I am not in the habit of telling bad stories about myself.
You must read this entry until the end to understand the title and why this merited a blog post.
Ask any mohel this question: What was your worst bris experience?
Some will talk about a family that may have been pushy or impatient
Some will talk about a hostile environment
Some will talk about a less than perfect circumcision
Some might even mention how once "a long time ago" a baby needed to go to the hospital to get stitches.
Truth is, those who have experienced the latter case, will probably not be willing to admit it.
I thank God every day that I have never had a baby who required any medical care beyond that which I provide for him.
But, were you to ask me the question, I would tell you about the time (6 years ago) the baby, a first boy in a wonderfully special family circumstance (can't give away more details... to protect the innocent), wouldn't clot after the bris. Back in his home, I literally bandaged and rebandaged him 8 or 9 times, to no avail.
Of course, he was crying the whole time. And while he was never in danger - he did not lose a significant amount of blood, because when I put pressure (without a bandage wrapped around), the bleeding is under control - things just did not seem right.
Meanwhile, the baby's parents and grandparents (who were also present) were giving me funny looks:
Is this normal? (No it isn't)
Why is it taking so long? (I don't know)
Is this your first bris? (no. I have done this hundreds of times)
Should we call a doctor? (If you feel it necessary, call the doctor).
I told them, "I am doing everything I normally do. I am using the bandages that promote hemostasis. I am wrapping them correctly. I am putting ample pressure, for more than the necessary length of time."
Then I spoke with the doctor, who had been briefed by the family. He told me, "How bad is it? If you think I need to suture him up, bring him over and I'll take care of it."
I said, "I don't think it's bad. The bris was done properly. He just isn't clotting. Here's what I'll do: I'll try it one more time, and if it doesn't work, we'll bring him to you."
"OK."
I tried it one more time, accompanying the effort with a sincere and heartfelt prayer, and the next bandaging did the trick. No medical intervention required.
So why do I tell this story? Because over the weekend I happened to see the mother from this story - and when she saw me she said "OMG. You did his bris. I'll bet you remember it."
Yes. I remember it very clearly.
"You should know," she said, "a little while after the bris we had him tested. He does have a minor clotting problem."
Ba-bum-ching!
I am sure I asked in those days if there was any history of hemophilia. I must have been told "No." Armed with the information I had, we proceeded with the bris in the proper time.
For me, this is a story that has waited a long time to come full circle. I am grateful for the vindication.
Showing posts with label bleeding. Show all posts
Showing posts with label bleeding. Show all posts
Saturday, January 28, 2012
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.
Tuesday, December 15, 2009
Methods of Circumcision
Most parents looking to have their son circumcised just want it to be done as efficiently as possible, as speedily as possible, with minimal pain to the baby.
Of course they'd prefer the circumcision be aesthetically pleasing, and that the circumcision heals sooner than later with no complications.
When doing research about ANY mohel, the end results are important. (I've written elsewhere about the demeanor and the ceremony and the need for things to be done at your speed.) And most people leave the method to achieving those end results up to the mohel, and how he feels most comfortable getting there.
However, there is not "only" one way to circumcise. And if it is important to you, it is important to ask about methods, and to inquire if the mohel can accomodate your desires.
Please note that I use Method #2 presented below and as described at the end of this post.
There are some methods which are questionable according to some (in some cases, many) rabbinic opinions. There are others which are standard - even if the "innovation" in them is "only" hundreds of years old. And there is old-school, bare bones (literally), which is advocated by few.
Sadly, those who advocate the latter method often knock everyone else, even going so far as to declare other circumcisions "unkosher" and requiring hatafat dam brit - a ceremonial drawing of blood from the circumcision scar that would "kosherize" the bris. This is not only a form of lashon hara and rechilut (talebearing), but is a lie, a form of fear-mongering, and does nothing but increase hatred amongst Jews.
Hmmmmm. That last paragraph was a mouthful. Take a deep breath and let's move on to methods:
INTRODUCTION
Bris Milah has three steps:
1. Milah - the removal of the foreskin
2. Priah - the removal of the membrane that is found between the foreskin and the glans
3. Metzitzah - drawing of "distant" blood
The foreskin is drawn forward and removed. The membrane is often removed with the foreskin. If it is not completely removed, then it is torn and folded back beyond the glans. Finally, blood is drawn from the wound.
In the interest of space, the methods described will not include metzitzah, which will be the subject of different posts.
And I will leave the issue of whether the mohel is wearing gloves up to you, the parents, as well. I've addressed this in a number of posts already. [Search "sterility" in the keywords]
Method #1. Clamp
Of course they'd prefer the circumcision be aesthetically pleasing, and that the circumcision heals sooner than later with no complications.
When doing research about ANY mohel, the end results are important. (I've written elsewhere about the demeanor and the ceremony and the need for things to be done at your speed.) And most people leave the method to achieving those end results up to the mohel, and how he feels most comfortable getting there.
However, there is not "only" one way to circumcise. And if it is important to you, it is important to ask about methods, and to inquire if the mohel can accomodate your desires.
Please note that I use Method #2 presented below and as described at the end of this post.
There are some methods which are questionable according to some (in some cases, many) rabbinic opinions. There are others which are standard - even if the "innovation" in them is "only" hundreds of years old. And there is old-school, bare bones (literally), which is advocated by few.
Sadly, those who advocate the latter method often knock everyone else, even going so far as to declare other circumcisions "unkosher" and requiring hatafat dam brit - a ceremonial drawing of blood from the circumcision scar that would "kosherize" the bris. This is not only a form of lashon hara and rechilut (talebearing), but is a lie, a form of fear-mongering, and does nothing but increase hatred amongst Jews.
Hmmmmm. That last paragraph was a mouthful. Take a deep breath and let's move on to methods:
INTRODUCTION
Bris Milah has three steps:
1. Milah - the removal of the foreskin
2. Priah - the removal of the membrane that is found between the foreskin and the glans
3. Metzitzah - drawing of "distant" blood
The foreskin is drawn forward and removed. The membrane is often removed with the foreskin. If it is not completely removed, then it is torn and folded back beyond the glans. Finally, blood is drawn from the wound.
In the interest of space, the methods described will not include metzitzah, which will be the subject of different posts.
And I will leave the issue of whether the mohel is wearing gloves up to you, the parents, as well. I've addressed this in a number of posts already. [Search "sterility" in the keywords]
Method #1. Clamp
The foreskin and membrane are grasped with a hemostat and a clamp is applied to the foreskin. There are two kinds of clamps that have been utilized by mohels over the last sixty years. The first is the Gomco (on the right in the photo), which is often the method of choice for doctors in hospitals, but is not largely used by mohels. The second is the Mogen or Bronstein clamp (on the left), which is the method of choice for many mohels in the US (though most Orthodox mohels, including me, do NOT use it). The foreskin and membrane are then removed together in one incision, with a scalpel or bris knife.
Method #2. Shield
The foreskin and membrane are grasped either with a hemostat (as in method #1) or skillfully with the fingers. A metal plate with a thin slit is applied to the foreskin, leaving the foreskin resting above the plate, with the glans safely shielded below. A scalpel or bris knife is used to excise the foreskin.
If the membrane is removed along with the foreskin, metzitzah follows.
If the membrane is not completely removed along with the foreskin, it will either be cut with scissors, or the mohel will tear it with his sharpened thumbnails - in both cases to reveal the entire glans.
Method #3. Free hand
Without using any device other than a blade, the mohel will estimate the length of the foreskin, grasp it with the thumb and forefinger of one hand and excise the foreskin with the knife in his other hand.
Membrane removal will follow that of method #2. Metzitzah will follow.
PROS AND CONS OF THE METHODS
Obviously, the "con" of the baby having skin tissue removed and being subject to the pain of circumcision, and any bleeding are a given. If you are having your baby circumcised, it is assumed you understand that this is the down side (if you even view it as a downside) of the spiritual, national and Jewish significance attached to this procedure - which is the fulfillment of a commandment.
The pro: Baby bears the mark of the covenant established between God and Abraham, and all of the Jewish people, which established God as our only God, and we, the Jewish people, as His firstborn, the chosen people who have a mission on this earth to spread monotheism and ethics to as many people as we can.
Pros and Cons of #1 (Clamp)
Benefits include:
* Usually a bloodless circumcision.
* The mohel may not even need to use a bandage.
* If applied correctly, the glans is protected.
Cons:
* Usually a bloodless circumcision. (Blood is an essential element of the bris)
* Estimating the end of the foreskin along the shaft is inexact
* The FDA has issued severe warnings about the use of the clamp, as it could grasp and amputate the glans or the tip of the glans.
* The pain of the crushing of the foreskin is immense
* Once the clamping mechanism is applied, the estimation of the foreskin is irreversible. Even if one were to remove the clamp and then reapply it correctly before excising the skin, the skin tissue that remains would be dead, and would liekly either become the equivalent of a growth or fall off on its own.
* In order to achieve its desired effect, the clamp usually needs to be on for a significant amount of time - from 30 seconds to five or ten minutes. This is significantly longer than the next methods which take 3-4 seconds.
* Rabbinic approval is scant.
While Reform and Conservative mohels will often use this device, Orthodox mohels who use it usually do not have rabbinic dispensation to do so. Many will use it out of their own convenience (in other words, not because they have the baby's best interests in mind) so they need not come back and check the baby. This is not nice - every baby should be checked after the bris. No matter the method used.
Those who use it usually swear by it. I think they feel this way because of the lack of necessity to follow-up. But I may be wrong.
Pros and Cons of #2 (Shield)
Pros:
Quick procedure
* There is blood (necessary component of the bris)
* No chance of anything happening to the glans
* Until the actual incision is made, nothing is irreversible
Cons:
* Estimating the end of the foreskin along the shaft is inexact
* While the foreskin is not crushed, it is squeezed tightly for a few seconds.
The shield is an innovation which dates back at least four hundred years. It's purpose was (and remains) to protect the glans which is at great risk of being cut or amputated when a bris is done by anyone other than an extremely skilled operator. Like in the previous method, once the shield is in place, the actual removal of the foreskin - cutting along the shield, is the easiest part of the job.
Pros and Cons of #3 (Free-hand)
Pros:
* Quickest procedure
* Relatively painless
Cons:
* Estimating the end of the foreskin along the shaft is inexact
* There is no chance to second guess because the mohel never gives himself a chance to double check before excising the foreskin
* The possibility exists that the blade might cut the glans
* If done by anyone other than a skilled operator, the outcomes could be disastrous
The only people who still do brisses this way are some Chassidic Jews. While each person is entitled to have an opinion, those who do it this way are the most outspoken about - and against - any other form of circumcision.
THEREFORE
You may have noticed that the con that reads "Estimating the end of the foreskin along the shaft is inexact" was on every "con list." This is because many mohels were never taught to use a surgical pen to mark the edge of the foreskin before beginning the procedure. If the mohel's initial estimation is marked with a pen or marker, the "con" is removed from each list, as long as the mohel makes sure to cut along the mark.
I wrote about pain in the last few sections of this post. In simple terms, I think it is important to numb the area before the bris, but I think injections are not the way to go about doing it. There are topical methods out there that do just as good a job, and don't cause the baby pain from three "shots."
My Method
In addition to marking the end of the foreskin, I use Method #2 for a host of reasons. While I personally do not agree with methods #1 and #3, I believe that the bris is kosher if the operator is fit to be a mohel. I also think that parents should know what they are getting in to when hiring a mohel, and that the method which best suits your needs should be employed for your son.
When I circumcise, I aim to remove the foreskin and membrane at the same time, to minimize pain to the baby and the need to bother him too much. I always check the baby later, either a few hours after, the evening after, or the day after the bris. I wear gloves. I package all my instruments and bandages and sterilize everything in an autoclave machine - unless it is sterile in its packaging, e.g. gloves and drapes.
I hope this has been helpful to you. As always, feel free to contact me by email with any questions, or call me
* Rabbinic approval is scant.
While Reform and Conservative mohels will often use this device, Orthodox mohels who use it usually do not have rabbinic dispensation to do so. Many will use it out of their own convenience (in other words, not because they have the baby's best interests in mind) so they need not come back and check the baby. This is not nice - every baby should be checked after the bris. No matter the method used.
Those who use it usually swear by it. I think they feel this way because of the lack of necessity to follow-up. But I may be wrong.
Pros and Cons of #2 (Shield)
Pros:
Quick procedure
* There is blood (necessary component of the bris)
* No chance of anything happening to the glans
* Until the actual incision is made, nothing is irreversible
Cons:
* Estimating the end of the foreskin along the shaft is inexact
* While the foreskin is not crushed, it is squeezed tightly for a few seconds.
The shield is an innovation which dates back at least four hundred years. It's purpose was (and remains) to protect the glans which is at great risk of being cut or amputated when a bris is done by anyone other than an extremely skilled operator. Like in the previous method, once the shield is in place, the actual removal of the foreskin - cutting along the shield, is the easiest part of the job.
Pros and Cons of #3 (Free-hand)
Pros:
* Quickest procedure
* Relatively painless
Cons:
* Estimating the end of the foreskin along the shaft is inexact
* There is no chance to second guess because the mohel never gives himself a chance to double check before excising the foreskin
* The possibility exists that the blade might cut the glans
* If done by anyone other than a skilled operator, the outcomes could be disastrous
The only people who still do brisses this way are some Chassidic Jews. While each person is entitled to have an opinion, those who do it this way are the most outspoken about - and against - any other form of circumcision.
THEREFORE
You may have noticed that the con that reads "Estimating the end of the foreskin along the shaft is inexact" was on every "con list." This is because many mohels were never taught to use a surgical pen to mark the edge of the foreskin before beginning the procedure. If the mohel's initial estimation is marked with a pen or marker, the "con" is removed from each list, as long as the mohel makes sure to cut along the mark.
I wrote about pain in the last few sections of this post. In simple terms, I think it is important to numb the area before the bris, but I think injections are not the way to go about doing it. There are topical methods out there that do just as good a job, and don't cause the baby pain from three "shots."
My Method
In addition to marking the end of the foreskin, I use Method #2 for a host of reasons. While I personally do not agree with methods #1 and #3, I believe that the bris is kosher if the operator is fit to be a mohel. I also think that parents should know what they are getting in to when hiring a mohel, and that the method which best suits your needs should be employed for your son.
When I circumcise, I aim to remove the foreskin and membrane at the same time, to minimize pain to the baby and the need to bother him too much. I always check the baby later, either a few hours after, the evening after, or the day after the bris. I wear gloves. I package all my instruments and bandages and sterilize everything in an autoclave machine - unless it is sterile in its packaging, e.g. gloves and drapes.
I hope this has been helpful to you. As always, feel free to contact me by email with any questions, or call me
Monday, October 12, 2009
The Danger of Arrogance
Before you read this, please note: I share this conversation with you not to scare you, but to help you become aware of the possibilities out there, and to know there are ways to avoid many of the problems discussed here. My suggestions appear at the end of this entry, so please make sure to read through to the end.
Over the weekend I had an interesting conversation with a pediatrician friend of mine. Our discussion drifted towards the topic of this blog (circumcision) and he shared with me some horrific stories of circumcisions that came to his attention after the fact, when there was a problem.
Mild Problems
In cases where the baby is a bleeder, or the mohel needs help in containing the bleeding, the baby either needs to be sutured (a couple of stitches), cauterized, or, in some cases, better pressure needs to be applied to seal the wound. In some cases, different products that are often used to help coagulation can also be applied to stop the bleeding, without the need for the stitches or cauterization.
Thank God, I have never needed to send a baby to the hospital: I ask about hemophilia in advance, and I was trained very well in the skill of bandaging.
Different Problems
There is a small margin of difference between removing too little skin and removing too much skin.
Too little
Pros: easily correctable, no long term damage, might not need a correction
Cons: Baby may look uncircumcised for a long time, may need to be corrected, Baby has to go through two procedures (One person told me a story of how his son had a second Bris because the first was considered meaningless.)
Too much
Pros: Baby will definitely look circumcised. There won't be a need for any cosmetic adjustments
Cons: circumcision scar will be enormous. Sex (as an adult) will be a less pleasurable (perhaps more painful) experience.
All in all, these are a matter of debate regarding the pros and cons. Obviously a perfect circumcision every time would be preferred. But as all mohels (like all doctors) are human and are by definition not perfect, the guarantee of perfection would be dishonest. Instead, we do the best we can.
Below, I will explain steps that can be taken to help avoid these problems.
[See this posting about the different methods for how to do a bris]
Bigger Problems
My pediatrician friend described to me examples of children he examined who had been damaged by the mohel. "Damage" does not refer to brisses which are not 100% cosmetically beautiful - those are common enough and are no cause for concern. The penis generally heals nicely and functions normally.
But when the glans is nicked in the process (through the removal of the foreskin, a bris exposes the glans to the edge of the corona), or cut or [shudder] amputated, this is real damage. If an artery that can not be controlled through simple mohel techniques is somehow cut, we have a real problem.
The DANGER of ARROGANCE
Most mohels are trained by expert mohels in Israel or the US. If they follow the instructions of their teachers and do not look for shortcuts to make the process quicker, they can do no damage to the babies on whom they operate.
But if they think they know better, and worse, declare that they are the only ones who know how to circumcise and that others do not do "kosher brisses" because of the methods they employ to protect the baby - this is not only arrogant. It is stupid.
Methods ALL Mohels Should Employ
To reduce the negative possibile outcomes of a bris significantly, there are two steps I highly recommend. Most mohels already do the first in one form or another. Very few do the second. They are:
1. Use a Shield - a device that protects the glans during the incision. Whether one uses a traditional shield, or a clamping device such as the Bronstein/Mogen clamp, if the glans is pushed out of the way when the shield or clamp is applied, it will not be damaged in any way by the circumcision. (There are FDA problems and halakhic (Jewish law) problems with some clamps)
2. Outline the edge of the foreskin with a marker before beginning the procedure - This will reduce the "margin of error" significantly, and will assure a significantly better chance of having a clean and even incision all around.
The Arrogance
If a mohel decides he can do a better job freehand (using just his fingers to hold the foreskin, and a knife to excise, without using a shield to guide his incision and protect the glans - see method 3 here), I maintain that he is a fool and should not be allowed to operate.
To suggest that "God wants it to be done this way" is arrogance of the highest order.
I am not suggesting that I know what God wants any better than someone else. As a Jew who believes in the Torah, I believe God wants us to circumcise our sons, and that there are a few other requirements as to what is supposed to take place during a bris.
But I also believe that we are to take every precaution to assure that the chances of danger to the child beyond the inherent danger of removing skin tissue (the definition of the bris circumcision) be reduced to an absolute minimum.
I repeat (and add):
EVERY mohel should use a device that guards the glans
EVERY mohel should mark the edge of the foreskin before beginning
EVERY mohel should wear sterile gloves
EVERY mohel should maintain a sterile field during the bris
EVERY mohel should not allow any part of his body to come in direct contact with the open wound during or after the bris.
With proper monitoring and education, we can minimize the negative bris stories as we take charge in taking good care of our sons.
Over the weekend I had an interesting conversation with a pediatrician friend of mine. Our discussion drifted towards the topic of this blog (circumcision) and he shared with me some horrific stories of circumcisions that came to his attention after the fact, when there was a problem.
Mild Problems
In cases where the baby is a bleeder, or the mohel needs help in containing the bleeding, the baby either needs to be sutured (a couple of stitches), cauterized, or, in some cases, better pressure needs to be applied to seal the wound. In some cases, different products that are often used to help coagulation can also be applied to stop the bleeding, without the need for the stitches or cauterization.
Thank God, I have never needed to send a baby to the hospital: I ask about hemophilia in advance, and I was trained very well in the skill of bandaging.
Different Problems
There is a small margin of difference between removing too little skin and removing too much skin.
Too little
Pros: easily correctable, no long term damage, might not need a correction
Cons: Baby may look uncircumcised for a long time, may need to be corrected, Baby has to go through two procedures (One person told me a story of how his son had a second Bris because the first was considered meaningless.)
Too much
Pros: Baby will definitely look circumcised. There won't be a need for any cosmetic adjustments
Cons: circumcision scar will be enormous. Sex (as an adult) will be a less pleasurable (perhaps more painful) experience.
All in all, these are a matter of debate regarding the pros and cons. Obviously a perfect circumcision every time would be preferred. But as all mohels (like all doctors) are human and are by definition not perfect, the guarantee of perfection would be dishonest. Instead, we do the best we can.
Below, I will explain steps that can be taken to help avoid these problems.
[See this posting about the different methods for how to do a bris]
Bigger Problems
My pediatrician friend described to me examples of children he examined who had been damaged by the mohel. "Damage" does not refer to brisses which are not 100% cosmetically beautiful - those are common enough and are no cause for concern. The penis generally heals nicely and functions normally.
But when the glans is nicked in the process (through the removal of the foreskin, a bris exposes the glans to the edge of the corona), or cut or [shudder] amputated, this is real damage. If an artery that can not be controlled through simple mohel techniques is somehow cut, we have a real problem.
The DANGER of ARROGANCE
Most mohels are trained by expert mohels in Israel or the US. If they follow the instructions of their teachers and do not look for shortcuts to make the process quicker, they can do no damage to the babies on whom they operate.
But if they think they know better, and worse, declare that they are the only ones who know how to circumcise and that others do not do "kosher brisses" because of the methods they employ to protect the baby - this is not only arrogant. It is stupid.
Methods ALL Mohels Should Employ
To reduce the negative possibile outcomes of a bris significantly, there are two steps I highly recommend. Most mohels already do the first in one form or another. Very few do the second. They are:
1. Use a Shield - a device that protects the glans during the incision. Whether one uses a traditional shield, or a clamping device such as the Bronstein/Mogen clamp, if the glans is pushed out of the way when the shield or clamp is applied, it will not be damaged in any way by the circumcision. (There are FDA problems and halakhic (Jewish law) problems with some clamps)
2. Outline the edge of the foreskin with a marker before beginning the procedure - This will reduce the "margin of error" significantly, and will assure a significantly better chance of having a clean and even incision all around.
The Arrogance
If a mohel decides he can do a better job freehand (using just his fingers to hold the foreskin, and a knife to excise, without using a shield to guide his incision and protect the glans - see method 3 here), I maintain that he is a fool and should not be allowed to operate.
To suggest that "God wants it to be done this way" is arrogance of the highest order.
I am not suggesting that I know what God wants any better than someone else. As a Jew who believes in the Torah, I believe God wants us to circumcise our sons, and that there are a few other requirements as to what is supposed to take place during a bris.
But I also believe that we are to take every precaution to assure that the chances of danger to the child beyond the inherent danger of removing skin tissue (the definition of the bris circumcision) be reduced to an absolute minimum.
I repeat (and add):
EVERY mohel should use a device that guards the glans
EVERY mohel should mark the edge of the foreskin before beginning
EVERY mohel should wear sterile gloves
EVERY mohel should maintain a sterile field during the bris
EVERY mohel should not allow any part of his body to come in direct contact with the open wound during or after the bris.
With proper monitoring and education, we can minimize the negative bris stories as we take charge in taking good care of our sons.
Wednesday, September 9, 2009
Cleanliness and Efficiency
If you were to ask me what are the top criteria I think anyone should seek in any mohel, I would say to check two things: his cleanliness and his efficiency.
Each of these has different components, and I will try to be brief:
Cleanliness
Cleanliness includes:
* The way he presents himself. If he looks polished, he is polished. If he looks like a slob, he probably is a slob.
* Maintaining a sterile field. It is very hard to maintain an absolutely sterile field in the public setting of a bris, but it is possible to do your best. Sterile drapes, gloves, bandages, and packaged instruments sterilized in an autoclave machine should all be standard.
* He should use a wastebasket for any packages, paper towels, diapers or used gauze pads he uses, to eliminate any mess which might turn people off.
* While there will be bleeding at a bris, he should keep it to a confined area, and be able to minimize any bleeding from straying beyond the immediate bris area
This leads into our second component...
Efficiency
* He should come on time and set his instruments in place in time for the designated hour.
* Everything he needs (diapers, wipes, receiving blankets, gauze, wine, kiddush cup, etc.) should be set up before the ceremony begins.
* The actual circumcision should take a minimal amount of time.
* Bandaging the baby should be a quick ordeal.
* Unless he has been asked to speak by the parents (often to explain the ceremony), he need not speak except: to "M.C." (if there is no other), to give the father and sandak quiet instructions, and to tell the father when he is to appoint the mohel his "shaliach" - messenger - to perform the mitzvah on his behalf.
Each of these has different components, and I will try to be brief:
Cleanliness
Cleanliness includes:
* The way he presents himself. If he looks polished, he is polished. If he looks like a slob, he probably is a slob.
* Maintaining a sterile field. It is very hard to maintain an absolutely sterile field in the public setting of a bris, but it is possible to do your best. Sterile drapes, gloves, bandages, and packaged instruments sterilized in an autoclave machine should all be standard.
* He should use a wastebasket for any packages, paper towels, diapers or used gauze pads he uses, to eliminate any mess which might turn people off.
* While there will be bleeding at a bris, he should keep it to a confined area, and be able to minimize any bleeding from straying beyond the immediate bris area
This leads into our second component...
Efficiency
* He should come on time and set his instruments in place in time for the designated hour.
* Everything he needs (diapers, wipes, receiving blankets, gauze, wine, kiddush cup, etc.) should be set up before the ceremony begins.
* The actual circumcision should take a minimal amount of time.
* Bandaging the baby should be a quick ordeal.
* Unless he has been asked to speak by the parents (often to explain the ceremony), he need not speak except: to "M.C." (if there is no other), to give the father and sandak quiet instructions, and to tell the father when he is to appoint the mohel his "shaliach" - messenger - to perform the mitzvah on his behalf.
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