Saturday, January 1, 2011

What Can Go Wrong At A Bris?

Aside from the cream cheese being moldy, and the family rabbi not being prepared to speak...

REPAIRABLE

If a mohel has, minimally, a decent reputation, he will not likely do anything during the bris that will cause permanent damage. Obviously the foreskin will be removed, but depending on what else comes off with the foreskin, even a foreskin has a possibility of regenerating.

Here are a few samples of things that can "go wrong," that are entirely fixable/correctable within a few minutes of the bris:
1. Not enough foreskin removed (talk about undercutting the competition!)
2. Excessive membrane (or ha'priah) remains, either on account of not having been touched, having been partially removed (but not completely), or on account of it looking aesthetically unpleasing
3. the glans is slightly twisted in how it sits back in the shaft, misalligned from post-bris bandaging (or natural state).

Just like after a bad haircut one can always take off more hair, if not enough skin is removed (which can happen), or not enough of the or ha'priah is removed, it is always possible to fix. And if a mohel notices or realizes it either during the bris or upon checking the baby right after the bris, the best time to take care of it is that moment.

Like everyone else, mohels are human, and are therefore not perfect. Most brisses go well (or even 'perfectly') in the first attempt. But in the event that either the baby has an anatomical issue which was undetected before the bris (redundant foreskin or membrane), or the mohel did not remove exactly what he intended or hoped to remove, this is easily reconciled.

It is not pleasant to hear, and even more difficult to understand. But remember that while expert surgeons have all the time in the world, in a closed room, with no one crying, to check and double check and go over the same things to make sure everything is perfect, a mohel has very different circumstances in which he operates.

This is not to say the mohel is unprepared for his work environment. But anything can happen. Someone can bump into the mohel, the sandak (who holds the baby during the bris) can slip, the baby might move. If the surgeon doing a circumcision does not take enough skin off, no worries. He'll just go back and do what he needs to. No harm done. Nobody is the wiser. Noone saw the process. All everyone sees are results.

A mohel has a different job. Ideally all will go well the first time, with no need for "touch-ups." But if there is a need for a "touch-up," would it not be best to take care of it while the wound is fresh so the baby need only experience the surgery in one window of opportunity?

Of course it is. And this is something parents must understand. And this is something mohels need to make clear to parents. And, most importantly, need to make clear to themselves.

I'll return to this point at the end.

NOT REPAIRABLE

I've already addressed in other posts how to avoid doing damage to a baby.
1. If the child is born with an anatomical abnormality that requires a reconstructive surgery, a mohel should not be touching the child. His long term use of his manhood is a lot more important than the mohel's ego, your child's having a bris "on time," and certainly the mohel's remuneration.
2. If too much foreskin is removed, what we call "a completely denuding of the shaft" case leaves the baby with (arguably) a very clean circumcision, but many lost nerve endings, plus a penis that will have one long scar, instead of a shaft that is supposed to have a small circumcision scar near the edge of the corona.
3. Any damage to the glans, which is most common in circumcisions done with certain clamps (though mostly by unskilled operators or careless operators) or when the circumcision is done freehand - e.g. without the use of a shield. [In some cases this can be surgically repaired, but the stories are never pretty]
4. If the mohel does anything that lands your child in a hospital, even if your child does get better, this becomes an emotionally taxing experience you need not have - and the emotionally negative experience is irreparable.

MOHEL NEEDS TO BE UP FRONT - ESPECIALLY WITH HIMSELF

It takes a big man to be able to say "I made a mistake." An even bigger man learns from his mistakes, and tries very hard never to repeat them.

A mohel must remember that he is being given a tremendous responsibility - some will call it a real "z'chut" (merit) - to introduce a Jewish baby boy into the bearing of the mark of the covenant.

The ceremony is important, the people are important, and the bris is important. But the baby is most important, and the mohel is not important. The bris must be done right, the end result must have a baby with an as-near-to-perfect circumcision as possible. The baby must be in as good health after the circumcision as he was before. He must not be bleeding. He must be bandaged properly, such that when the bandage comes off, the circumcision needs no more attention (beyond minimal preventative ointments).

Swallow the ego, talk to the parents, remind them that your job is to return to them a baby with the kind of circumcision the parents asked for. Hopefully the baby does not need a repair. But if he does need things to be adjusted or corrected, it better be you, mohel who is doing it now to make things perfect in a way that will never require a relook, as opposed to a surgeon who is correcting your problems because you were too chicken to do anything about it when you could have.

The pediatric surgeon in New York who told me he had done touch up work for every mohel in New York was not kidding. He could make such a claim because no mohel is perfect. But if the mohel would also drop his pride and ego and fix up any problems right away, it would save the child a lot of pain and discomfort along the way - such as general anasthesia and a re-circumcision at age three or even older.

As an imperfect human being who happens to be a mohel, every now and then not enough of the membrane is removed during the bris, which would leave an unsightly puffy ring of skin below and even alongside the glans (sometimes covering the glans once healed) were I to leave it alone and not remove it right away. [And I thank God every day this is the "worst" of any "problems" that arise] 


I have learned to swallow the pride and to take care of the issue right away: 
Some parents appreciate the honesty and appreciate that, in the end, their baby will never have any issue. 
Others are disappointed that not everything happens at the bris itself. But they get over it once I am finished and they are once again holding their baby. 
Some choose not to stay in the room.
Some don't even remember any 'immediate follow up' 
Some choose to stay in the room to try to calm the baby. 
Others have it affect them, others think bad things about their mohel
And I am sure others will not call the mohel again, even though the baby is fine afterwards and has a beautiful circumcision.

My hope is that, in the end, everyone is satisfied with the results. In the here-and-now of a bris, a half hour period that carries a whirlwind of emotions, it is hard for some parents to recognize the necessity of quick decisions and actions that a mohel must make, to respond to whatever surprises or minor necessary touch-ups come their way.

The parents hire a mohel, and put their trust in him, to give the baby a kosher bris, hopefully with minimal pain to the baby, but certainly with the expectations of positive results, a baby who has a nice circumcision, who is not bleeding, who is bandaged properly, and who is resting peacefully already on the road of recovery.

I do believe that the few extra minutes at this time, when necessary, far outweigh any long-term questions or "what-ifs" or "should we have a corrective surgery?" that may come up down the road.

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