Ep109. The Secret Thoughts of Presidents: Dr Bob Hare

: 00:00:02

: 00:00:10

Hello there listeners. It's Suzy Do from the Australian Society of Anesthetists, and thank you for listening to episode 109 of

the Australian Anesthesia Podcast. It's where we talk about all things relevant to anesthesia in Australia. I mentioned at the

start of our last episode that I would take a few minutes to share some tips from what I've learned in my podcasting journey

in the hope that it also helps you with your patients and your leadership journey and public speaking because it certainly

helped me with mine. Last time I talked about the late night FM DJ voice, and I can't help saying that without exaggerating

the late night FM DJ voice. And in this episode, I want to build on that by applying it to how we introduce ourselves. In

particular, I want to focus in on how we say our name. How I see it is that how you say your name really builds, really adds

to that first impression of how people see you, whether it's in a social context or a formal meeting or standing up to give a

presentation.

: 00:01:13

And what I often see is the tendency for people to say their name too quickly or quietly, because of course you know your

name, but you've gotta remember that your audience, we may not know your name. We may be thinking of other things, and

this is our moment to first meet you. So by taking that time to say your name clearly and slowly, it can impart so many

things like credibility, confidence, and just that you want to ensure that I know your name. So three things to consider when

you say your name, whether you're doing it in your late night FM radio, DJ voice is say your name slowly and clearly. The

other thing about saying it, and it also follows on from what I was saying about the late night FM DJ voice, is to put a

downward inflection at the end doing so.

: 00:02:05

And there's been a lot that's spoken and written about this. There's some experts out there in terms of vocal intonation, but

doing so makes you sound more confident. There are certain cultures where they add an upward inflection in the end, and

Australians, we tend to do it a bit as well. So what that sounds like if you're putting in that upward inflection is, hi, my

name's Susie N rather than, hi, my name's Susie n Susie n versus Suzy New. If you say your name with that for inflection, it

adds this element of uncertainty. It sounds like a question. And you shouldn't have to ask a question about saying your

name because you should know who you are. So that's the second thing. The third thing is that we tend to introduce

ourselves, say our names within a sentence. So just say that sentence. So say, hi, my name is Suzy N.

: 00:02:59

Some people do other things like they say, um, or put a click in, like a nervous click because we're often thinking about

something else. And you sort of expect, I suppose, that you're gonna just punch your name out. But it doesn't always come

across like that. So there's a real difference between saying, hi, um, my name's Susie New. That just adds this real

uncertainty as to who I am or it, it, it makes your audience, your listeners think that you're uncertain about who you are. So

if you are uncertain about who you are, are you gonna be certain about what you're gonna be talking to me about? The other

thing I've mentioned clicks. Some people have a tendency to have a nervous click, so they might say, hi, I'm Susie New. So

just try and take that moment to be very conscious about introducing yourself and how you say your name.

: 00:03:44

And maybe, you know, maybe since I've been doing this, I've been noticing, and maybe it's just 'cause I'm getting older, or

maybe I just sound bossier, I don't know. But I tend to get less patients mistaking me for a nurse or a registrar. And that

used to happen a bit because I'm shorter, I'm female. There's a whole bunch of reasons. I don't know, unconscious bias, all

of that. We often, I might be with an older presenting male and it'll be assumed that they're the boss. But anyway, since I've

been saying my name more confidently and with my downward inflection and slowly and clearly my patients trust who I am,

I suppose. So that's my talking tip for today, I suppose. Let's call them talking tips. Anyway, let's move on to introducing my

next guest. And this episode is literally an oldie but such a goodie.

: 00:04:33

It's, it's both an oldie because of my guest, no offense Bob, but he is the earliest surviving past president of the Australian

Society of Anas. I have to say earliest because there is actually Don Maxwell. He's older than him, but Don was president

after him, if that makes sense. So the guest I'm talking about today is Bob Hare, who was president for the A SA in the early

1980s. And that's as far back as we can go in terms of speaking to past presidents who are still with us today. It's also an

oldie because I recorded this episode a few years ago. I've only published snippets of it before, but I was really inspired to

publish the whole episode due to a recent conversation I had with Zane. Thank you very much Zane, for your inspiration.

Zane told me how much he liked the podcast.

: 00:05:20

Thank you for that. And I asked which episodes in particular he liked and he said he really enjoyed the 90th birthday

episode. That one almost killed me to produce an edit, but I'm so so glad that he said that. But he said that he really liked the

history focus episodes because it just gave a really good context to Australian anesthesia. And it was also for him a really

nice break from studying for the first part exam. So I, I really loved that it was someone at the start of their career really

enjoying some insights from people who are happily in retirement, but who have also just given so much to what we now

call anesthesia in Australia. So there is plenty of history in this episode. We mentioned some big names in the world of

anesthesia in Australia, some significant men and women there. Bob and I go through having just this wonderful chat week

comparing our various anesthetic techniques that we have come across through our generations. Some of the innovations

that have occurred and as well some of the changes in our role as anesthetists and some of the important work that he and

the a SA has done to raise the status of anesthetists in Australia. It's always great catching it with Bob and I'm sure that you

are also gonna really enjoy this conversation and I'm really honored that I can bring it to you. Alright, let's get into it.

: 00:06:39

Well, thanks for giving up some time with me this morning. I didn't realize that when I became president of the a SA that I

would get to join quite an exclusive club, which is that of the past presidents. And it's been lovely getting to meet people

like yourself. So I'm really, really delighted to be able to sit down and have a bit more of a chat with you and also just share

our conversation with the public, with the members out there.

: 00:07:07

Thank you.

: 00:07:08

So you were a SA president in the early 1980s.

: 00:07:13

I was 81 and 82. Yeah.

: 00:07:15

And you heard about Dave McConnell, didn't you?

: 00:07:18

Yeah, Dave McConnell died. All the presidents prior to me are dead and some of them post me have also passed on thinking

of people like Ben Barry. Yeah, Richardson. And

: 00:07:31

I've had a chat with Don Maxwell. His podcast came out in time for the as a's 90th birthday. And I was gonna ask him if I, if I

had permission to share how old he is. 'cause he's as old as the a SA. That's right. He might not want me to tell everybody. I

think you

: 00:07:44

Don need to ask him about that, but I reckon he'd be happy to share it.

: 00:07:49

I miss seeing him at the president's drinks. He said he's just not getting so confident about heading out. And I normally see

him at the cocktail function.

: 00:07:57

The president's cocktail function at the s Scientific meeting.

: 00:08:00

Yeah, that's the one. I don't know who gets an invitation. Do you get invited to that?

: 00:08:05

I get invited just about everything and for obvious reasons I can't come to them unless it's here. But no, there, there's a

president's cocktail party at the scientific meeting. I started that because Did you, I was concerned that the overseas gurus

had come and, and often be only one person, a hugely grueling schedule where they had to go to each of the states at that

meeting. They would get balled up with the bright people who were doing research and never get to know the people who'd

done the hard work to organize the meeting. So I thought it would be a good idea if we started that. So we started that in

about: 1980

Speaker 1 00:08:38

That's a great legacy. And I think it's wonderful. 'cause you're right, the organizing committee are invited the board and the

council and all the invited keynote speakers and it's just this great meeting of people. Wow. Great. Well thank you. Thanks

for starting that tradition

: 00:08:53

. Yeah. One of the few things

: 00:08:56

I thought today, if it's okay, I might ask you about what anesthesia practice was like in your time.

: 00:09:03

That's an interesting question. , yes. Anesthetic practice in mind. I'll tell you, I gave one ether anesthetic just with a

timmel bush mask just to show that I'd done it. But one of the huge benefits, of course, it was not only thone, but prop

profile and prop profiles made a huge difference to people and patients and how they feel about anesthesia. We didn't have

pulse oximetry. We didn't have capnography.

: 00:09:26

What timeframe is this? Oh,

: 00:09:27

I'm talking about when I started giving anesthetics, which is 1962. You, I graduated in 67. That's what we were doing.

: 00:09:35

So you trained without pulse oximetry?

: 00:09:38

Uh, we, our pulse oximetry came in years and years later. , we monitored with the finger on the pulse and blood

pressure, and that was it. Various others developed a little pulse meter. So you stuck it on the finger, it'll give you a blip. We

didn't have computer screens on, uh, anesthetic machines. The drugs were not as, uh, specific in their actions as they are

now. For instance, muscle relaxants were not as easy to use. They became more and more specific to their actions with less

side effects. That was one of the things. But as I say, pulse oximetry terribly important now. And capnography were the

province of the research lab for much of my time when I was doing it. Oh,

: 00:10:17

Really?

: 00:10:17

And uh, anesthetic machines. The boils machine was a very good machine.

: 00:10:22

Oh, I like the boils machine. . Yeah.

: 00:10:24

Then there were the developments. And I think frankly, that the anesthetic machine is over-engineered for the job that it's

doing.

: 00:10:31

Oh, it's very complex nowadays. Yes.

: 00:10:33

Well, young people probably wouldn't think that because they're very savvy with the mechanical things and electronic

things. One of my good friends, Ian, Phil Pot is very smart. Chap thinks on his feet, a retired from anesthesia. He is now 90.

And, uh, he said he'd like to know what a new machine was like. So I took him into the operating theater and I said, and turn

on the oxygen. He couldn't turn on the oxygen.

: 00:10:54

It's so intuitive on a boils. You just have a rotter, you have a dial, and you see it move. I agree. I I actually made a video to

explain to people how to start pre oxygenating a patient just from how to turn on the machine because there's, there's about

three buttons you've gotta make sure that you push to get it all started.

: 00:11:11

So that, that was one of the differences. The other is improvements in pain management post-op, ah, but also at the chronic

pain and the sort of things that the faculty of pain medicine look after. I went to a meeting in New Zealand, a SA meeting and

there was a chapter, I think his name was Wright. He was a resuscitation and he gave a talk about intravenous use of

morphine. I thought, well, this is good. You can actually put morphine into the drip for postoperative patient.

: 00:11:38

So this was a, a breakthrough?

: 00:11:40

Well, it was in a way. But what was even more was the surgeon I was working with had been involved in the dialysis unit. He

did the shunts for the dialysis and they were using a pump. It occurred to us that we might use a pump instead of putting

the morphine into the drip where the drip rate would be either dictated by the pain needs or the fluid needs, we started to

inject morphine from a syringe into the side arm of a drip. I think we were possibly the first people to do that, but not

necessarily. Wow.

: 00:12:10

But

: 00:12:10

I think that would made a huge difference.

: 00:12:13

So before then, was intravenous morphine commonly used?

: 00:12:17

No, intravenous morphine was not commonly used. Postoperative management was fairly standard. So postoperative pet or

morphine iam, four to six hour, which wasn't totally satisfactory. Many years later we realized the importance of simple

analgesics in combination with opiates, with postoperative pain.

: 00:12:36

And then if you wanted to give morphine intravenously was part of the fear, the risk of overdose because you've got this

mixed bag and these mixed needs of giving analgesia and giving fluids. The

: 00:12:45

Risk of overdose always there. Of course. And the other thing was we had patient operated syringe, so could press the

syringe and get a burst of morphine. Well, people started to think, well that could have been addictive. But anyway, it was

the early days of,

: 00:12:58

So separating the morphine into a pump and having that secret from the fluids mm-hmm. Was a huge shift in how you could

deliver morphine postoperatively,

: 00:13:06

I think it was. We also did some research and we had a professor of pharmacology who was able to do morphine essays.

Um, but that, that was helpful.

: 00:13:16

Guess going back, you trained in Melbourne?

: 00:13:18

No, I trained in Adelaide. Came across to Melbourne during the training and got my first part here. I dunno whether you want

to know all this sort of stuff. We are just having a chat, aren't we said. But there was anesthetist in Adelaide, uh, pop

Daniels. I said, I want be Anes. And he said, look, biggest hurdle is anatomy. Uh, a lot of aspiring anesthetist and surgeons

failed their anatomy, uh, exams. So I started studying anatomy. I really studied like mad. And it's the exclusion,

unfortunately, of my family. I

: 00:13:48

Think that goes for all study. The exams are hard.

: 00:13:51

Actually, I got the Renton Prize that year.

: 00:13:54

Oh, did you? Congratulations.

: 00:13:56

That was about 66 or

: 00:13:59

Oh, I didn't know. I was speaking to a Renton prize winner. That's a hard prize to get. Well done, well done.

: 00:14:05

So that's how we practiced. And it, it was a challenge. Probably more challenging in a way, but

: 00:14:10

I wonder, when I was in Cambodia, they gave me a small baby to anesthetize for a PDA location. Yeah. And the monitoring.

There was an esophageal stethoscope. Oh,

: 00:14:18

Wonderful. Good on you, Susie.

: 00:14:19

Did did you ever use esophageal stethoscopes? Is that, is that something that you're familiar with?

: 00:14:24

I have used it, but not, not a lot.

: 00:14:27

I can't say I, I could hear very much at the time. I, I definitely handed the stethoscope back to my colleague who I thought

should have, have more say on whether this doctor was closed or not adequately. But you mentioned, um, muscle relaxants

and you said they, they weren't as targeted as they Oh, they

: 00:14:42

Weren't just targeted. You know, more side effects, particularly with tuber. Keine and Flexeril were the ones that were used.

They weren't bad, but they were often side effects. Particularly with tubbier. You get hypotension. Uh, other adverse

reactions? Well, now the new one. What, what's the new one? It came in years after I finished. But very expensive

: 00:15:01

In terms of muscle relaxants. Yeah, yeah. Well we've got all the, oh gosh, the benzo, lyo, quinolones. Like atracurium,

cisatracurium, curium. Are you, I think you've sugammadex.

: 00:15:11

Ah, that was the one I was trying to, I couldn't remember the name of you because that was the other thing too. The duration

of effect of say ri reversing ri and particularly if you're in a private practice, making sure that your patient was back in the

recovery room so that they could get onto the next case. There was a bit of an art in that.

: 00:15:30

Oh, I can imagine.

: 00:15:31

You know, to be able to work out your doses on when to reverse them. It was more difficult, I think, than it is now. But we

are going back to the very early days.

: 00:15:40

. Yeah. Well, this is fascinating. We don't practice this anymore. Penile

: 00:15:44

Is terrific drug, but not as good as

: 00:15:45

Propofol. And penal is the trade name for Thiopental.

: 00:15:48

Thiopental, yeah.

: 00:15:49

I've used a little bit of thiopental in developing countries. Yes. And it was actually when I trained, it was the go-to for Yeah.

Ga cesarean sections. Not so much now. 'cause you can't get it anymore in theaters.

: 00:16:00

Actually, you, you're right. It went off the market, didn't it? Yeah. For good reason.

: 00:16:04

surgery to advance.

One of my thoughts is, and tell me whether you disagree or not, is that as, as anesthesia has advanced, that has enabled

: 00:16:13

Absolutely. No question about that. Particularly. We did very little surgery when I started. Why? Because there were huge

risks then of anesthesia. You didn't have an anesthetic and lift was absolutely necessary. And then as that anesthesia

improved, and the other thing given by specialists Yes. Then, uh, a lot of other procedures insured, and I do agree with that,

but there's a surgeon that say, oh, well, you know, there's been a lot of advances in surgical technique, equipment and

sutures. And I go along with that. True, true. But

: 00:16:41

I agree. You mentioned in your Jeffrey k oration, which would've been called the Presidentials address back then. Oh,

: 00:16:46

Geez. That was in Tasmania. That was years ago. Yeah. Yeah. I wasn't very well versed at public speaking. It was nowhere

near as sophisticated as a discourse as you would've given. I

: 00:16:56

Know. And you know, this is the benefit. I've just read it, so I can only imagine how you would've delivered it perfectly. But I

wanna ask you about the safety of anesthesia, because you make a good point that you only did surgery and anesthesia

when it was necessary. Yes. These procedures, like cosmetic surgery just couldn't be done. But with that, the mortality and

the morbidity would've been higher than it is nowadays. Yeah. Were were you aware in your practice or in your colleagues'

practice of people who had patients die under anesthesia?

: 00:17:26

Yes. Things had improved by the time I started doing anesthesia. You know, I had a cardiac arrest, uh, in my first week. Oh

: 00:17:33

Geez.

: 00:17:33

this patient

The surgeon was doing bowel surgery and he opened up the diaphragm and they started ca internal cardiac ionist was, and

: 00:17:42

Survived,

: 00:17:42

Survived the patient, survived . That's amazing. In fact, had I had more experience, uh, than about two or three

weeks without anesthesia, I probably would've been able to, um, assess the patient better. But the pulse just went off and

, and that's all we had.

: 00:17:56

Yeah, that's a really good point about the value of the preoperative consultation.

: 00:18:00

You give anesthetic for anything with almost with impunity, but that comes onto with preoperative, uh, valuation

assessment of the patient.

: 00:18:07

Yes. And

: 00:18:08

This is something that I was very concerned about when I was president, particularly because for a number of reasons,

Susie Anesthesia wasn't as highly regarded and anesthetist as they are now. I think anesthetist and anesthesia has got held

in high regard. But then the medical profession, particularly the surgeons and the public in general, didn't regard our

specialty highly. In fact, the public would often say, oh, you're, you're a niece. Oh, you are a doctor. Are you ? Yes.

: 00:18:40

We still get that Bob. Maybe not often .

: 00:18:43

But on the other hand, as the, uh, influence of the a SA, the faculty and the nieces themselves became more apparent.

People say we sometimes they say, we are the most important person in the room.

: 00:18:53

Yes. We like those people. . Yeah.

: 00:18:55

Like that may also have come about as a result of a film that I didn't ever see that, but it was called Green for Danger. I think

it was in a film about someone running out of oxygen in the operating theater or something like that. But over the years, the

regard for a anesthetist and anesthesia has improved. And I think we've got sort of equal status, uh, with surgeons probably

now in: 1970

mm-hmm . And, um, one of the things that we did was to change the constitution so that in order to be a full a

SA member, you had to have specialist training. Yes. And people who hadn't, could be associate members with all the

benefits except voting. And I think that was probably, uh, one of the things that boosted our status in the medical

profession.

: 00:19:47

Yes. I think so. Getting

: 00:19:48

Back, did you want me to talk about the preoperative assessment too?

: 00:19:51

Yeah, I do. And I'm glad I read about it in your presidentials address because it's something that's come up in the last few

years about the desire to remove the specific item numbers for the preoperative consult. I don't know the exact figures, but

over 90% of initiation of anesthesia items are associated with the preoperative consult item. So the argument was that, well,

if it occurs so commonly together, why don't we just roll them into one and make it the one item number? Exactly. And in

response we said absolutely not. No. And we talked about how we, we, the a SA really advocated for it to be a separate item

number. And I frequently tell this story to people. And as I read your presidentials address, I actually wondered if you were

one of the key people at the table when these discussions were happening.

: 00:20:41

I wasn't. I just came in as president and I was chairman of meetings and all that sort of thing. The only thing I think I did, did

that had a real impact. Well, it was our preoperative number. I've forgotten what the item number was now was in jeopardy.

So, uh, de O'Brien and myself flew to Canberra and spoke to the relevant, uh, health official, pointing out the importance of

the preoperative visit. And it was retained, but I think it was in danger of, uh, being lost. The other thing is, if, if it's lost, the,

uh, status of the anesthetist is lost too, in a way, he becomes a technician. Mm-hmm . And I think also for the

patient's point of view, they need to be appraised beforehand of what's going on, introduced to the anesthetist and may Oh,

: 00:21:21

For sure. It's just good medicine. Yeah.

: 00:21:24

That put at ease about anesthesia because a lot of people still in this modern age, uh, are concerned about, uh, the

anesthetic and the surgery. Not surprisingly, at one point I had a patient who had indicated that she was terribly scared of,

of being put off to sleep. So what I did is look, come in to, uh, the hospital and we, we will get into a theater that's not being

used and we'll do a dummy run. Mm. She came in a few weeks beforehand, hopped her on the table, and I put a blood

pressure cuff on her and then, uh, squeezed a bit of skin. So that's about what it is. And she was eternally grateful. In fact,

she wrote me a letter after the surgery, one of the few letters you get. But it is nice when you get a letter to thank me for that.

: 00:22:07

Oh, that's lovely. How did you find yourself becoming president? What was the steps? Ah,

: 00:22:13

Actually, I'll tell you the genesis. I belonged to the Anna said group in Melbourne, and Herb Newman was secretary of the

Victorian section of the a SA. And one day he said to me, would you like to take over as secretary? And I said, no. And he

said, well, you are. You will . So I became, I

: 00:22:31

Became voluntold. I say, now, yeah,

: 00:22:33

Press gang. And so then I became, I virtue of the way things go, chairman. And then we were, were flying over to, um, Perth

for an a SA meeting. And Kester Brown came up to me. He was in the plane too, and he said, you're gonna be president of

the as. SA. I said, oh, thanks Kester. Dunno why I got qualification except for two things. One, I was chairman of the

Victorian section and also presidencies then were rotated through the states, so it was gonna be Victoria's turn. So in the

Perth, I was made President-Elect and went on from there. I'm very happy that I got involved in a SA affairs too. I've gotta tell

that. Well,

: 00:23:11

That's good. What do you think's been your highlight being involved in a SA affairs either as president or before or after

presidency?

: 00:23:18

Oh, gee, , that's hard to say. Um, maybe having some influence, particularly as I say, in the status of anesthetist. I

don't think young Anis have to worry about that anymore. I mean, they're, they're very cluey people. Uh, you've gotta do

very well to get into medicine first for a start and then to get into anesthesia. But in a way you're seeing the a SA flourish, I

suppose. Well, particularly from the sort of thing that you've done is outstanding. I might say that now, when I started

whatever state the president was in, somebody would be the secretary, uh, working leases.

: 00:23:50

Oh yeah.

: 00:23:51

Yeah. And they would put out a newsletter and do all that sort of thing. And then they decided Ben Barry was one of the

Butterworth. And that was in: 1970

worked from, uh, Elizabeth Street, which was the rooms of the first anesthetic group in Australia. But even still, the

Secretariat was actually one of those spandex folders with all the stuff in it. It's amazing how the, uh, a SA is now, it was

pretty amateur amateurish set up then with computerization, with the mobile phones and all that sort of thing. The a SA has

taken this, and they used it for communicating with patients of course. And members of the a SA and there's so many things

going on with the a SA and they have a glance at the, uh, magazine. It's just, that's been marvelous. I think it really is

working very well.

: 00:24:42

It is. It's going from strength to strength, which is great. Oh,

: 00:24:45

I think so. Well, you know, an interesting thing is, I'm not sure when it changed from the annual general meeting to the, uh,

scientific meeting the name, but the A GM people spoke and they gave a talk in front of a microphone. And, uh, that was

about it. Then as anesthesia became more and more specialists who, who were scientists, researchers and so forth, things

improved to the point where you didn't get much out of a single person talking. Some were good, others weren't. And then

came sessions, you know? Yes. The way break off for sessions and all that sort of stuff. And then of course, PowerPoint

made a huge difference. It did. Really did.

: 00:25:26

Yes. True. True.

: 00:25:28

PowerPoint and computers. And, and another thing that I thought about was, uh, communication when I was for first, what

about 15 years? I suppose if you are on call, you have to be at home. Uh, so that the, uh, surgeon or the hospital, usually the

surgeon directly, particularly from private practice, could contact you on your telephone

: 00:25:49

Of course, on your landline at home. That's a

: 00:25:52

Landline.

: 00:25:53

Yes. . And

: 00:25:55

Then I wrote a history of the Melbourne Anesthetic Group, and I was just looking back at that. And in 1978, we had the

license for a radio paging station at our rooms. And that allowed us to have pages so you could actually leave your home.

The pager would go off, a surgeon would leave a message, and then you either went back phone somewhere or did it.

: 00:26:18

And that was the late seventies,

: 00:26:20

1978, we got our radio receiving station. Then the mobile phones came. And the first one was a sort of huge thing. They call

it the brick. And uh, then of course with mobile phones, you could do anything. I mean, you're on call. You could, uh, be at a

restaurant or you could be doing 101 things and still be on call. So it to relieve things enormously.

: 00:26:40

Oh, that's revolutionized. At least your social life when you're doing a lot of on call. I didn't realize you were on the WFSA for

so long. Tell me what that was like.

: 00:26:49

Oh, Susie, I mean, it was a wonderful thing to be doing. Possibly the highlight of being involved in anesthetic, uh, affairs.

But you've had a huge, uh, influence in, uh, affairs in a SA and get involved in a lot of things. But, and my name quite a lot of

overseas travel and Kester Brown sent me to Vietnam. That was interesting. At the time when, of course the bombing had

ceased,

: 00:27:10

What, what time was this?

: 00:27:11

About 1980. So I took over some equipment there and gave them some lectures. But that sort of opened up your eyes to the

world. Well, my eyes Did you go to Laos?

: 00:27:21

Yeah, I've been to Lao a couple of times. Yeah. Uh, the hospital that I work with or volunteer with in Cambodia, they have a

sister hospital in Lu Rung.

: 00:27:29

The first person to go there that I know from Australia, I forget his name. Terrific guy Tasmanian still gets involved in a SA

: 00:27:36

Hayden, was it Hayden Pert. Hayden

: 00:27:38

Pert, that's right. I was secretary of the Asian Australasian section of the WFSA. And for some reason I was talking to, to

Hayden and he showed interest, and I think he might've been the first tus to go there, at least from Australia.

: 00:27:51

He's such a trailblazer. He's been and done so many things in terrific guy. The global health stage of anesthesia. You said

that Kester Brown sent you to Vietnam.

: 00:28:00

Yeah, Kester, he was the educational officer of a SAI think he didn't ever become president or anything like that. But

anyway, we all know he had a huge influence in anesthesia both worldwide as well. And he must have been on the

education subcommittee of the Asian, a Australian regional section.

: 00:28:16

Ah, okay. I think he's tapped a few people. A lot of people on the shoulder.

: 00:28:20

Oh, I think

: 00:28:21

So. To get involved with global health. And he's been hugely influential.

: 00:28:24

Another one who's passed on Susie.

: 00:28:27

Yes. Very, very sadly. Did you know Keer well?

: 00:28:30

Oh, yeah. Had a lot to do with Keester. Yeah, of course. Well, I worked at the kids hospital in Melbourne, the Royal Children's

Hospital in: 1965

roundabout when I was finishing off there.

: 00:28:50

Wow. I think our careers shouldered Kester, if that's a a a way to phrase it. So it sounds like you were a trainee when Kester

first became director. Yeah. And I was a trainee during the similar year that third year of my training doing pediatrics and

obstetrics at the Children's hospital. I did my pediatric rotation and it was the year, I think after Kester had just retired from

being director or being at the Children's Hospital. Yeah. So between you and I, we've, we've shouldered Kesters career as

director at the Royal Children's. Oh,

: 00:29:27

Good. Yeah,

: 00:29:28

There you go.

: 00:29:29

When I was there, John Stocks was still alive. And John Stocks and Ian McDonald, as you probably know, were the people

who pioneered the intubation of neonates.

: 00:29:39

Ah, I thought that was Margaret McClellan's.

: 00:29:43

Margaret McClellan was the boss, but she, she had left a couple of years before I came. And John Stocks was actually

director, but uh, no, it was stocks and Ian McDonald and, uh, Adelaide and Isist. They pioneered intubation of neonates prior

so that they'd have tracheostomies. And then John was pioneering recovery at the Children's Hospital. Greta McClellan, she

worked out that the combination of Lene put through a CO2 canister on your balls machine could produce toxic gas. Oh.

That was her contribution. Oh, that's the other thing I didn't tell you. We used Tri Lean initially before Halothane came in.

Yes. Terribly difficult to use. Putting someone up to sleep with just tri put a lot of people off doing anesthesia. I think it was

terribly hard to use.

: 00:30:33

So I, when I was in Fiji, I had a Boils machine that had four rotters on it. Yep. It had oxygen air, nitrous and Lene or

Trichloroethylene I think it's called, isn't it? And then there was also a CO2 knob that you could turn on and off the CO2 you

turn on.

: 00:30:48

Yeah.

: 00:30:49

The, the rotters were, were broken, the interlocking system. It wasn't the interlocking system. The, um, hypoxia prevention

system. So I could, on that machine had I connected Tri Lean Yeah. I could dial up a hundred percent nitrous and tri lean

Yeah. And turn off the CO2 absorber. And really, if I wouldn't knock off a patient very quickly if I,

: 00:31:11

But that's what they did initially, didn't they? That was a way of inducing anesthesia.

: 00:31:16

Really?

: 00:31:17

Yeah, it was in, in America. Yeah. It's sort of hypoxic. Tell

: 00:31:21

Me about this technique. I've No,

: 00:31:23

You'll have to look that up. I don't know enough about it, but, but that's what they did. Yeah. Um, really , almost

asphyxiate them with nitrous oxide.

: 00:31:32

And could you dial up a hundred percent nitrous? I mean, I thought there was that anti hypoxic device. Yeah, you

: 00:31:36

Could. No, you could do that. Really. Actually, you know, the other thing, you probably heard this sort of thing before when I

was the, um, deputy director and I gave an anesthetic for a young man having a nose operation. Well, towards the end, I, uh,

you know, as we all do, turn off the rous and turn on the full oxygen.

: 00:31:55

Yes.

: 00:31:55

And, um, he went blue

: 00:31:58

. Oh.

: 00:31:59

Was thinking how, what are the ways that a patient can go blue? And so what I did was I tried to turn on the oxygen, uh,

cylinder. Yes. Because maybe oxygen's not coming through for one reason or another. And anyway, I couldn't do that

because the, uh, the oddly who looked after the anesthetic machine had the key to the, uh, to the oxygen cylinder in his

pocket. And he was out having a smoke. So, oh gosh. Anyway, he got him in at, the problem was it was the nitrous oxide

oxygen switch, which

: 00:32:28

Still happens. Which,

: 00:32:29

Um, I'm glad that I was the first person to give an anesthetic there because Oh no. What had happened is that this was the

first anesthetic after the holidays and during the holidays they had to service the suction. And the suction oxygen. Nitrous

oxide came down in a single penant that came down from the ceiling. And there wasn't any key to tell you which hole to put

the oxygen.

: 00:32:51

So you just made it up. Alright,

: 00:32:52

But which one to put the, anyway, John Mayland took that on and uh, got things changed and coated. Yes.

: 00:32:58

And now we've got the index and the sleeve system and all those sorts of things. And

: 00:33:02

The other thing that's important is that the director of anesthesia or some responsible person checks the equipment after,

uh, there's been servicing.

: 00:33:10

Yes, absolutely. I did not realize that, you know, I've learned something that the Boils machine that I thought was broken

was actually designed to deliver a hundred percent nitrous. So it was the pre, the pre anti hypoxic device boils machine.

There you go. Tell me what Tri Lean was like to work with

: 00:33:26

Tri Lean, which was a, of course, an agent for a dry cleaning. Did you know that ? Yeah.

: 00:33:33

I remember one of them was a dry cleaning agent.

: 00:33:35

Dry. Oh, actually terrific. For getting stains off fabric and so forth.

: 00:33:40

I think it's still used, isn't it, as a dry cleaning agent now? Yeah,

: 00:33:44

I think so. It's kind of nice smell and all that. And a blue color. Yeah. But it was awfully difficult to induce a patient who put

'em off to sleep with thigh pen tone. And then to get them deep with chilene was quite difficult. And it took quite a long

while. And I know everybody had to do a bit of anesthesia, you know, all the residents and it put some people off. They

couldn't say, oh, this is hopeless. How, how did we go about doing anesthesia if it's all like this? When I, when I was a

student, Adelaide, the director of anesthesia, a chap, the name of Marshall, I think he was New Zealander, had a halothane

vaporizer, but he also had a key to it so that he was the only person who could use it, turn it on and off. It was thought to be,

uh, potentially very dangerous. It was quite a huge difference. Huge difference to anesthesia.

: 00:34:27

Wow. So Hahan was thought to be too dangerous. And so everyone was encouraged to use Lene instead.

: 00:34:32

Oh, yes. But then of course it came into use. 'cause I realized it was a very valuable agent.

: 00:34:38

Can I take a little segue, Bob? What do you think the next 90 years might be like for anesthesia in Australia? Or what do you

wish it might be like? Well,

: 00:34:48

In the next 90 years, hopefully we won't need anesthesia in 90 years.

: 00:34:54

Wow.

: 00:34:54

That's what I'm thinking. I think anesthesia eventually, you probably won't need it. So many things are now not requiring

surgery. They're being treated in one way or another that's different. True. I would think they might to be able to perfect

electronic, uh, ways of keeping the brain anesthetized and that sort of thing. Anesthetists may not be around in, in 90 years.

Oh gosh. Will we be around in 90 years?

: 00:35:18

No, we won't be .

: 00:35:19

No. I mean, humankind would be totally different. Good

: 00:35:23

Point. Yeah. Do you think surgery will still be required? Well,

: 00:35:26

Maybe not so far in the future. They may be able to treat just about everything else by, uh, giving things, as you say,

intravenously or radiotherapy or 101, things like that. Yeah.

: 00:35:36

Suzy, you, I have tell you something that I've been thinking about the podcast. Yes. Something interesting that you may

think about. And as I say, my uh, thinking has mainly been on the status, uh, of anesthetist and how it's improved

enormously. I mean, I think the young anesthetists is probably highly respected, particularly by the surgeons and the

community as a whole. But I took over an anesthetic practice from a group that had worked with a lot of surgeons from, uh,

in Melbourne. And so I took over and I, it was almost already made practice. They were all older men and they pretty well all

had, uh, served in the, uh, second World war.

: 00:36:11

Right. Were is the anesthetists or the surgeons?

: 00:36:14

No, no. The surgeons. Yes. Surgeon and the anes surgeons too. But the surgeons in particular, and uh, which was all very

good. Uh, and, uh, he was one surgeon in particular didn't work with him very often, but they would have the orderlies and

people like that sometimes giving the anesthetics, uh, when they were in the field. Anyway, there was one surgeon that, um,

I can remember this. He'd be doing a b bowel surgery and then he'd say towards the end, before he was sewing up, you can,

you can turn it off now. He's used to ether. Mm-hmm . Yes. And, you know, wanted a quick recovery with, had I

turned it off, I you wouldn't be able to sew, sew the, uh, abdomen up, that's for sure. And, uh, right at the end, I always give

Anes always gave anesthetics with a left arm out on a board. Yes. And, uh, towards the end, a a after he'd finished, he'd

throw off his gloves, come round, palpate the patient's pulse and say, she'll be okay, doc.

: 00:37:06

Oh, good. . I don't think I've seen a surgeon feel a pulse for a very long time.

: 00:37:11

Well, that's what they did.

: 00:37:13

. Oh, they learnt the hard way. .

: 00:37:17

Oh, well, you know, to then we, I mean we, there was a, um, there was a resuscitation, uh, in Melbourne, uh, sorry, east

Melbourne where we worked, who'd come in and put the drips, drips into patients on the right, on the requirement of the

surgeon. And this guy had come in and fully, you know, his CS up into the operating theater, sometimes smoking, and then,

uh, insert a glass cannula

: 00:37:39

Wow. In cannulas when

: 00:37:41

You think about that. Uh, yeah. He, he, he, he was the guy who's going to have to do the resuscitation post-op who was

before we got involved, and Denise was, would sort of coming and come out and not be involved in post-op and the glass

cannula would last.

: 00:37:54

Wow. So a couple of things. I wanna pick up the term resuscitation is when you say that, what do you mean? Well,

: 00:38:00

The people that would come round and resuscitate, well, for instance, this chap had a, a closely liaison with a blood bank.

And, um, uhhuh, if a maternity patient, for instance, was bleeding a lot and you know, they could bleed and die, he would be

there with the blood, put the drip in and get the blood going. That was the sort of what the resuscitation was. Oh, this guy

was invaluable. And is this the,

: 00:38:20

The makings of emergency medicine in a way Yeah. And maybe ICU medicine.

: 00:38:25

Yeah. Well then in private practice, but not in public practice. In private practice, you couldn't really, uh, look after your

patient post-op because you'd be in another hospital doing another list for somebody.

: 00:38:36

Yeah, true. And so they would help to resuscitate your patients afterwards.

: 00:38:39

operating field not good.

Oh yeah. Yeah. In fact, in many, in many cases, you wouldn't be involved in the patient after you left the, uh, hospital, the

: 00:38:46

Because that's a whole specialty or field that we don't have anymore. We don't have resuscitation.

: 00:38:53

No. I suppose we, I suppose we

: 00:38:55

It's the ICU resident or the

: 00:38:57

That's right, that's right.

: 00:38:59

Medicine

: 00:38:59

Specialist. What I tried to tell anesthetists over the years is look, try and do all or most of your anesthetics in one institution,

whether it be private or not, and then you can look after 'em. Yes. Also, postop, particularly, I made a point of doing this, uh,

for postoperative pain. I had worked at one hospital Yes. For about the last 10 years and was able to get involved in that.

: 00:39:19

Exactly. I think us being involved in that perioperative medicine before and after is

: 00:39:24

Oh, that's an interesting thing that Yeah, I would've, yeah, that's very interesting. Period. I must keep up with that and what's

going on about that. But, so anesthetists could consider themselves well enough trained to be, uh, able to look after

postoperative complications. Now we're not saying that when I worked at the, uh, uh, hospital doing bowel surgery and I'd

get involved with postoperative pain, but when something went wrong with a patient, then a physician would come along. It

was the same physician all the time. And do the postoperative or perioperative management. I, I suppose so I don't, I didn't

consider myself well enough trained or had enough knowledge to look after somebody, for instance, who was going into

cardiac failure or something like that.

: 00:40:08

Yes. I think it's changed now.

: 00:40:10

Has it? Yeah.

: 00:40:11

Yeah. I think so. I think especially when we come out of training, that's my theory is we are like pluripotent stem cells. Yep,

yep. And we've got, I partic personally did a lot of ICU time in my training. Yeah. Yeah. And so I was very comfortable

managing an ICU kind of patient, uhhuh , stabilizing them in order to get them to ICU. Yeah. And taking on that

pre and post-op resuscitation if required.

: 00:40:33

So the young anesthetist would be equipped to do all that?

: 00:40:37

I think so. And I think it's getting more complex. It's

: 00:40:40

Great news because I think you need continuity with your patient both before, which I've talked about and after I was happy

to do the pain management. Of course.

: 00:40:48

I think some are dabbling in it more things like people who are coming in on warfarin and having to swap the warfarin over

to K Clexane and then when to restart the warfarin. Like some anesthetists will manage that. Some will hand it over to a, a

perioperative physician. Some will do it in consultation. It's, there's more options to get involved now.

: 00:41:05

So it's called perioperative medicine and it's not limited to anesthetist then.

: 00:41:08

Yeah, true. I think the people who are doing perioperative medicine, there's, you know, geriatricians, there's general

physicians who are, who are getting involved. Mm-hmm. The big studies are looking at various outcomes from surgery, are

looking at common conditions like how aggressively do we need to control blood pressure Yeah. And diabetes before

people head into surgery. You know, physios, nutritionists if you are having major cancer surgery. Yeah. What's the best

diet you should be on? What's the best exercise regime uhhuh you should be on in order to get the best outcome from your

surgery?

: 00:41:40

since my time.

It's sort of evolving now, isn't it? Just, yeah. Well, very interesting actually, that, that would be the biggest change I imagine

: 00:41:49

Can I come back and ask you about glass cannulas?

: 00:41:53

Yeah.

: 00:41:54

Did you use them?

: 00:41:55

No, I didn't. But he would've to do a cut down.

: 00:41:58

I see.

: 00:41:59

Very, very expertly and, uh, sew the glass cannula in. But obviously as far as Mr. Dr. Mann was concerned they were gonna

last. Yeah. Whereas, uh, cannula, even our modern cannulas, they get clagged up and fiction and all that sort of thing. Have

you seen a glass cannula? I mean, they're tapered.

: 00:42:15

I've never seen one. Then

: 00:42:17

It's gotta be sewn, you know, tied in.

: 00:42:19

Right.

: 00:42:20

They'd be doing this with a patient asleep of course. But that, that stopped when they realized that, uh, anus could,

uh, do the job just as well or better, in fact. Yeah. I I probably think I would've given them more than half my anesthetics over

the years without a drip.

: 00:42:35

Really?

: 00:42:36

Oh yeah. Hell yeah. ,

: 00:42:38

I mean, wow. It's like, I, I teach my registrars, like you'd always give an anesthetic, you would always put a drip in. No.

: 00:42:44

Unnecessary Susie for a lot of patients. And

: 00:42:49

The only, the only exception was when I was anesthetizing children having radiotherapy. Yeah. They were the only patient

group that I never put a drip in. That's

: 00:42:56

Interesting. And

: 00:42:57

That's so interesting.

: 00:42:59

One surgeon I worked with, who was the one who employed, uh, Dr. Dreman, the resuscitation. Do you know he, he would

order for postoperative fluid, rectal, uh, water.

: 00:43:07

Oh wow.

: 00:43:07

The water is intro in introduced with an sort of MA bag into the rectum. Oh

: 00:43:12

My good. And patients tolerated that. Yep. I suppose they did. Weren't I ? Well,

: 00:43:19

I'm too old now, but I can think. Okay. I could give an anesthetic for an appendix for about, I reckon the appendic hour was

expensive probably for about two, $2.

: 00:43:30

Wow.

: 00:43:31

No, two pounds. That's right. Yes. 'cause when I started it was pounds. What would it cost to give an, an anesthetic apart

from your fee? What would it cost to give an anesthetic now for an appendix 2, 3, 400.

: 00:43:43

Oh, more I think, I mean we were, uh, we were talking recently about the cost of sugammadex and I think it's just come off

patient, but I think it was up there as a few hundred dollars a vial. Yeah. For one dose. So we're talking thousands of dollars

for any procedure nowadays. I think even just opening up all the single use disposable things,

: 00:44:05

That's what worries me a bit. And, uh, we could go on on see the other, the other thing that did annoy me was disposable,

uh, equipment. Oh. That one of the biggest, I think, advances was the, uh, Larry Jewel mask airway. I think that was terrific.

Uh, piece

: 00:44:19

Of equipment. Oh, yes. True.

: 00:44:20

And you blew it up with a 20 mil syringe. Yeah. And there's a feeling at the hospital I worked that. Then you threw that

syringe out. 'cause it was one only use. I mean, I find that criminal, I suppose it's the same. Yeah.

: 00:44:33

. Oh, it's gotten worse. There's things like single use, torn case, single use laryngoscope blades. Single.

: 00:44:40

How can, can you dust?

: 00:44:42

As my friend says, it's like you go to a restaurant, you put the spoon in your mouth, you don't think it's has to be a single

use spoon, do you? And where does the laryngoscope go? Right, . It's the same spot. . Yeah. Yeah. So

single use stainless steel .

: 00:44:58

Amazing.

: 00:44:59

You know, amazing's one word for it. Look, it's been great chatting with you, Bob. Before we go, is there anything else that

you wanna say? This has been a great chat. I really love just comparing our different techniques and things. It's been great.

: 00:45:10

Yeah. There is something, I think you, someone ought to do a podcast of view, Suzie. Oh, you've got a lot. You'd have a lot

of anecdotes and, and especially about, you know, your, your overseas work.

: 00:45:20

You know, I love asking the questions. I'm actually not so great on the other range, but thank you.

: 00:45:27

I look, to be perfectly honest, I've had a lifetime of anesthesia. I, I, I don't get involved in it anymore. Uh, you do that, you

move on. But I have been reading and, and I'm very impressed by, uh, what you have been saying in journals and so forth. I

think you've done a terrific job taking the initiative to do podcasts and that sort of thing. So yeah. Thank you. Someone

ought to get you and put you on a podcast,

: 00:45:51

. I'm happy to one day when

: 00:45:54

I'm happy to do something in conjunction with Jim or whatever you want, Susie,

: 00:45:58

That'd be great. Let's, let's schedule another chat with Jim and because I think you, when you guys get talking, we, I learn a

lot. .

: 00:46:06

Thank you.

: 00:46:14

Well, I hope you enjoyed listening to our conversation as much as we enjoyed having it. I think Bob and I could just nater on

for ages. In fact, I know we have over dinner and various other events. I really love comparing our approaches over the

years. He's probably thinking some of my techniques are crazy and I, I don't know if I'm ready to give a regular anesthetic

without an iv. Anyway, I really love learning about how much the practice of anesthesia has changed. And I find it really

humbling. Really, Dr. Hare talks about a time when anybody could give an anesthetic. And I'm concerned because there are

various people in decision making seats in this country that would love to see a return to this. I'm talking task substitution

here, especially in response to workforce issues that we're currently facing. And that's where a person with different,

usually less qualifications, a non-specialist, perhaps even a non-medical person, is giving the anesthetic.

: 00:47:05

That idea is certainly being entertained if not already undertaken in other areas of medicine. So who knows where we will be

in the future in 90 years, maybe not even within the next decade. But I know that for now, I and the a SA, the Australian

Society of NICaS and the A MA Austral Medical Health Association, of which I'm a federal council, we would like to see that

healthcare continues to be led and overseen by medical professionals. And you hopefully will be seeing or have already

seen some of the advocacy work going around tackling that issue. We definitely do not want to see healthcare overseen by

insurance companies or even as we're seeing overseas private equity firms. Alright, moving right along. If you enjoyed this

episode, then three others that you might also enjoy are episode 90, as I said at the start, that was the special 90th birthday

episode.

: 00:47:58

It has been and probably will be the only episode where I interview multiple other people. It features a SA past presents on

Maxwell, Greg Deacon and Mark Sinclair. So it's a bit of a president's fest and a unique look at the a SA and not just the a

SA, but anesthesia and the history of anesthesia in Australia. Ultimately, I really enjoy putting that episode together. It was a

great formulating a story and I hope you enjoy how that all comes together. The other two episodes, which might be of

interest to you, are episodes 85 and 86. These are my full conversations with a SA past president, Dr. Don Maxwell, who I

mentioned at the start. He's, I dare say, the oldest past president to still be with us. And I broke up that conversation into

two parts there, episodes 85 and 86. Dr. Hare very kindly suggested that, uh, a podcast with me might be of interest to some

people because of some of the work that I've been doing overseas.

: 00:48:57

If you want to hear more about the global health efforts from the a SA, then I have a whole playlist of podcasts. It includes

updates from Fiji, Mongolia, and East Timor. I haven't put one off about some of the work that I've been doing in Cambodia.

Maybe that will come one day. Who knows? They sit on the OD deck page of the a SA website. OD deck stands for the

Overseas Development in Education Committee. And of course, I'll put a link to it in the show notes. Speaking of Cambodia,

I've just returned from another trip to Cambodia and I'm often looking for people to join me. So if you are interested, you can

find more information on that OD deck webpage. All right. I hope you've enjoyed our little ramble through anesthesia history

and onto Global Health. Thanks once again for listening to the podcast. Definitely feel free to reach out to me. I love your

feedback. I love your ideas. For Future Podcasts podcast@asa.org au is the best way to reach me. Until the next episode, I

hope you stay well, stay safe and be kind to each other out there.

Transcription by Barevalue.