Dogs

Rose and Louis. Good dogs.

The malleability of dog DNA is extraordinary. Cats of all breeds look more or less alike but a chihuahua and a Great Dane don’t look anything like the same species. Canis lupus familiaris has been living with us and serving us for perhaps 23,000 years. Unconsciously employing the same mechanisms that underlie evolution, humans have selected the canine characteristics they desired to accelerate change. Dog personality was pushed towards a more puppy-like mentality from the cold detachment of an adult wolf, making them more suitable as domestic companions – and less dangerous. Russian research has shown that this personality adjustment can be achieved quite quickly in wolves. Even diet has been manipulated and the domestic dog can digest starch entirely unsuitable for other canids.

In spite of the domestic felid’s familiar habit of torturing their captives, in the wild, most cats kill their prey quickly after an ambush or brief pursuit. Lions are the exception to these solitary feline hunting methods. Wolves on the other hand are certainly pack animals and their hunting technique is a relentless pursuit of the herd to identify weak, old or sick individuals. They have an exquisite sense of smell. Death when it occurs is not quick or pleasant. The pack catches and pulls down the much bigger ungulate by targeting the soft parts. Wolf pack hunt success rates are in fact low. Perhaps one in twelve hunts for moose end in a kill and wolves are adapted to a famine-or-feast existence. They are also at risk of injury during a hunt. Pressure from these predators keeps the ungulate population fit, healthy and numerically sustainable. The recent reintroduction of the grey wolf to Yellowstone had an astonishing and very rapid positive effect, a so-called trophic cascade, forcing changes in the behaviour of elk that has benefited the whole environment with marked diversification of both plant and animal species.

The physical features of dogs were initially selected for utility in hunting or defence situations. The ancient Roman bodyguard the Cane Corso, the Dobermann and the Rottweiler were all developed for the protection of their owners or their property. Great Danes were bred big enough to tackle wild boar. (These dogs are actually German mastiffs. Their name was changed, like that of the Alsation, because of anti-German feeling.) Sighthounds became fast enough to run down prey too swift even for wolves to catch. Wolfhounds and deerhounds grew huge and lanky with long rough coats. Short-legged terriers could follow their quarry into the earth – as their name implies. I feel the Cane Corso with its traditional cropped ears would have been a better choice for the Devil’s hellhounds in The Omen than the rather pleasant-looking Rottweilers they actually used.

A magnificent Cane Corso. Google them for more striking images.

The appalling ‘sports’ of dog fighting, bull- and bear-baiting produced ferocious animals with immense bite pressures and extreme tenacity once they locked onto their victim. Animals with a back story like this do not look like good prospects for pets – unless you actually want to weaponise your dog. Recently some breeds’ more aggressive characteristics have been ameliorated by selective breeding but horrific attacks still hit the headlines.

Dog breeding eventually went beyond the practicalities of hunting, guarding, fighting and baiting. The desire to produce an appearance conforming to a seemingly arbitrary breed standard has resulted in characteristics that make some dogs unfit for a normal active life. It’s the kind of unhealthy obsession that led to abominations like the tumbler pigeon. Flat-faced (brachycephalic) dogs have trouble breathing, eating and panting – but look cute. They also suffer eye and skin problems. The short-legged Dachshund, bred to hunt badgers, ended up looking like an achondroplastic Doberman – but looks cute. Dachshunds have spinal problems and the inexplicable desire to have a German Shepherd’s back slope downwards towards its rear legs has left them with spinal trouble too.


The first dogs I knew were working collies on the farm rather than pets. My grandparents had two grey and white long-haired collies called Mac and Spot. At bedtime we thrilled to tales of their bravery in tackling vicious hedgehogs or herding foolishly reluctant ducks into their house for the night. Great sagacity was attributed to them.

My uncle had a classic short-haired black and white Border Collie called Nell of whom I was very fond. A railway line ran past the end of our farm road. The main road crossed over it by a nearby bridge. Nell met her end by vaulting the parapet of this bridge, mistaking it for a fence, and plunging onto the tracks below.

Not all the farm dogs were as friendly as the late Nell. One of them had David Bowie-style odd-coloured eyes and would rush to the limit of its chain to snarl and bark at us if we came near, nose up-turned and lips curled back from its teeth. I resented this no-go area around the shed where it was tied up. In frustration I fired a light, dried, herbaceous plant stem at it using my home-made rowan bow and was horrified to see it snag in its thick coat (with no skin penetration). Scared I would be caught abusing the dog, I screwed my courage to the sticking place and advanced on my opponent. To my surprise he let me disentangle the stick without so much as a whimper and we got along fine from then on. Not that I recommend shooting arrows at dogs as a training method… Even allowing for the fact that domestic dogs can digest starch the collies’ diet of bruised maize and milk did not seem adequate. I never saw them given any meat – but they did get butcher’s knap bones from time to time.

When I was a child we still had hill farms on the estate and watching the shepherds work the dogs was fascinating. Our shepherd put a small metal plate with a hole in it into his mouth in order to whistle but my father could make a piercing whistle without any artificial aids, not even his fingers. I have always needed to use my fingers for a proper whistle. Most enjoyably there were often collie pups to play with. The shepherd would note which ones naturally set about herding the hens in the yard as an indication of whether they would make good working sheepdogs. My mother was averse to dirt and smells and would never allow dogs or cats of any age into the house.

Most farms would have a smaller dog as a house pet and ratter in addition to working collies. My grandfather told me he set up a slate with a pull-cord in the byre to cut off the escape route of rats eating the cows feed at night. He then put his terrier in for a gleeful slaughter of the thieves. People forget the practical purpose these dogs were bred for and seem surprised if an occasional dopey grey squirrel fails to escape their pet. In addition to his collie my uncle had a Corgi called Wendy who was adept at finding hedgehogs in the woods. We would roll them up in hankies to take home. The spines would stick through like Mrs Tiggywinkle’s cap. We noted the hedgehogs were well-colonised by fleas.

Our farm mechanic, Bill, liked to shoot and owned a Golden Labrador called Biddy. He brought her to work with him so that his three daughters wouldn’t ‘spoil’ her. He kept a Cairn Terrier at home to occupy them. Biddy was amazing. She was devoted to Bill and a brilliant retriever. He would tease her by ordering her to ‘fetch the screwdriver!’ She understood ‘fetch’ but obviously had no idea what object Bill desired. Frantically she would bring him a variety of things lying around the garage workshop until by chance she picked up the screwdriver. Bill would make a big fuss over her success and Biddy would be ecstatic.

To train her, Bill would send her to the back of the garage where she couldn’t see what he was doing then throw a rag doll, a familiar toy of hers, far into the adjacent stack yard with its long grass and weeds. After making her wait for the command he would release her to quarter the stack yard, nose down, until she found the doll. She was infallible on a shoot, retrieving everything Bill shot and some birds other dogs had missed.

Finally, under constant pressure, my mother relented and allowed us a dog. It was to be my younger brother’s pet primarily. He wanted a Beagle. They are lovely looking dogs but I would not recommend a pack hound as a pet. They don’t even bark properly! The Beagle he chose was the dominant pup in the litter, reflected in his name: Winston. With hindsight this was also a mistake.

Winston with his humans

Bill the mechanic demonstrated that Winston was prepared to defend his food if challenged and told us we would have trouble if he did not learn to accept removal of his bowl while he was still eating. Winston remained obstinate and at times aggressive about meals and once bit Granny on the ankle when he thought she was interfering with his breakfast. I suppose the adults present should have been more forceful.

Typical of Beagles, Winston was not content with the entirely adequate diet we supplied and would sneak off to eat the cows’ ‘cake’ (processed feed) from the troughs in the byre. He would continue eating until he was so stuffed he could barely walk. He once disappeared for a few hours to return bearing a whole salmon wrapped in greaseproof paper. The farm was a mile from the nearest town and the mystery was never solved. No one from any of the farm cottages reported a theft. His attempts to dominate those around him finally ended after a confrontation with an off-the-lead Alsation while on a walk up the back road. He was never the same.


Our daughter was very keen to have a dog but while we were both working I felt this would be unfair to the animal which would have to be left alone during the day. We would also, by necessity, have to exercise it before and after a tiring day at work. Eventually my wife retired and I was working part time, so we relented. Our daughter accused us of deliberately waiting until she had gone to university but it was a practical decision. We needed the exercise.

The question then arose of what sort of dog to get. Obviously the right thing to do would have been to adopt a rescue animal but I was worried about the psychopathology of some of these dogs, many of whom had been badly treated or allowed to develop bad habits. There was also enough of the farmer in me to admire the look of pedigree stock and be put off by the chimeric disorder of mongrels. We also decided we wanted a ‘proper’ dog, not some deformed lap animal. An artist friend of ours who only paints outdoors kept a Hungarian (or Magyar) Vizsla for a companion while he was out and about. She died at an advanced age having become attractively ‘sugar-faced’ as Vizslas do.

Sugar face.

He replaced her with a wire-haired variety, as the original with her thin coat was vulnerable to cold weather. Smooth-coated Vizslas only have one layer of hair and cannot be kennelled outdoors in a cold climate. We did not intend to keep our dog outside. Our artist friend was fulsome in his praise of the breed and strongly recommended we get one.

Vizslas featured in a bronze statue, Budapest.

Using the Kennel Club website we located a breeder near Loch Lomond who had a litter for sale. While expecting all the pups to be spoken for we made enquiries. The breeder said she might have one dog and would call us back the next day. This sounded odd – but it turned out one of the pups was due to go to what the breeder considered was an unsuitable home and, furthermore, the buyer had delayed picking it up for frivolous reasons. We were told we could have this pup instead. Accordingly we went on a visit to Loch Lomond to see the litter. We thought we were inspecting the breeder but it turned out she wanted to have a good look at us!

Louis and his sibship. One of whom now travels in private jets.

We picked him up at eight weeks old. He was the last to leave his mother who leapt into our car before we departed as if she wanted to check us out. We set off for Edinburgh with him on my wife’s lap. Shortly after this the pup was sick but he would turn out to be a very good traveller eventually.

Louis as a pup

The first hurdle was what to call him. I wanted to go for something Hungarian and favoured Béla – as in Bartók, but our daughter said she didn’t want to have to explain why the dog had a ‘girl’s’ name – or have to shout ‘Béla!’ on Blackford Hill. In the end we compromised and settled on Louis for some reason. It seems to suit him. He has been subjected to many variations since then: Ludwig, Luigi, Luigi-Mo and even Lulu. He proved very easy to house train, taking less than a week, and has remained fastidious in his habits ever since.

The subject of neutering your dog is a fraught one. The primary benefit has to be the avoidance of unwanted litters, but it also removes the possibility of testicular tumours and benign prostatic hypertrophy in older dogs. It may reduce ‘humping’ activity and roaming but this is not certain. From a theoretical point of view, and being familiar with the appearance of geldings and bullocks (and castrati), I thought doing it too early might result in an overgrown animal with skeletal problems. In the end we waited until well after growth had ceased and had him done at 18 months. I cannot rid myself of feelings of guilt about this assault. It was distressing to sit with him in the vet’s waiting room after he was sedated and watch his bewilderment as he struggled to remain upright on jelly legs.

Louis netsuke.
Portraiture

‘Entire dogs’ still seem to me to have a more taught, muscular, disposition. A lovely dog, a Weimaraner cross, whom we sometimes meet, has also been ‘done’. We asked his name once and were told he was called Fidel. ‘He’s been neutered, so now we call him Fidel Castrato,’ said the owner cheerfully. What a splendid joke I thought. Maybe the chap’s a writer. A few months later the James Bond film Die Another Day was on TV while I was pottering about. There was a scene in an outdoor café where the villain points the gun at a waiter called Fidel’s groin and says, ‘Now round up some more girls and take them to Room 42. Unless you want to be known as Fidel Castrato’. Fidel the dog’s owner was a plagiarist!

I would have to say that a Vizsla is not a suitable beginner’s dog. Vizslas are a very ancient breed kept by Magyar aristocrats for hundreds of years and exchanged between them as gifts. They have boundless energy and were bred to follow a mounted huntsman all day. After the two world wars and the associated devastation of Hungarian society Vizslas were down to a few hundred specimens and were in danger of extinction as a breed. In view of this shallow gene pool great care has been taken with blood lines in rebuilding their numbers to their present huge popularity. However, some English and American specimens seem a bit too skinny and nervy to me. Louis comes from solid Hungarian stock and is now calmness personified.

Rather like choosing your child’s name, what you think will be an original and fashionable selection often turns out to be common as muck – and Vizslas are now ubiquitous. Everybody knows about the ‘velcro dog’ nickname. I have to say Louis is not prone to their typical habit of climbing on top of you at every opportunity, but he does like to be with you all the time. Vizslas are in the ‘hunt, point, retrieve’ group of utility gun dogs – and all that that entails. They are scent hounds, obsessionally exploring the aromas of town and country. They point. They have a very strong prey drive and will pursue anything; suitable (squirrels and rabbits) or unsuitable (cats). In five years of trying, Louis has only caught one squirrel. At first nonplussed to find it in his mouth he did despatch it fairly quickly then shot off. He wouldn’t give it up but returned empty-mouthed quite quickly. Too quickly to have eaten it surely. Retrieving, at least in Louis’ case, is not such a strong trait. At most he will fetch a ball three times before becoming bored and setting off on some new, more engaging olfactory exploration.

The first 2 years of ownership were testing. Inevitably it started with the chewing thing and the the razor sharp puppy teeth took a toll on our hands and chair legs. It was a blessed relief when the adult teeth with their blunt points came in. Then there was the boundless energy. In the early days of puppy walking we met a chap in the street using a theodolite. As Louis hauled us forward, nose to the ground the man made it clear he wanted to engage with him. He had an eastern European accent. “My sister has Vizslas,’ said the chap, laughing. ‘Vizslas are like pup till five!’ This was a depressing but accurate analysis.

Having a dog means frequenting unusual places in all weathers. Louis has an comic aversion to rain. He doesn’t like casual water either and avoids puddles. In the end Louis calmed down a lot and, if a reward is pending, he is flawlessly biddable. He has a sweet nature but is a bit forward and tends to greet visitors with a good sniff around their perineal areas. At 32 kilos he can have you off your feet in an unguarded moment should a squirrel or cat hove into view. His tail is heavy and thrashes about in company – at coffee table level. Our first experience of entertaining with him around resulted in the near clearance of the fizzy flutes on the drawing room table. We are wiser now.

Louis by Kelly Stewart

In a coffee shop near our house there were a number of charming dog portraits by a local (Australian-origin) artist called Kelly Stewart. We asked her to do Louis and were delighted with the result. He now stares calmly at the front door from the wall above the kneehole cabinet, greeting everyone as they come in.

Coronary Cares

After residential redevelopment the old Royal now looks more like Central Park West

When I started writing this piece at the end of last year I was awaiting some cardiac investigations. After a lifetime in medicine I was finding out what it’s like to be ‘on the wrong side of the desk’ as an oncology colleague once put it. An episode of chest pain had ended with an attendance at A&E. After negative tests on the day, I was recruited to a study (TARGET-CTCA) looking at whether a CT scan of the coronary arteries (CTCA) might be helpful in the setting of acute chest pain which did not appear to be a heart attack. There are two arms to the study – scan or no scan. I was ‘randomised’ to the scan arm of the study. The examination was to be performed at a later date. In the meantime my cardiologist ordered an MRI myocardial perfusion scan – which was normal – then I had the study CTCA – which wasn’t.

The following piece contains medical details, technical stuff and a great deal about death – so be warned. Medical jargon uses acronyms because the full titles of things are too cumbersome to use in rapid communication. For example, coronary care units, where they take you when you have a heart attack, are referred to as CCUs. Referencing this sort of thing, one of the sketches in our cabaret at the Final Year Club Ball consisted of nothing but such acronyms. The punchline involved an SEN from OPD and an SHO with an MGB GT V8. We opened the show with the line: ‘From the people who brought you I Tedious and The Sound of Mucus…’ which set the intellectual tone for the evening. We knew our audience.

In those days the medical school was still in the purpose-built Italianate building next to the McEwan Hall and the Teviot Row Union. As clinical experience increased, students made the short journey across Middle Meadow Walk to the Royal Infirmary more and more frequently. The proximity of these sites has now been lost – and with it some of the magic of an Edinburgh medical training.

Clinical medical training only began in earnest after graduation with pre-registration house officer (PRHO) jobs. They lasted a year, split evenly between surgical and medical experience. House officers are also called residents because they were once expected to be resident in the hospital throughout that year. The Royal Infirmary of Edinburgh where I did my surgical house job (an unfashionable orthopaedic post) had a residency, also known as the Mess, where we ate and, if possible, slept when on call. Originally residents had to pay for the honour of training under the surgical and medical gods. In the Mess we ate around a huge dining table covered with a white tablecloth. We were attended by Robbie the Butler who would take orders for breakfast while our bleeps went off, summoning us to the nearest telephone. The food was the same modest canteen fare from the kitchens that everyone else in the hospital ate and there was little sense of privilege.

The mess silver, donated by previous residents and accumulated over many years, had been stolen, but the billiard room was hung with interesting old mess tabletops carved with the initials and dates of previous residents going back to the nineteenth century. The signatures of illustrious visitors such as George V, Queen Mary and Prince Philip had been professionally carved into the surface for permanence. Philip visited in 1961. He enjoyed the event so much that proceedings overran and the London train had to be held at Waverley for him. The mess table tops hang in the new Royal now, ignored by the passing throngs. You can read more about the history of the Mess here:

https://www.rcpe.ac.uk/journal/residency-mess-royal-infirmary-edinburgh-history-and-traditions

By my time we were only resident in the hospital when on-call for the wards, but the frequency of this could be onerous; some posts demanded every second night and every second weekend in the hospital on top of the standard five-day week. Non-medical friends would ask how much time we got off at Christmas and I would have to point out that ‘we never closed’. Having completed this first year satisfactorily, you were eligible for full registration with the GMC.

Being a house officer turned out to be even worse than the appalling accounts I had heard from my seniors. It was like the stress you might expect during a war, and like a war, it bound us together in relentless adversity. Life-and-death crises, interpersonal aggro and steep learning curves all took place in a setting of extreme sleep deprivation. Any hint of flakiness under fire would affect your reference, so we all suffered mutely behind a mask of cheery efficiency. I suppose it did generate a degree of camaraderie among us. Certainly anyone who hadn’t experienced it couldn’t truly understand what we were going through. We propped our brains up with fags and black coffee. At 4am when you’d worked 20 hours straight, the pleasure of tea, toast and marmalade prepared for you by a kindly yellow-uniformed domestic lady was intense. I developed the ability to go to sleep in an instant and wake up fully functional just as quickly. I had no sleep pattern. This proved very useful when off duty as you could seamlessly enter party mode without the need for any rest. Time off was never sweeter.

My second house job, from February to July 1980, was at the Northern General Hospital on Ferry road. I was the sole house officer for the neurology wards and throughout that post I experienced the nagging anxiety that every fleeting symptom I experienced was the harbinger of some horrific ‘nervous’ disease. I was, after all, surrounded by genuinely awful cases. Uncertainty about what I wanted to do with the rest of my career added to my general unease.

The opportunity to apply for senior house officer (SHO) posts arose early in the year and I realised my indecision had led me to miss the deadline. Checking the closing date in the British Medical Journal, I was seized with panic. I decided I did want to give the big game a go instead of drifting off into a subspecialty – or general practice. I went to see one of my consultants, the notoriously brusque Clifford Mawdsley, to explain the situation. I told him I wanted to apply for the Edinburgh SHO jobs. I thought I might have a chance of the CCU post at the Royal Infirmary. This job involved nine months working in the unit with three months of general medicine tacked on at the end – and was the least popular of the various SHO options. It all depended on whether it was still possible for me to be considered. Mawdsley called me a silly bugger – then phoned John Matthews who was the senior physician in Wards 28/31 with the attached CCU. Putting the phone down, he said, ‘Right, get yourself up there now and he’ll see you’.

In his office the patrician former international cricketer and I had a chat about my future. I did my best to seem decisive and keen. To my relief he said a late application would be accepted. I submitted my CV, was interviewed and subsequently appointed to the cinderella CCU post. I later learned that my success had caused consternation among my contemporaries. They had spent six or seven years slaving to be ‘top’ while I’d had to repeat the third year of medical school. This was due to a combination of my own indolence and my father’s illness and death in the weeks leading up to my resits. I had no academic profile whatsoever and worse; I was considered an eccentric.

As advertised, the CCU job was heavily weighted towards the unit but it transpired that one of my medical school contemporaries, fellow SHO and budding cardiologist, Mike McLeod, wanted some additional CCU experience. I gladly swapped a three month block with him and ended up with a full six months of general medical experience. Shortly after completing our SHO year, Mike contracted a severe viral infection that had been circulating in the city. He returned to work, perhaps not fully fit, and collapsed and died while on call at the Eastern General Hospital. Ten years later when I was appointed consultant radiologist at the Eastern we held clinical meetings in the seminar room where a memorial photograph of Mike hung on the wall.

House officer duties in neurology with a bit of on-call respiratory medicine weren’t really adequate preparation for running the CCU of a large teaching hospital. Apart from other appropriate skills, I had never intubated anyone. Just before taking up my new post I went to Philadelphia to stay with friends. I read Samuel Shem’s novel House of God, about junior doctors in Bellevue Hospital. It reminded me of my NYU student elective there in 1977. I also spent some time lying on a scorching beach at Ocean City, New Jersey, reading Leo Schamroth’s An Introduction to Electrocardiography (a textbook on ECG interpretation). In early August 1980 I returned to the Royal and reported for duty, a rank above the poor residents in the mess.


One of the commonest complications of a myocardial infarction (MI), known colloquially as a heart attack, is ventricular fibrillation (VF). In this condition, the heart muscles simply tremble and circulation of the blood ceases. The patient has no pulse and is clinically in cardiac arrest. The ECG is easy to interpret in VF because it shows only chaotic electrical activity. During my six months in CCU I did little else but ‘defibrillate’ people who had gone into VF. This was achieved by passing a powerful DC electric current through their chest known colloquially as ‘shocking’ them. The hope was that this would induce an electrical ‘silence’ in the heart allowing a normal heart rhythm to become re-established.

The patients in CCU were treated in separate rooms with ECG monitors above the doors. The monitors indicated instantly when a patient had gone into VF. You then grabbed the resuscitation trolley with the defibrillator and made for the relevant room. Sometimes a degree of residual cardiac function meant that patients entered a twilight state of diminishing awareness before becoming fully unconscious. Humanity demanded that you wait until the victim was completely unaware before putting 200 joules of electricity through their chest. On one occasion a patient took an unusually long time to pass out. I paused over the bed with the paddles raised ‘unaware’ that some of the conducting gel I had applied had oozed down onto my fingers. Once the patient appeared to be completely out, I told the nursing staff present to stand away from the bed.  I applied the paddles to the patient’s chest and pressed the buttons to deliver electric salvation. The charge threw me backwards against the wall where I slid to the floor, stunned. Fortunately, the patient and I were both in ‘normal sinus rhythm’.  

Another procedure frequently performed in CCU was the insertion of a temporary pacemaker if the patient’s heart rate had become too slow (bradycardia). ‘Temporary’ indicated that it was only required during the acute phase of an MI. If the condition persisted then the patient might require a permanent, implanted, pacemaker. The pacing room was separate from the CCU, lying across a corridor which led to the adjacent general medical ward. A pacemaker drives the heart by delivering a regular electrical pulse to the inner surface of the right ventricle. Pacemakers were positioned under X-Ray guidance, a process known as ‘screening’ and the image was displayed on a TV monitor. A foot pedal turned on the screening which showed a real time image of the patient’s thorax on the monitor. A lead apron was required to protect your body from the almost daily exposure to scattered radiation. Over this onerous garment you were gowned and gloved-up as required for a sterile procedure. Later, I would do this many times as a radiologist. It was hot under all those layers.

The right side of the heart receives venous blood returning from the body. The right ventricle pumps it through the pulmonary arteries into the lungs where carbon dioxide is expelled and replaced with oxygen. Venous blood is noticeably dark in colour while oxygenated arterial blood is bright red. To place the pacing catheter inside the heart, a Seldinger Technique was used. This is a means of increasing the calibre of the access to a vein until it will accept the thickness of the pacing wire.

The patient was tilted slightly head down on the table to avoid the potentially fatal ingress of room air into the central venous circulation. This head-down positioning also caused the central veins to become more distended creating a bigger target for the initial venous puncture. After infiltrating local anaesthetic, a small syringe attached to a long needle within a plastic sheath or cannula around it was used to work your way backwards from under the right clavicle until you hit venous blood. You slid the plastic cannula forwards and pulled out the syringe and needle leaving just the plastic cannula (hopefully) in the right subclavian vein. A stiff metal guide wire was passed through the cannula then the cannula itself was removed. A nick was made in the skin with a scalpel at the point where the wire entered the body, then a larger bore catheter was fed over the guide wire through the incision. Finally the guide wire itself was removed leaving just the largest catheter. You had to put your thumb over the end of the catheter to stop blood pouring out. The pacing wire could then be fed down the catheter into the superior vena cava leading directly to the right side of the heart.

The X-ray image intensifier allowed you to see the progress of the wire from the subclavian vein, through the superior vena cava, into the right atrium, through the tricuspid valve and on into the right ventricle. One hoped to place the tip of the wire against the inner ventricular wall where it could drive the heart at a normal rate. Only the air in the lungs, the soft tissues, the bones of the thorax and the pacing wire can be seen on X-Ray screening. The chambers of the heart are invisible and the progress of the wire through the various structures had to be inferred from the shapes it made. It was possible to get lost down the coronary sinus that drains into the right ventricle. The leads at the proximal end of the wire was then attached to the pacing ‘box’ strapped to the head of the bed. The box delivered a regular electric pulse, the rate and voltage of which could be set. It also told you what voltage was required to ‘capture’ the heart rhythm This was known as the pacing threshold. A low threshold meant you were in a good position, a high threshold a poor one, possibly up against dead infarcted heart muscle. Once everything seemed satisfactory you stitched the wire securely to the skin to maintain its position and covered it with a dressing. This was my first experience of using X-ray equipment to guide a procedure.

An elderly lady with a profound bradycardia (very slow pulse) needed a pacemaker. Her heart rate was so slow she was barely conscious – and very confused. I had successfully placed the wire but the problem was that as soon as I put her heart rate up to normal, she came round, tried to pull the pacing wire out of her neck and get off the table.  The nurse assisting me with this tricky procedure suddenly announced to me that she didn’t feel very well. While gently restraining the patient to maintain the placement of the wire, I suggested the nurse go and get someone to relieve her and help me stitch in. She set off across the room but half way to the door she began to sway and then fainted, striking her head loudly off one of the big cast-iron radiators. She ended up motionless on the floor, apparently unconscious. ‘Scrubbed’ and unable to operate the intercom while pinning the patient down, I had to yell for help – which seemed to take forever to arrive. The fainting nurse recovered without any major sequelae.

When the blood supply to the heart is blocked by a coronary artery thrombosis the heart muscle supplied by that artery dies and stops working. It may also generate abnormal electrical activity of its own (see under VF above). One of the patients I paced during the early part of the post developed pleuritic chest pain. This is a sharp pain when you breathe in and usually indicates irritation of the sensitive lining of the lung called the pleura. My registrar did a round of the unit and when he came to the patient with the pain he pronounced that the pacing wire must have gone through the patient’s dead heart tissue and was now irritating the pericardium causing symptoms identical to pleuritic pain. He clinched this opinion by pointing out that the pacing threshold had risen. He told me I must reposition the tip of the pacing wire to relieve the pain and place it on a healthy bit of heart muscle so that we could continue pacing him. Just as I made the arrangements to return him to the pacing room for this, his wife turned up. I explained that we had to make a minor adjustment to the pacemaker and she would soon be able to see him.

I got the patient positioned head down, cut the anchoring stitch on the wire and pulled it back a little. He immediately went into ventricular tachycardia (VT). This isn’t quite as bad as VF but it is a serous arrhythmia nevertheless. I asked him to cough, as this sometimes terminates the rhythm without any formal intervention. That worked and I made to move the wire again. He immediately went back into VT. After this had happened three times, each time terminated by coughing, he went into proper VF and I had to shock (defibrillate) him. I had to shock him twice more and although the final position of the wire was not ideal the threshold was OK and I accepted it with gratitude. As we pushed him back across the corridor to CCU his wife was sitting in the corridor waiting, handbag on her knees. ‘That’s all fine’ I said cheerily. ‘You can see him now.’

Some cardiac arrests are true arrests, i.e. the heart is not fibrillating but has ceased to beat at all. This is known as an ‘asystolic’ arrest, systole being the contraction of the heart’s ventricles. In this setting I learned how to insert pacing wires ‘blind’ at the bedside without the help of X-ray screening. It was usually a last ditch effort involving inserting and re-inserting the pacing ‘wire’ through the large bore cannula. You hoped to place the tip in the right ventricle by trial and error. Pushed far enough, the tip would either be in the right ventricle or have gone past the heart altogether into the hepatic portion of the inferior vena cava in the upper abdomen. It might even have passed through the right ventricle and into the pulmonary arteries. If, when you turned on the pacing box, you could capture the heart rhythm, you knew you were in the right place. You could then force it to beat at a normal rate. If there was still no pulse you knew the heart was too badly damaged to recover, a phenomenon known as electro-mechanical dissociation.

Ultrasound imaging of the heart was in its early stages then but I witnessed the first use of a portable cardiac ultrasound scanner in CCU. The cardiology registrars were keen to try out their new equipment and a suitable case appeared. A young woman had been admitted, suffering from multiple pulmonary emboli (solid material passing through the right ventricle and blocking the pulmonary arteries). There was no obvious origin for these emboli.  Usually the source would be blood clots travelling up to the heart from veins in the legs or pelvis known as a deep vein thrombosis – or DVT. She had none of the usual signs or risk factors for a DVT. We watched in silence as the scan showed a large mass oscillating in the right ventricle. It was clear now that clots or pieces of this tumour were breaking off and going into her lungs. We hoped this would turn out to be something benign called a myxoma. I was able to go to theatre to watch the attempt at curative surgery. Sadly, the external surface of the heart had a ‘peau d’orange’ appearance due to malignant infiltration. The tumour was a sarcoma and there was nothing to be done. I was intrigued by seeing the physical proof of what I had seen on the grainy greyscale image. Much later in life, ultrasound would become the mainstay of my clinical practice as a radiologist.

By December of 1980 I was feeling a great deal more confident, almost blasé, about my duties in CCU. I was never a ‘good riser’ and always left my departure for work to the last minute. It didn’t take long to drive from my flat in India Street to the Royal Infirmary where I had a coveted parking permit. On the morning of 9th December 1980 the radio alarm went off as usual. I heard the presenter say, ‘…and we will return this morning’s tragic news after the weather forecast.’ I wondered who had died. Someone important it seemed. The forecast completed, the ‘pips’ went for 8 o’clock and the presenter, Brian Readhead, said. ‘It’s 8 o’clock on Tuesday the 9th of December. Former Beatle John Lennon has been shot dead by an unknown gunman who opened fire outside the musician’s New York apartment where he lived with his wife, Yoko Ono, and his son.’

In CCU life and death went on as usual. A couple of weeks after Lennon was shot, on Christmas Day, we had five deaths before lunchtime. I’d seen five sets of grieving relatives by the time the sister and house officer from Ward 28 bounced into the unit bedecked in tinsel, intending to hand out presents. We suggested they didn’t bother. 

A few years ago, I visited the Science Museum in London.  On the top floor are the Wellcome Galleries, a museum covering 500 years of medical history.  There are many interesting exhibits: pieces of ancient equipment, scale models, dioramas of historic breakthroughs and life-sized figures. There is a model of a British Man-of-War with a naval surgeon carrying out an amputation below decks and a Victorian chemist shop complete with the chemist in his stovepipe hat. Having circumnavigated these tableaux, I came to the final one labelled ‘A Coronary Care Unit of the 1970s’. There in front of me was the very set-up we had in the Royal.  I’d lived long enough for the working environment of my junior doctor years to end up in a museum.  

Oh, and my CTCA showed ‘moderate coronary occlusive disease in my left anterior descending (LAD) coronary artery and a possible narrowing at the ostia (origin) of the LAD from the aortic root’. Most of us wander about unaware of any cardiac sword of Damocles hanging over us, but thanks to the trial I am now aware. Better the devil you know?