Saturday, November 5, 2011
Post Op Bleeding - The Myth of the Bleeding Vein
When done properly (and barring extremely rare circumstances), a mohel should never be faced with a situation in which he requires medical intervention to help stop bleeding post-op.
Between the various coagulating bandages which are available, and the never-fail "if you put enough pressure on it it will stop bleeding" method, with a little time and patience, bleeding can be put under control.
I have been blessed that I have not had to make such a call in my career. I did have one case about six years ago when my following textbook procedures did not seem to work. We called a doctor, and he offered to take care of it if I couldn't get things under control. With my next effort, however, the bleeding stopped. Thank God.
It is important to me (for obvious reasons) that the baby not be bleeding when he is turned over to his parents after the bris. This is why I always check and change the bandage immediately after the bris, so I can give the baby the proper attention. For better or worse, the bris takes a very small amount of time. Some babies clot very quickly and my bandage-change takes 2 minutes. With some babies it takes a little longer. A Five-Minute-Pressure-Application usually does the trick on more seemingly-difficult cases. [It's never pleasant for a mom to be in the room, unless she is totally calm and collected, during this time. Some choose to stay in, some choose to stay outside. But the baby is usually crying during this time (unless someone is putting a pacifier in his mouth), until I let go and close up his diaper.]
Because I put so much care into this, and know that some babies bleed more and some bleed less, and also that much of the aftereffects are heavily influenced by the bandaging, the amount of time doesn't affect me. Of course I would love for all babies to be a "chick-chock" case with no extra time. But we are all human and imperfect, so we do our best.
Which leads to the myth. I have had some fathers call me after their son's bris, clearly concerned that something went wrong. These always happen when I did not do the bris, which I would venture to suggest is the reason they are calling me instead of the mohel they used. In some cases the father himself did the bris (which I offer as an option to fathers, but most decline), and in some cases the mohel did the whole thing.
Note: when "the father does the bris" it is set up for him by the mohel, leaving him with the relatively simple task of excising the foreskin by cutting along a metal plate (see the photo in method #2).
Also Note: The first time anyone does a circumcision, there might be a feeling of "how did I just do what I did?" which accompanies a feeling of "I ruined this child for life." Which isn't true, but it might feel that way.
So the father says to me, "It took a lot of time for the mohel to stop the bleeding. He said I cut a vein."
Well, let's see. There are veins in that section of anatomy. When otherwise healthy skin tissue is excised, it stands to reason a vein will be cut. But not a major vein, whose repercussions could be quite disastrous. Unless, when the mohel in question set things up, he set up a circumstance, where the father (who does not know otherwise) removed too much skin from the shaft!
The way I see it, there are two possibilities:
1. The mohel set things up improperly and did not guide the father properly in the act of the circumcision excision.
2. The mohel had a difficulty with the bandaging (possibly related to previous point, though not necessarily), and felt the best way to explain his challenges was to blame the father for the mohel's mistake.
The bottom line is this:
Problems arise when too much shaft skin is removed (the original shaft skin should be as close to the corona of the glans as possible - give or take a couple of millimeters). Bleeding challenges can arise in any circumstance. It is the skilled mohel who knows to remove the proper amount of foreskin, and who can then get the bleeding under control - sometimes in very little time, and sometimes with a little more time and patience. I have seen what look like open "bigger veins" in a freshly circumcised penis, but with pressure (like with the rest of it), the bleeding stops. I do believe God would not have given us this commandment, to be done in this manner, if complications would arise on a regular basis. A mohel should own up to his own inadequacies (if he has them) and should not fault a vein, a father, or anything other than himself if not everything goes smoothly.