.
But I think we still will continue to do myocardial cinematograph,
which is something we started to do with Oliver as multi get blood to scan in
the first place before Myocardial Centigrams became the most popular test.
And it served our vascular surgical patients very well.
It did. So it's been exciting and that's why I'm still alive.
Well, that's a lovely interview. I really enjoyed that.
Sanjay, thank you very much. You are welcome. It was great.
I pulled the plug, Angela, and it was great.
Thank you very much.