Friday, February 10, 2017

Parental Vigilance

Dear Parents,
I can not emphasize this enough. (I've written about this before)

After the bris is over, and I am finished with MY job, YOUR job kicks in.

So let me explain to you what MY job is, so you understand what your job is and why your job is very important.

My job:
1. To get as even and aesthetically pleasing circumcision as possible. To achieve this I use a surgical marker to guide the incision
2. To make sure I take off the correct amount of foreskin, which actually has a small range of flexibility, and not to take off too much.
3. To make sure that beyond removal of foreskin there isn't an excessive amount of membrane left behind, which could give the baby the appearance of being uncircumcised.
4. To control the bleeding and make sure the baby is well on the road to healing and recovery post circumcision
5. To give you information about how things will look over the next few days and weeks
6. To give you instructions for after-care and what your job is over the next few days and weeks

Which leads us, most obviously to YOUR job
1. To follow the instructions for after-care (see 6 above)
2. To be in touch with ANY and ALL questions
3. To keep the diaper area as clean as you can during the healing process
4. Over the next few days, weeks, sometimes months, to avoid the Fusion Concern
5. To be aware of the Chubby Baby Syndrome

It boils down to this.
After circumcision, the body realigns the penis and restructures itself in the absence of the foreskin. Depending on how the circumcision goes, there may be a ring of leftover membrane between the incision spot and the glans, or there may be no membrane there at all. IN EITHER CASE, because the baby spends so much time on his back, and especially if he becomes chubby over time, the glans has a tendency to sink a little back into the membrane or the shaft and stay there, giving the baby a partially (as opposed to completely) circumcised look.

Which is where YOU come in.
Every time you change his diaper, every time you give him a bath, make sure that the glans is free and clear of anything that is below it. It really is a very simple massage every time his diaper is open, until time (could be weeks or even months) indicates that no intervention is required any more.

In simple terms - I met an adult recently whose parents did not take care of this when he was young. After a brief consultation I suggested he speak to a urologist, and he ended up having corrective surgery. This could have been avoided if his parents had been vigilant!


Tuesday, January 31, 2017

Being Prepared for Out of the Ordinary Circumstances

As much as possible, I try to meet the baby a couple of days before the bris. It gives me a chance to speak with his parents face to face, and it also helps prepare me in terms of what to expect with the technical side of the circumcision.

In other words, not all male anatomy develops in the same way.

In examining a baby recently, I noticed that the glans was extremely close to the body in its natural state, while when pushed on the two sides of the shaft to elongate the penis, the entire organ seemed to emerge. I have seen situations in which the entire penis was inside the body, requiring a reconstructive surgery to draw everything out - which I was later privileged to observe in the operating room, under the skilled hands of one of the finest surgeons I have ever seen in action. But this was not so extreme at all, as everything was external, it just seemed pulled by nature to be less prominent.

I explained to the parents what I needed to do - to be as precise as possible in marking the foreskin, to avoid this problem, and to see to it that everything looks right after the bris.

As luck would have it, the marking went perfectly, the incision was precise, and it looked like all was going to be smooth sailing. However, as sometimes happens, I noticed afterwards that there was extra membrane, necessitating this quick touch-up.

But it turned out to be so much more. What is often a tiny piece of membrane tissue turned out to be a significant amount of below the foreskin webbing. It kept emerging, causing me to realize what was pulling the glans almost into the belly itself. 

Thankfully, it seems this was it. When it was all removed, the baby looked like every other baby post-bris, and the internal issue he had that was pulling his penis, making everything so retracted, was resolved. 

As I told the father, if we hadn't taken care of this now, he may have developed phimosis or the inability to have a complete erection, with internal membranes pulling him away from being able to do what he'll need to do one day.

Baruch Hashem, a good ending and a happy story. It's a warning to mohels to be humble and to remember that not everything is "textbook" every time. It is also a reminder to parents that mohels must treat each case as if it is the most important thing he is doing now. I have seen cases similar to this one in which the circumciser erroneously removed ALL shaft skin because he thought that was what was required due to the unique anatomy.

Thankfully that wasn't the case here, wasn't the approach tried nor the results achieved (which were actually quite impressive)!

May we be blessed to deal positively with all new situations, and be guided to always fulfill the mitzvah of bris milah properly, including in non-textbook circumstancs. 

Friday, December 9, 2016

The Blessing We Don't Wish on Anyone

I got a call for a bris which included the question, "Our baby was sent to the NICU. Will this delay the bris?"

The proper answer to this question is "For what reason was he sent to the NICU?"

If the baby was brought there for observation and as a precaution because the doctors were concerned about something, then the next question follows, "Did they just observe and run tests? Or was any intervention required?" Because if he required antibiotics, then the bris date would likely be pushed off.

In this particular case, as the doctors did nothing but observe, they were just being cautious out of a concern, which was likely based on a need for the baby's system to mature ever so slightly, which is not a sign of illness, but just a simple sign of normal development.

So I told the mom, I think the bris will be taking place on time.

Her response: "So when will the bris be?"

If she called me Tuesday, and her baby had been born the previous day, I told her, "This coming Monday. In six days." To which she responded, "Oh boy..." indicating there is not enough time to prepare.

Of course, there is enough time, it's just overwhelming. But she is coming from a situation where her previous son (same mohel as this time!) had some issue which caused his bris to be delayed a week. Her most recent memory of bris preparation is having TWO WEEKS from birth until the bris.

Since the bris typically takes place on day-8 of life, from one perspective it is a blessing to have a little more time to prepare for the celebration.

On the other hand, that "blessing" usually means there is something wrong with the baby that is causing the bris to be delayed. And any kind of medical situation is not the kind of blessing we wish for a newborn.

Things happen. Hopefully the doctors are amazing at what they do. And all little boys should be able to have their brisses in a timely fashion.

Thursday, December 1, 2016

Blogging Mohel Lives Life as well!

I've noted before that sometimes life gets in the way of blogging. Thank God, between the Jewish holidays, moving, Thanksgiving, and just plain business as a mohel and a husband and father (and rabbi of a synagogue!), things have been good, and quite busy!

One day we'll begin exploring new topics here. In the meantime, please check out the Welcome Message and the All You Need to Know Blog Post.

I look forward to hearing from you! Best of luck with your pregnancy, birth, and with your baby!

Friday, October 7, 2016

Holiday Season

This time of year always brings with it frantic calls from people whose timing has them needing to schedule a bris on a holiday.

I got a couple of calls for Rosh Hashana bris.
I'm doing a bris on Erev Yom Kippur (YK Eve).

And I am sure that come this Monday and Tuesday I will get calls seeking my availability for the holiday of Sukkot.

Alas, unless you come to me for the holiday (and you are always welcome!) I serve as a pulpit rabbi and cannot leave for the holiday. :(

Wishing everyone well, Shana Tova, and a year of healthy babies!!

Sunday, September 4, 2016

The Bedside Manner Mohel

After my post-bris visit (which SHOULD BE a given with every mohel, but is not), I spent about 20 minutes talking to the baby's father, who gave me the whole history of how they found me. [a.k.a. "best kept secret in Florida" - flatterer]

There are a few mohels who have been in Florida for a very long time, such that "everyone" in certain circles uses them. In fact, before calling me, this couple called my friend Rabbi Howie Seif (the Knife), who was unable to serve because he was leaving town, but he gave them my name.

I do the same for him when I get calls when I am away.

But even Rabbi Seif wasn't the first mohel they lined up. All of their friends use a certain mohel, about whom they heard - from those very same friends - that his bedside manner is not what they need. Breaking the mold of just calling the guy everyone hires, they called around, got a few names, did their research and eventually got confirmation from a friend about me.

The phone calls: Baby's grandfather called. We spoke. Heavy focus on bedside manner being important.
Then the baby's father spoke. Again, assurances that the kind of bedside manner they'd be getting is what they are looking for.

And after the fact, after I spend 1/2 hour in their home the day before the bris, plenty of time at the bris (in minutes before and after) explaining what will happen, what did happen, and of course in caring for the baby, as well as another visit to their home to see the baby a few hours after the bris (to remove his bandage and make sure all was well), the father of the baby told me, "You were just what we needed."

I wish for all parents of a boy to have a similar experience as this one. Many mohels have a wonderful bedside manner, and give the time to the parents and explain everything, and address their concerns. 

Some, obviously, do not. Which is unfortunate. 

The bris is a holy act, a defining experience of the Jewish people for close to 4,000 years - in fact, the OLDEST TRADITION WE HAVE. Of course it should be joyous, of course it should be celebrated properly, and of course it is something we should be proud of and we should never need to defend it.

But for the parents of the baby, there is a natural tension and unease. Because the baby is, after all, undergoing surgery, and we want that to go well, and for the baby to be in a good place as far as his healing is going, as quickly as possible after the bris. And the parents sometimes need to be coddled through the experience, because as much as we want to do it, it doesn't make the experience an easy one.

Enter the Bedside Manner Mohel. And all will be OK!!

Monday, August 22, 2016

Twins again - and French origin

Judging by most of the population's proclivity for having children in single doses, multiple births are not very common. Of course, with IVF and other fertility advancements, multiples have probably become more common these days - nonetheless, most people have one baby at a time.

In the last few years I've presided over brisses of twins around 10 times (with a few additional situations where one of the twins was a girl - so it was only one bris).

In two cases (two separate sets of twins) the parents were living in the US but had relatively recently moved here from France - can't get into all the reasons why, though I'm sure that one reason is obvious to everyone. 

What's up with French Jews having twins? :)

It is most fun for me for two reasons as well. My last name is a European word which means "ticket" - and it is so French of a word that these lovely families feel an additional connection with me owing to my French origins, beyond our being Jewish. (FTR, I know of no Billets from France, and I speak as much French as Huckleberry Finn)

The second reason is harder to explain, but it is 100% true. While I speak a decent Hebrew and with an undistinctly American accent (living in Israel for a year as a kid helped me fashion my own version of an Israeli accent - though my vocabulary limitations are a dead giveaway), every time I'm in Israel and find myself in Jerusalem, whether in conversation with a vendor or when either asking for or giving directions to someone, I'm inevitably asked "Ata Tzorfati?" (Are you French?) Maybe it's a complexion thing, or maybe it's a style of Hebrew-speak, but it has happened so many times I don't even wonder what it's all about anymore.

Anyway - point is, there is a connection beyond words that exists between me and French Jewry. And I am always honored to be the mohel for the twins - and even enjoy the occasional single bris that life brings my way. 

Wednesday, August 17, 2016

How I explain what happens in a bris

Letting the cat out of the bag here will take away a little of the entertainment factor from those who will hear this shpiel in the future, but I imagine that this, like all blog posts, will eventually get lost in the blogosphere.

For the record, I've described how things look after the bris here and here and here, and I've even offered a link to a medical website that shows textbook images (computer generated, not photos) of a pre-circumcised and post-circumcised penis.

In the moments before or especially AFTER the bris, I like to explain to parents what has happened to their son.

Then I pull out my model, the one I "carry with me always" - and here it is:

Imagine my fist being hidden by the cuff of my sleeve (if you look carefully, you can detect it below the cuff). Now: CUFF = FORESKIN.  FIST = GLANS (head of the penis)

In the act of circumcision, the foreskin (imagine the entire cuff) is grabbed and excised, leaving the glans to emerge from the incision-spot, to be completely exposed and not covered by the shaft-skin, (or the shirt below the cuff.)

Watch as it emerges.
The tip emerges

It takes a second or two.
Almost completely out

And then we are free and clear!

You didn't really think I was going to cut the cuff of my shirt just for a demonstration, did you?

It is important to note that the fist (GLANS) is free and clear of any skin so that nothing will heal attached to it. Anything attached to the glans makes the bris "unkosher" and needing a repair.

It is important to also know that below the foreskin is a membrane that we aim to remove during the circumcision as well. Sometimes it comes off during the circumcision, sometimes it needs to be torn and folded back, and sometimes it needs to be excised afterwards - using hemostat and scissors.

One of the things I do is use a marker to help guide the incision so that the skin that should remain on the shaft remains, and we avoid having a significant amount of extra skin removed.

In other words - this should be avoided:

We want the glans to be revealed, but we don't need to reveal the lower layer of the shaft..

Now that I've given away my secret, what will I do for fun in explaining this stuff? Maybe not everyone will read this blog post. There is hope!

Thursday, July 21, 2016

Twins - With A Twist

Yesterday I did a bris (double bris, really) for twins. Their parents have been married for 8 years (I think) and have gone public about their infertility and the herculean efforts they went through to get to this stage.

The story is explained in the video that is included here. Suffice it to say, they made the video to inspire others to see that miracles can happen in this day and age, and that having friends and family who love you can make all the difference.

And the brisses for the boys serve as a testament to the direction they're headed in the raising of THEIR SONS.

Here is how it went down on Facebook.



Wednesday, June 29, 2016

Topical Analgesics



I am not recommending this product. The picture is here to make this blog post more exciting
For those who want to numb the foreskin prior to the procedure, I recommend you speak with your pediatrician about what options there are, and getting a prescription for a topical analgesic.

Easily the most popular namebrand topical analgesic on the market today is EMLA cream.
Image result for EMLA cream
This is EMLA cream - probably the 5% stuff recommended in the 2nd article linked below

There are studies about other topicals used for circumcision. Of course, understand that all of these studies are done in hospitals where the circumcision procedure is typically considerably longer than a traditional bris. In these case-studies, the baby is "under the knife" or the circumcision instruments and implements for much longer.

The following options are for those who have a compounder nearby - or if your doctor has a prescription idea that sounds like something described below.

The first article I became aware of - saying a 30% lidocaine (with 70% acid-mantle base cream) if efficacious and does not have significant absorption of lidocaine in the body:  http://www.ncbi.nlm.nih.gov/pubmed/8414860

The second article notes the previous one, but suggests that a 5% lidocaine-prilocaine cream is even better: http://www.ncbi.nlm.nih.gov/pubmed/10912985

See also this: https://www.uspharmacist.com/article/drug-therapy-considerations-in-circumcision
This one raises other options which include injections. Injections might be the most effective, but remember that no child likes shots, especially not in his penis, and that shots hurt when administered, and have the possibility of hurting later as well.

For those who want something to numb the area, I recommend topical creams as described above. The cream needs to be put on for at least 20 minutes before the procedure (though the longer it is on the more effective it is), and wrapped in place with a piece of plastic-wrap so it doesn't rub off in the diaper.

For those who opt not to do this, your baby, like millions before him through the generations, will be fine.