February 10, 2021
San Francisco — The whole thing started with Ma Heaney, really. In her youth, hospital legend had it, Ma had been a nurse-anesthetist up in Shasta County, delivering babies in the back country at the foot of the mountain with her country doctor husband.
As I heard the story, in winter they traveled by horse and sleigh through deep snow, out to the farms and ranches, to attend women in labor and help them through the difficult hours that brought their children into the world.
By the time I met her in 1964 she was nearing retirement as the Delivery Room supervisor at St. Mary’s Hospital, near the panhandle of Golden Gate Park in San Francisco, and didn’t take any crap from the July harvest of a dozen freshly graduated new interns, of which I was one.
By the time I rotated onto the obstetric service part-way through my first year out of medical school, I think I had a bit of a reputation myself. I was five years older than the average graduate, and while few med students were married in those days, I was an Army vet and had a couple of kids of my own. I was a hard worker and capable enough that I didn’t put up with any of the casual bullying by senior residents and nurses, nor even by the few staff physicians who liked to throw their weight around.
At medical school in Philadelphia, rather than scoot off home from night call at the first opportunity, I had hung around at the hospital where, technically, I was supposed to remain when on call anyway. I hoped that when things got busy in the Emergency Department, surgery, or OB, the senior doctors would discover something useful for me to do.
Clinical training, with actual patients, begins in the third year of school, after we had spent the first two years cramming our heads full of medical information about anatomy, biochemistry, physiology, pathology and the rudiments of medicine, surgery, pediatrics, neurology and obstetrics. In the third and fourth years therefore, we divided our time between classroom and making rounds with our professors on the wards. Eventually we attended the various outpatient clinics, and in our final year on surgical rotations and delivery rooms we got to scrub up, gown, and stand at the side of the operating and delivery tables as observers. For practice, we took histories from live patients and did admission physical exams. On certain nights we were assigned to be “on call” in various locations. There was often little to do and we were sometimes bored and ignored. Most students, sleep-deprived as they always were, slipped out when things were quiet and went home to get some much needed rest.
Maybe an upperclassman tipped me off or maybe I just thought I’d give it a try, but I usually stayed around my assigned places of duty, particularly the Emergency Department. Sure enough, hanging around until the ER docs and nurses got used to my presence eventually resulted in my being given some task or other they were far too busy to attend to.
For example, only a few days into my time in the ER an elderly drunk had wandered in from a nearby alley with a five-inch laceration on his face. He was still rambling and half-asleep on the gurney. For the first time, but not the last, I smelled the distinctive metallic pungency that results from the mixing of ethyl alcohol and blood. The man was making belligerent noises but was not combative. As I watched the E.R. doc explore and clean the wound, he began to explain what he was doing at each step, and why. He then asked if thought I could suture the wound. I had read the texts, studied the illustrations, and once in the service when Frankfurt suddenly turned cold and we had nothing left in my private’s monthly pay packet, had sewn my wife a passable winter coat out of an Army blanket So I said, “Sure, I can do it.”
Leaving me to attend to other problems, he came back to check my progress a few times and then examined the result when I was finished. I had paid attention in my plastic surgery lectures, and my tiny, closely spaced stitches with 6-0 nylon looked like they were going to leave our patient with as little scarring as anyone could rightfully hope for, probably less than if the work had been done with bigger, fewer stitches by a harried emergency room doc.
After that, every time I was on call in the E.R. I was given a steady stream of wounds to sew up, each one with another careful instruction on how to assess the particular underlying damage prior to beginning the closure, and with intermittent coaching as I worked. Once at three a.m. when a patient required a super-specialist to do a complicated repair of the nerves and flexor tendons of his injured hand, and the hand surgeon’s own resident couldn’t be found, the E.R. doc recommended me as a competent assistant, and I went into the operating room for my first official experience as a surgical first assistant.
On the obstetric rotation, the student’s job was mainly to sit with the patients through their hours of labor and observe the process attentively from beginning to end. We were assigned patients as they were admitted, and stayed with them for the entire labor. Among the patients to whom I was assigned, the longest labor was 36 hours. She was a very overweight teen who had not known she was pregnant when she came to the hospital that day with severe abdominal pain, which proved to be labor. She was there on her own, as terrified with the whole idea of being pregnant as she was at being in labor. With no preparation for the event and altogether overwhelmed, she screamed at the top of her lungs with each contraction for the entire 36 hours. Poor kid, no matter how I tried, I was powerless to comfort or reassure her in any way.
Attending staff, residents and sometimes interns delivered the babies, but there was one job no one really wanted. When parents had requested it, the interns performed circumcisions on their three-day-old boys. After I had watched a few, one intern taught me how to do circumcisions with the two main types of clamps that had been invented for the job.
Then, when the nurses called him in the middle of the night for a circ, he had the them call me instead. Of course the first time or two he got up anyway and came in to make sure I was doing OK, but after that I was on the regular rotation to do the tiny but critically important task. Often when the nurses had difficulty reaching an intern and I was on duty, they called me.
I became a mini-celebrity among the med students on the obstetric rotation. A Jewish classmate told me with a grin that I was, “the Irish Mohel of Philadelphia”.
A couple of weeks and many circs later, an excited classmate woke me in the on-call room, saying that his intern was in trouble with a circ and wanted me to come and help him. Arriving, I found the intern pale and sweating bullets, his eyes big and scared. There was a lot of blood and raw tissue where the head of the penis should be and the intern was terrified that he had cut too deep. Terror had shut down his ability to think and he was about to faint.
It scared me too. It took me a full minute of calm, systematic inspection to figure out what lay before us, but I finally realized that the probability was that he had been too hesitant and had not cut completely through the foreskin. We were looking at, I decided – I hoped – was the bloody interior tissue of the foreskin itself. After confirming my theory with a thin probe gently inserted between foreskin and glans penis, I made one very careful snip through the remaining innermost layer of the foreskin, which, falling aside, revealed the completely uninjured head of the kid’s penis. After we both took a few deep breaths of relief, I encouraged the shaken intern to finish the surgery himself, and stayed with him for moral support while he did it. I suspect I made a friend for life. And if the newborn boy had known what was going on, it would have been two friends.
It chanced that after med school I never did another circumcision. Decades later I concluded that since the original rational for male circumcision, potential infection under the foreskin, was no longer difficult to prevent or treat, it was probably a ritual that was, a) medically unnecessary and, b) impossible to rationalize on any other basis.
The larger lesson I leaned from hanging around rather than absconding as most exhausted students did in the middle of the night, was that at 3 a.m. when something goes wrong, the powers and abilities of even most junior trainee become magnified by the complete absence of anyone more qualified.
Two years after the my experience as a “circumcision consultant” to an intern, I was myself an intern (nowadays called a first-year resident) at a large private hospital in San Francisco. The fact that it was a private hospital, with few non-paying clinic patients and with full staff of private doctors, meant that interns and residents rarely got to do hands-on surgical procedures, of the kind they did at the county hospitals. Private patients expected to see their doctor at the wheel.
Despite the scarcity of opportunities for solo experiences, St. Marys had a cadre of excellent medical staff volunteers, called the “Teaching Staff”, to make sure we got all the training we could handle. In return for their service as our teachers, interns were assigned to all of their patients to do detailed and complete admission histories and physical exams, to write admission orders, and to be available day or night when the nurses needed a doctor to answer a question, evaluate a problem, make a decision, order a test or prescribe a medication. Only if the intern couldn’t handle the given situation would the attending physician need to be called.
During two-month rotations on obstetrics, interns watched the attending doctor deliver a lot of babies and maybe got to suture up the episiotomy incision, if they were lucky. In the first few months one or two interns may have gotten to deliver a baby or two.
Though I liked OB and might have hoped for more experience, I was willing to live with that, but then something entirely different happened.
There was something unusual going on in the delivery room that year. It was the mid-sixties and Michael Flanagan, the Chief of the OB Department had learned a new and safer way to administer anesthesia for labor and delivery. It was essentially a local anesthetic, a later version of novocaine, administered through a seven-inch needle at a precise moment early in labor, into the partly dilated cervix at the four and eight o’clock positions. Just as in the dentist’s office, the anesthetic numbed the cervix so that its subsequent dilation and the contractions of the uterus were pretty much painless. And late in labor just before the work-space inside the vagina disappeared and the pelvic floor was stretched by the baby’s head, the same needle, and a guide, called an Iowa trumpet, delivered more local anesthetic through the vaginal wall to the pudendal nerves on either side, numbing the pain of the stretching of the opening. Deadening those nerves also allowed enlarging the opening a bit with an episiotomy, later to be sewn back up after the baby was born.
Called a Paracervical and Pudendal Block, the local anesthetic, though it had to be injected into a very precise location at a very precise moment in order to work, avoided the necessity of giving the mom medications and anesthetics that could make both mother and baby very drowsy. But it was a new technique, very hands-on for the obstetrician, who ordinarily left pain control to the anesthesiologist. At St. Mary’s only Doctor Flanagan was using the nerve-block technique.
So I began my rotation on obstetrics sitting with patients, and doing what I was told. Even the few clinic patients we had were delivered by the chief OB resident, a kind of abrasive guy, I thought, so I avoided him.
But Flanagan was friendly and energetic, so I asked him to teach me — show me really because I had no one on whom to to practice once shown — how and when to do the injections for the nerve blocks. Which he did with enthusiasm. On several occasions he let me watch closely in order to identify the precise location on the cervix into which he injected the anesthetic. At his request one or two of his patients allowed me to do a vaginal examination in order to memorize by feel, the landmarks on the pelvic bones that bracketed and therefore precisely located the pudendal nerves for the second-stage injections.
That accomplished, we both intended that would be that.
Meanwhile, at some point Ma Heaney had come up as I arrived on the ward and asked me to countersign for a sedative she had administered during the previous night to a patient of one of the staff obstetricians. She had done this to other interns, some of whom had gotten huffy with her about expecting them to approve, after the fact, the somewhat heavy sedation she sometimes employed without waking up the attendings for an order, and without consulting in advance with an intern trained in the modern philosophy of avoiding heavy sedation of mothers in labor.
But I had been in the Army, and I knew better than to be the newly fledged lieutenant who gets into an pissing contest with the platoon’s master sergeant. Besides the medications had been given hours earlier and the mother and baby were fine, so I said sure, and signed the retroactive order, adding with a chuckle, trying to come off as being unconcerned and with no hint of rebuke — “a hundred of Seconal…sounds like that kid may be a little sleepy when he gets here”.
She gave me a speculative look, but said nothing. Hell, before I was born that woman was out in the middle of the night in the dead of winter on some isolated farm in the mountains giving medications to a woman in labor by the light of an oil lamp. Medical fashion might have changed slightly over the decades, but her experience gave her good reason to know that mother and baby would be fine with whatever part of her medication was left in their systems by the time the baby was born. Since…
There was another liberty she took, again because she judged the rules to be in conflict with reality. Technically, nurses weren’t supposed to do pelvic exams on women in labor. In order to minimize the risk of introducing an infection, a terrible problem a hundred years earlier, the number of exams was to be limited to those done by the obstetricians themselves. On the other hand, every obstetrician on the staff relied on Ma Heaney to know exactly when to call him in to deliver the baby. That service allowing them all to sleep as long as possible at night or see a few more office or hospital patients during working hours, and still get to the delivery on time. She was to call them from wherever else they were when the cervix was at seven centimeters dilation. Seven was two centimeters short of the nine that signified that a delivery was imminent. The final two centimeters of dilation would provide enough time for the doctor to get to the hospital from home or office. There was only one practical way to discern the precise dilation of the cervix in a labor bed — by how the rim of the cervix on the baby’s scalp felt to the gloved hand of a skilled and experienced examiner.
When the phone rang at 1 a.m. a couple of weeks into my OB rotation it was OB nurse-Carol Rogan. “Doctor Franklin,” she said, “Ma Heaney wants you to come in and deliver a clinic patient who’s just come in.”
“But Carol”, I explained, “I’m not on call tonight.” Charlie, the truculent chief OB resident had was on call that night and she had made a mistake… I thought.
“No, Ma says she doesn’t want him to take care of this patient, she wants you.”
Leery of pirating my boss’ clinic patient, I still hesitated. In the short silence, Carol finally explained the circumstances, “The patient is Ma’s granddaughter. She’s eighteen and single. Ma wants you to give her a paracervical and pudendal and deliver her with forceps.” Application of forceps, in this case to protect the baby’s head, control its emergence and thereby minimize the risk of tearing of the mothers vaginal and perineal tissues. Forceps. Another thing I had never done. Although I had performed one uncomplicated delivery in med school and theoretically knew how to apply forceps, itself a little tricky, I had never applied the steel utensil, except miming in the air with no mother or baby present.
“Carol, I’ve watched them but I’ve never done a paracer….” I began, but Carol cut me off with, “Ma says she knows you can do it and she wants you to come over.”
Already wearing scrubs I slipped on my shoes and was out the door in seconds. St. Mary’s had built a brand new six-story interns and residents apartment building just across the street from the back door of the hospital. My intern classmates and I were its first occupants. A St. Mary’s intern’s salary was only $3,000.00 a year in 1964, but a brand new San Francisco apartment for my wife and (then) two kids made choosing that internship a no-brainer for me.
Striding into the Delivery Suite two minutes later I was met by Ma Heaney, who listened while I listed all the reasons why I was not qualified to do what was proposed, then said, “Flanagan taught you how to do it. I know you can do this.” She and Charlie had some sort of history and it was clear she really didn’t want him taking care of her granddaughter. Besides, she was right. What Doctor Flanagan had taught me wasn’t that hard to do if it was done at exactly the right moment and at just the right anatomical spots.
That settled, Ma took me to meet my patient. Even at first glance she seemed to be a great kid. A scared teen, she was being brave so as not to embarrass her tough old pioneer grandma. Dark-haired, small and pretty, she looked determined to do her part and to trust us to do ours.
As with all the patients, I was able to sit with her so that we could get to know one another a bit, and I explained to her exactly what was going to happen. Ma went off to do other things, and, I thought, in order to take the pressure off of me. With encouragement from Carol and me, the young woman bore the initial contractions bravely until it was time to move her from her bed and in to a table with stirrups for the paracervical block. Which went very smoothly. The ‘Iowa trumpet’ needle guide was shorter than the needle, and allowed the needle protrude to just the right depth, depositing the lidocaine among the fibers of the dense paracervical nerve plexus on each side of the cervix, or neck of the womb. The anesthetic soon deadened the nerves that carry the pain messages to the brain. Within a couple of minutes while still fully alert, the young woman was having no pain with her contractions.
Later when the cervix was fully dilated and the baby’s head moved further down the birth canal with each contraction, we again put her on the delivery table as she continue to push the baby out. With the baby descending, it soon came time to put the second set of locals into the pudendal nerves before the workspace was filled with the baby’s head. Again, it worked just as Mike Flanagan had shown, much to my relief. Then, with the area completely numb I made an episiotomy incision to make plenty of room for the forceps, which slipped on just as the textbook described they would. It seems illogical to cut perfectly healthy flesh, but the surgical cut heals cleanly, quickly, and with minimal scarring, whereas if the tissues do tear, significantly more scarring and lasting damage occurs.
Before long the brave granddaughter delivered a healthy, wide awake little girl, to everyone’s delight and my relief. There is no happier place in the world than a delivery room in the moments after the safe arrival of a new child. And I have had few greater pleasures than to have shared those moments with new parents and the delivery room team.
The granddaughter had done her grandma proud, and I was enormously proud of her for it.
A few midnights later I was working on a chart at the nursing station and I heard Ma on the phone with one of the staff obstetricians. She was saying, “Doctor, I’m calling to tell you that your patient is ready.” From under his warm covers he must have asked, “seven centimeters already?”, to which she responded. “No, not seven centimeters yet. She’s just reaching six centimeters and is perfect for a paracervical.”
I could hear and alarmed squawk from the phone, and a faint, “Paracervical? I don’t do paracervicals!” And then Ma delivered the hook so matter-of-factly he never felt it go in: “No, but Doctor Franklin does them. He did my granddaughter and he’s right here.” Sleepy and confused, he must have told her to have me go ahead and call him for the delivery, because she beamed a smile at me and hung up the phone.
With Ma explaining her doctor’s decision to the patient, off we went to the delivery room. No sooner had I put the paracervical block in when her OB popped into the room, in a state of mild confusion. Who the hell is Doctor Franklin, he was wondering? And why is he giving the anesthetic to my patient?
I imagined how this must appear to the patient. I was standing at the foot of the table, scrubbed, gloved, masked and gowned, and the newly arrived attending had taken a position at the side of the delivery table, didn’t exactly know who I was nor what a paracervical block was.
At that moment the patient began to have another contraction, the first since the block, and I asked, “Are you having any pain?” The doctor, with his hand on her belly feeling a strong contraction said, “Yes”, at the very moment she calmly said, “No.” His head snapped around only to catch her smiling, peaceful expression.
As he turned back to me, I explained I had just injected local anesthetic into the cervix at the 4 and 8 o’clock position and in a few minutes I’d inject locals into the pudendal nerves on either side and do an episiotomy. He knew that the baby would be born within the next few moments after that.
The doctor was asking me questions and to the patient it would have seemed as if I was teaching him what I was doing. With the patient seeing me as some sort of consultant, and with her own doctor at her side, neither of them seemed to mind when I just naturally proceed with the pudendal block, episiotomy and delivery. Besides which, because of the steady march of events, it would have been awkward for the attending physician to switch places with me at the last minute. In addition to which he wasn’t scrubbed, gowned or gloved.
Holy smoke, I had just delivered a baby with the private OB standing right there. That was two deliveries for the OB intern, already tying our intern class record.
Ma made that same phone call every time I was on duty, and by the end of my two months on the obstetrical service I had done 100 deliveries.
Of course the staff doctors must have figured out what was going on. Perhaps they checked with Doctor Flanagan, but in any case no one ever objected and I was not aware of any declining the paracervical for their patients. I even delivered the baby of the niece of one of the staff obstetricians, Gil Ayotte who had begun as a country doctor in Quebec and had a wonderful French-Canadian accent that always reminded me of Maurice Chevalier.
Delivering those babies was probably the most fun I had in all my years of training.
At the end of my rotation, Carol Rogan and a delegation of delivery room nurses came to me and asked me to please apply for the obstetrics residency program when my internship ended. I was moved and gratified, but declined. I explained that I had loved my time there as an intern, sitting with the patients and staff and being part of the joyful outcomes, but I knew that as practicing obstetrician I would never have time to spend hours with the women in labor, and would have to rush in at the last minute, having missed most of the fun. Ruefully, they said they understood.
Over the next few years hospital staffing showed the first signs of a massive shift that has taken decades, and doctors began making a career of working full-time in hospitals. If that kind of practice had been available for obstetricians in 1964, I’d have done it!
A year after my obstetrics rotation as an intern, when my wife was in labor with our third, a daughter, I was catching a nap in the on call room when Carol Rogan rushed in and told me the labor had accelerated dramatically, and they couldn’t find Doctor Flanagan who was somewhere in the hospital. There were some pager dead-spots at St. Mary’s and Flanagan, who had already done the nerve blocks, was in one of them! As I was completing my five-minute scrub at the sink, from a few feet away at the delivery table, Carol nervously urged me to hurry because the baby was, “really on the way!” As I gloved and approached the table I said, “It’s OK, Carol … just don’t let the head pop.” (If the head emerges too quickly during birth and suddenly decompresses, the pressure change can cause veins to break in the newborn’s brain, resulting in the potential for damage.) She placed three fingers atop the baby’s head and as she eased it out I stood by and let her finish the delivery. I knew it wasn’t her first, but I wanted her to know how much I trusted her. We clamped and cut the umbilical chord. Then she took Lisa up to meet her mom while I delivered the placenta and massaged the uterus to stimulate the final contractions that stop it from bleeding.
Good thing she knew not to let the head pop. That little baby, with all her wits about her and two boys of her own in college, is working as a prosecutor, protecting kids in this county’s family court system.