Dr Peter Wallace: Intensive Care in Scotland

Dr Peter Wallace is a retired anaesthetic consultant from the Western Infirmary in Glasgow and a Past President of the Association of Anaesthetists. He was a specialist in intensive care and cardiac surgery, and helped to establish the emergency patient transport service in Scotland. In this interview he discusses his career in clinical work, and in ‘administration and politics’ with various Associations and Committees.

Medical School

I actually had three or four months off school when I was five or six; I had polio and was locked away in the local infectious diseases hospital…, there was four or five of us got it, I think it was the last outbreak and I ended up reasonably normal. One boy died and one ended up deaf and one ended up with a bit of paralysis. I remember bits of that and it only came back to me when I was training in medicine and I saw someone having a lumbar puncture done and… that was, I suppose, my introduction to medicine.

I qualified in ’68 [from Glasgow], really didn’t know what I wanted to do at that stage and I did a house job in medicine in Glasgow. I had trouble getting a surgical job and I went to a district hospital in Ayrshire which was a district that didn’t have many students… and that was one of the best things that I’ve done because I found there that you did two/three months in casualty, three months in medical, three months in surgical ward, two months in the male surgical ward. There were two sisters in the surgical wards who I think I learnt more [from] in the six months there than I did in six years at university, and it was a great job and I thoroughly enjoyed it. I also got to know an anaesthetist then in particular, Graham McNabb… I did a lot of theatre work and I quite liked watching him working and as a person and… he had the respect in the theatre suite.

“Can you help me get a job in anaesthetics?”

Because I then went on to do six months in obstetrics and eventually got my D.Obs, and I think at that stage I was drifting towards doing a GP job. I didn’t want to settle down, and thought what else can I do? And my girlfriend at that time, later my wife, had started anaesthetics in another hospital in Glasgow a year before and she was quite enjoying it and I was two-thirds through my obstetrics job and didn’t have anything coming up, I phoned up Graham McNabb in Kilmarnock and said ‘Can you help me get a job in anaesthetics?’

‘A job in anaesthetics…’

I started anaesthetics then February ’70… and I liked it. They were all a good bunch, it was a big teaching hospital, there was a Professor Forrester, Alex Forrester, who was a funny wee man who clicked a pen all the time. We didn’t see him to do much anaesthetics, but he’d had a history of giving anaesthetics and we knew Forrester spray, he’d introduced that. He had done a lot which came up later in my life, both polio in Glasgow and he’d been across with the infectious diseases consultant to Copenhagen after the Copenhagen outbreak, and I didn’t realise that at the time there was an intensive care bit there.

It was a good training in Glasgow, the Royal had most things in it, but there was a separate obstetric hospital, separate paediatric hospital, separate neurosurgical hospital, and you did three months in each of those as registrar.

The  senior registrar job, I think looking back, that was the time you felt most confident you could do almost everything, because I could do from cardiac surgery to obstetrics, to bits and pieces, but very insular now looking back – the Royal Infirmary was the Royal Infirmary, we were wonderful, we were better than everyone else particularly in Glasgow and better than Edinburgh!

“The  senior registrar job… was the time you felt most confident you could do almost everything… from cardiac surgery to obstetrics”

I went out on rotation as a locum to Falkirk when I was an SR and I quite enjoyed working in the district hospital at that time… I really had enjoyed doing paediatrics as a registrar in Glasgow, but you had to go back for another three months as SR to do your higher training and I suggested that I could go to Ayrshire and do my Higher training. Ayrshire were delighted. They’d never had a senior registrar down and I thought that would get me in there for the next job coming up. So I went down to Ayrshire and I enjoyed that, it was a tiny wee hospital with two consultants… Although I was meant to be doing paediatrics they moved me around various hospitals, and at that time I was almost turned against it because there was a number of consultants in district hospitals that had chips on their shoulder, you know – ‘He’s from a teaching hospital, he’s down here as a clever senior registrar to tell me what to do, and I know what to do. I’ve got a Fellowship same as you.’ And that almost turned me against it, but I enjoyed [it].

Then there was a job at the Western in Glasgow, which was at the other end of the city, at the kind of snooty end, and I think it was Donald Campbell said, ‘Just apply for it to keep your nose clean’. So I went along to the interview for the Western job, with another person of my era and two more senior senior registrars, one of whom worked at the Western and it was her job, we thought. I was interviewed in the morning and the Health Board Officers said ‘If you come back at 2 o’clock, we’ll tell you who got the job.’ So I went across to a pub across the road, and the girl I thought was going to get the job had driven me in, in the morning to the interview, and … I can still remember saying ‘I’ll go and phone ‘cause it’s not me’ and there were two more senior ones that thought that they were going to get it and I went and phoned up, I can still see it, it was a corner box in the pub. I said, ‘Who got the job?’ ‘You got it, Dr Wallace.’… And I had to go back and tell this girl, who then had to drive me back, and then I had to phone the guy in Ayrshire who had become my great mate, that I wasn’t going to take it and I think that decision was based on, at that time if you went to district hospitals it was difficult to go back out. In fact it became easier later on. But if you went to teaching hospital and didn’t like it I thought I could always move because there were vacancies around.

Intensive Care

Alastair Spence was reader at that time, and I’d gone across when I was still an SR in the November/December of ’75, to do a research project with him for Entonox in post-operative care and it’s one of my regrets that we never got it published ‘cause it was actually quite good ‘cause if you had a cylinder – there were cylinders of Entonox and cylinders of placebo gas and it didn’t make any difference what was in the cylinder but if you’d a cylinder you’d less pain than the guys who didn’t have a cylinder. And I did two months there doing that and that was at the same time as I was appointed to the job at the Western. I started as a consultant in the Western on 1st January ’76, and really I was viewed as an outsider from the Royal. There had been no consultant been appointed to the Western from the Royal, there’d been consultants going the other way.

It was a smaller department and it was more traditional and more orientated towards private work than the Western I think… So I started there and the job then had intensive care in it, which I swore I’d never do really, I really didn’t see that as my future. And also the proposal [was] to have two sessions of cardiac surgery in it. Cardiac surgery at that time was done in Glasgow at the Royal Infirmary, which I’d done a lot of. They wanted to start another cardiac unit at the Western and I was the first person to have cardiac surgical sessions in my job.

“The job had intensive care in it, which I swore I’d never do, I really didn’t see that as my future”

I started with intensive care. At that time the intensive care unit of the Royal had been totally anaesthetic run. At the Western there had been a lot of opposition to setting up a separate intensive care unit, the physicians really didn’t want their patients taken away from them, and the anaesthetic department had very few people keen on doing intensive care, they were more interested in other bits and pieces of life. An intensive care unit had eventually emerged out of the respiratory unit, and the boss of the intensive care unit was a respiratory physician, a guy called Iain Ledingham who was a surgeon really but who then became a clinical physiologist and he had a big research background and was the dominant character in it, and two anaesthetists and I was the fifth person… and it ran well and I obviously worked there till I retired, but it was always being reviewed from general anaesthetic side as a bit odd…it was quite a hard time but I enjoyed it.

Iain Ledingham got involved with the hyperbaric chamber in the Western… nitrous oxide originally as an anaesthetic and then using various hyperbaric oxygen treatments for lung things and for gangrene and various bits and pieces like that, and he had the first blood gas machine in the hospital. He set up a research group of three registrars who were there to do research in sepsis to begin with but they then started transporting patients around, originally because the Western was meant to be redeveloped and they built another hospital, Gartnavel, three miles away, but then ITU was at the Western and surgical patients at the Gartnavel so they had to be transferred backwards and forwards so Iain set up this transport service which grew into a service for all the Glasgow hospitals, and then for the West of Scotland from Stornoway to Stranraer.

“The transport service grew into a service for all the Glasgow hospitals, and then for the West of Scotland from Stornoway to Stranraer…”

I was still in the mindset that I was an anaesthetist who did intensive care rather than an intensivist, which Ledingham saw himself as, and I regret that I didn’t work well enough with Iain looking back. I did get involved with him to some extent because of my history of having worked with sedation in pre-medication, and Iain was suggested as someone who might be interested in Propofol sedation in intensive care, and… I worked with him quite closely with the Propofol stuff and we produced one of the first papers with Propofol sedation in intensive care, which worked quite well. And then Iain and I did a paper on recent advances, the changing face of sedative practice,  which was quite reasonable and I’d done the paper before I’d finished as an SR, I’d got one in the British Journal of Anaesthesia, about post-operative pain, and looking back I regret I never really got into research very closely. I did bits and pieces, and Spence and [others] were telling me, ‘Just keep yourself for merit awards… just do one or two papers a year.’ And I kept that up, mostly clinical stuff. The sedative stuff I should have done more with ‘cause I was interested in it and Iain at that stage had these three Registrars who were there, able to do work.

Cardiac Surgery

So intensive care was my bread and butter at that time but then cardiac surgery came back to bite my bum. I think ’79… I went ’76 and they’d been trying to get the cardiac surgical unit started in the Western… and my two sessions then became active and I had to start the cardiac surgical service, really against the wishes of the department. The department, the majority were not keen on intensive care, cardiac surgery – ‘no, we don’t want that in my hospital’ sort of thing… ‘waste of money, waste of time’. And I went back to the Royal to relearn it and I came down here and to Bristol I think, I went to the National Heart here… to get my hand back and then went back and started, and actually I thoroughly enjoyed that stage. But I and the physics chap really generated all the equipment by borrowing it ‘cause… the money had gone into cardiac surgical registrars to come across but not anaesthetic services at that stage, and we borrowed ventilators and monitors and bits and pieces from various equipment companies round the west of Scotland, and got it going, and I’ve still got the anaesthetic chart from the first bypass in 1979 who lived. And looking back, my technique hadn’t changed very much from 1979 to when I retired in 2005. I used fentanyl rather than morphine, and I can’t remember what else, but it was much the same.

“Intensive care was my bread and butter at that time, but then cardiac surgery came back to bite my bum…”

One of the senior guys at the Royal was gonna come across [for] an honorary professorship at the Western… He was actually quite forward in wanting… this was before computers and he was very keen to have that and looking back, he had the right idea. It wasn’t the speeds that you’ve got now, it was a big machine in the corner which went and picked up pens and drew graphs, red one for that one, blue one for that one, and that sat in the corner. And part of the recovery room became the cardiac intensive care unit and the nurses were training at that stage…I did all of the bypasses for the next 18 months or so. I was the only consultant anaesthetist at that stage, with SRs coming in to do things.

Then the other two guys came across, I remember we had to fight to get extra SR people and eventually it ended up with a four-day bypass service, by the time I retired we’d done 1,000 bypasses and I was still doing it on a Monday, and I was quite enjoying doing it. When I retired I was still enjoying my work but I was ready to go. I’ve never done a private case in my life, which my children say ‘we could have been at private school if you’d done that and we could have been something!’ But no, I just always – I was NHS and I didn’t want to do private work.

“I’ve still got the anaesthetic chart from the first bypass in 1979… by the time I retired we’d done 1,000 bypasses”

I think there’s bits I do regret, that there was some research bits in cardiac, there was a lung water thing we were doing, there was a sedation thing we were doing, and I never pushed them through. There was some papers given at cardiothoracic meetings but I published very little, two or three publications out of that. I did some research on sedation and intensive care and there was later on bits on sepsis.

I met a guy called Willie Tullett who’d been an SR with us from respiratory medicine, in the lift, and he was then a consultant with A&E and I said, ‘Well do you fancy doing intensive care?’ So Willie came in and he was the first A&E Consultant in Britain to do intensive care, and literally by chance by meeting him in a lift.And he’s still doing intensive care, and in fact I was out for lunch with him recently and he said, ‘You changed my life! I was A&E, I then did mostly A&E and a bit of intensive care,’ and now he’s just doing intensive care. He was on the Inter-Collegiate Board and things, so I feel I had a hand in broadening out intensive care.

Emergency Transport

Iain Ledingham left and I think I was chairman of the Division at the time, coming up to the ’90s, and the shock team, of which there was two anaesthetists and a surgeon and at least three registrars, were then homeless and they came into the anaesthetics, and they were still moving the transport thing around. And it developed to provide a service for the West of Scotland, got bigger and bigger, and were eventually moving 300-400 patients a year and it was quite good from the management’s point of view that it meant that you could ‘safely’, in inverted commas, move patients if you’re short of beds. There was five intensive units in Glasgow at that stage, and another dozen around about the West of Scotland… And I took over the shock team and expanded it to four or five registrars and then got it included in a training scheme where registrars from the West of Scotland came through for three months at that time. The problem with that was they got experience in transferring tricky patients but there wasn’t the year-long time to do research which there had been before. But they kept producing a number of audits and various things and I became a world expert on transport of the critically ill. I did often admit that actually I only ever transferred one myself, when I was an SHO in the Royal Infirmary. There was a head injury had to go to neurosurgery and I was sent down to do this and I still remember hand-bagging this patient. But then because I’d taken over this transport thing, and I got involved in Intensive Care Society, and we wrote guidelines for transport and I started producing various papers about transport of the critically ill.

“There was a call from Stranraer… the shock team was ready to go… and that was Friday night. Never thought anything about it until I went in on Monday morning, the shock team had got back on Sunday!”

Some of the transports were [by] plane. There were very few helicopters at that stage. It’s now developed into  a National Helicopter Service. They were mostly from the West of Scotland for within an hour or two hours, ambulances, and Scottish Ambulance Service provided a mobile intensive care ambulance, and there was a fixed wing service, so the Stranraer and the far islands and Inverness. I remember there was a call from Stranraer and the registrar on the shock team was ready to go, [but]‘cause always two of them went, the second register, ‘I am not going!…I’m not going.’ And I then got someone else on call, I think obstetrics or something…and that was Friday night. Never thought anything about it until I went in on Monday morning, the shock team had got back on Sunday! The flight had been up to Stornoway, taken three times to come down, landed and the guy wouldn’t take off again. So this girl who’d done a favour was on Stornoway for two nights! I met her not so long ago, I said, ‘I’m awful sorry about that! I really feel guilty.’ She said, ‘It’s alright. You gave me a bottle of champagne the next week!’ I don’t remember that at all!

Administration and Politics

At the same time I was getting involved more in administrative and political things, and that started off in the Western in the department, I became chairman of the division, and… then the time came in when we were moving on to the trust thing with clinical directors and they wanted me to be clinical director and I saw it as a challenge – that would be early ’90s, ‘92, something like that, and there was a big battle in the hospital…all to be competing with each other… and I had the longest title, I was the Clinical Director of Anaesthesia, Intensive Care Medicine and Pain Relief Services. And there was a very aggressive surgeon,  he and I squabbled, I had a wonderful ability to get under his skin and it was one of the great pleasures in life.

Anyway, I remember a meeting where he said, ‘No, it’s only the people with beds that can have influence. We’ll have a vote…’ ‘I’ve got eight beds in intensive care… ha, [he] never thought of that…’ And that was quite a good time. I enjoyed that, had a budget of £12 million and you got all the bits and pieces of business manager and nurse manager and I had a separate secretary, and that was quite good. The only thing I didn’t like was you used to have half-past-seven meetings in the morning on a Friday and I hated getting up at that time and could never get to them!

“Could you tell our visitor the hotel’s been bombed…”

So I enjoyed that stage in life and then meanwhile I had got involved on various committees in Glasgow… I was Secretary of the Scottish Society of Anaesthetists in the ‘80s into ‘90s and then also got involved with the College visits to places, which I enjoyed. We were out at Craigavad and got phone call saying, ‘Could you tell our visitor the hotel’s been bombed’… there were people all over the place, there was guns… the bomb had been on the fourth or fifth and we were on the third, so all the stuff got covered in dust and then they said, ‘The hotel’s fine from the sixth floor up. You can go to the eighth.’ No way!

And I felt sorry for the Northern Irish at that stage ‘cause up till then during the Troubles if visitors had gone they stayed at individuals’ houses and we were the first ones that felt safe in hotels and then it all went wrong and we had to go and stay with people again.

“I got involved in Intensive Care Society and I can’t remember why I wanted to do these things. Probably just big-headedness or something like that.”

And then I got involved in Intensive Care Society and I can’t remember why I wanted to do these things. Probably just big-headedness or something like that. I stood four times for the Intensive Care Society before I got on the Council and I look back and think why the hell did I do that? I don’t know. And I got on there and it was a time that it was expanding…they got premises in the BMA… and it all became more formal and bigger… And I think I had a hand in getting it on board, because before that the Intensive Care Society had been run from Alistair’s bag and then Paul Waller came in after me and made it a much more formal thing and it’s now much bigger. The Intensive Care Society then resided with the Association in Bedford Square, and… I was on Council of the Association at that stage, and they said, ‘Go and do it and it won’t affect you here.’ And I did it and then was involved with the various committees after that, the Joint Committee in Intensive Care Training and there was the Intercollegiate Board… I fell out with them a bit over that at that time 95% of people doing intensive care were anaesthetists but the Intensive Care Society and the Joint Committee’s obsession was that other 5%, expand the 5%, and I was more interested in making sure that the 95% be trained better. And that time the College really didn’t do much to encourage that. And I wish I’d been more ameliorated to the non-physician side. I had nothing against intensivists coming in, but at that time, in the ’90s, there was only four or five full time intensivists in Britain. And I remember a fulltime intensivist [who] had a system where he did a month full-time but then was doing research and other bits and pieces, and I ended up doing more intensive care than he was, but he was an intensivist! And I’ve never called myself that, I’m an anaesthetist that does intensive care. And it’s developed on.

“In the ’90s, there was only four or five full time intensivists in Britain.”

At the Association I became Secretary when Morrell was President, while we were still in Bedford Square. And it really was a time that we needed to move and there was a great fuss of looking for new places and at the same time I think the whole structure of the Association changed. Bedford Square was a little homely group. There was I think six or seven staff at the most with one general manager but it was largely run by the non-exec people here once a week, the Secretary and the Chairman. And in fact when I was Secretary we were still doing all the minutes, I was doing the minutes of the Council Advisory and the E&R as part of the job as the Secretary. [Then] it was getting bigger and bigger and we had a professional interim manager… [who] I think turned things around, ‘cause he then got the secretarial staff, to do the minutes. Weeee, I don’t need to do the minutes anymore! We moved in in early 2002. And I was President by that time, after Leo, and I think we were settling down and that was a very exciting time with much more space, more staff.

Anaesthetic Practitioners

And I’d been involved with the anaesthetic practitioner thing. There’d been the Audit Commission report in the ‘90s [on the] shortage of anaesthetists in Britain and looking at anaesthetic nurses, nurses giving anaesthetics. And I was involved with the Audit Commission report at the time and… and we produced a publication which said we didn’t see a position for non-medical anaesthetists at this time, but then it came back I think when I was Secretary. We found that the Department of Health, the NHS modernisation and the College had been working together to plan development of the anaesthetic team, and in the middle of that was anaesthetic practitioners. And we were shown the draft and were allowed to make some changes to it, but it was bad the way it was done… they were gonna go ahead, whatever we did, and were we to be involved… I still remember it came up at this Council and their general attitude amongst the Council [was] for not having this… but my feeling was… it was gonna happen, we should get involved. And I remember thinking I’m gonna take a vote and I’m gonna lose this so we’ll just review this next time. And then during that time, the late ‘90s into 2000s, there was a group to develop anaesthetic practitioners as it was at that stage… And they’d come up with a pilot scheme in several places to train ODPs or science graduates I think at that time, to do this job which was supervised, and that’s an influence we did have. They always had to have a supervising physician, anaesthetist around… and there were two or three different places that started training half a dozen and I was involved in that till I retired, and then I thought I was away from it.

After I retired Peter Simpson phoned me up saying, ‘Scottish Office wants to look at anaesthetic practitioners. We want you to chair a committee.’ I thought ‘oh no, I don’t want it!’ I said, ‘I’ll do it for two years.’… In that time we set up in Scotland a training scheme which… was the same basis as down here, supervised ODPs and science graduates. I was chairing the Anaesthetic Practitioners Group and there was another group looking at Physician Assistance for Scottish Other Specialities, GPs and A&E in particular. And I said, ‘I don’t see why ours should be practitioners and you’ve got assistants.’ And the Scottish Office were against it and the President down here, she didn’t wanna change, the College didn’t want to change the names, but I bullied basically the Scottish Office into changing our ones from anaesthetic practitioners to physician assistants (anaesthesia). And once we had done that up there, training them, we did it down here. So I feel that’s my one contribution to changing levels!

Retirement

I was 60 when I retired. My mother looked at me and said, ‘You’re going grey son. You’re the first fat Wallace that ever went grey! They all died first.’ And then another time she decided I was drinking too much. ‘You remember you come from a family of wee fat men that drink too much and died young!’ So I’d always had this at the back of my mind, and doing my genealogy which I’ve done since I retired, there’s only one other Wallace that’s ever lived beyond seventy which I’ve now done, so I was determined I was gonna go on my birthday although as I said, I still enjoyed work. I don’t know how I was coping, I was up and down[to London] every week, and going up and down was a great stress, but you just did it. And I went on… four o’clock on Friday 21st January 2005, I retired. But I was still involved here for a while after that and I haven’t regretted… workwise I stopped clinical work altogether. I kept the Association going for another year, I think I was Past President.

“My retirement is full of five or six Gs: that’s golf, grandchildren, gardening, gym, gluttony and Google.”

I’ve taken to retirement. I’ve felt at times that life is all self-indulgence and I should go and do something. My wife keeps saying I should go and join the Community Council and things like that, but I never got round to it. I always meant to do it. I’ve got this glib thing that I say, that my retirement is full of five or six Gs, that’s golf, grandchildren, gardening, gym, gluttony and Google. It fills my life. But I have no trouble killing time at all.

Regrets? I’ve had a few. I regret not doing more research and I regret some of the papers that registrars had written up that I was to talk off, I never finished, and that affected them a bit. I’ve been an aggressive little swine at times, I also regret. But I mean I did have the small man syndrome I’m sure. And chips on each shoulder. I used to use that as a joke at times. ‘I’m a well-balanced Scotsman, I’ve got a chip on each shoulder and a glass in each hand!’

“I’m a well-balanced Scotsman, I’ve got a chip on each shoulder and a glass in each hand!”

I’d do it all again! I’d like to be an architect. I’d like to go back to that. I’d like to have done more art in my life. I’d like to have spent more time with my kids ‘cause that was part of being up and down here, I missed that, although I think my generation didn’t spend as much time with our kids as… my daughters’ husbands do.

My achievements… I’ve lived to 70! Nearly 71 now. I think being President of five associations and societies, the AAGBI was the biggest one. I coped here, I would say it was alright, but in fact I had a bad year because we were moving here, there was a lot going on, and then these anaesthetic practitioners started coming around again. And it’s a matter of just keeping the ship going and keeping it calm. Calling them anaesthesia physician assistants I’m quite proud of. I don’t know what else, it was just to get through life. I’ve got here!