MORBIDITY & MORTALITY

1. MORBIDITY & MORTALITY • RAHIL“The Man Who Doesn’t Need To Shave To Look Good” SHAIKH, MD Northeast Iowa Family Medicine July 23rd, 2014

2. Sponsors

3. Chief Complaint 1 day old M with unwanted foreskin.

4. HPI • Born to a 30 year old G3, now P3 mother via induced vaginal delivery (for post dates) at 40 1/7 weeks of gestation • Mother’s prenatal Hx complicated by mild tobacco abuse but otherwise nothing else pertinent • Baby was born on Tuesday April 29th, 2014 at 20:48 via NSVD with Apgars of 8 and 9, 3860 g (AGA)

5. PMH, PSH, FH, SH • Nothing significant

6. Review Of Systems • Goal in life was to urinate on Dr. Shaikh multiple times

7. Medications/Allergies • None • NKA

8. Physical Examination • Completely normal, healthy baby boy

9. Assessment & Plan • Routine newborn cares • Bottle feed • Circumcision

10. Timeline Of Events

11. Timeline Of Events

13. Did I do this?

14. Was there something wrong with the way I performed the circumcision?Was it too early as well?

15. Review Of Pertinent Literature • World Health Organization: Manual For Early Infant Male Circumcision Under Local Anaesthesia, 2011

16. Review Of Pertinent Literature • In healthy, term, stable male newborns, circumcisions can be performed anywhere between 12-24 hours after birth, as long as the baby has voided • WHO and AAFP have the same stance • I waited 16 hours after birth to perform the circumcision • 12-24 hours does not apply to SGA babies, babies whose penile shaft length is < 1 cm, preterm babies, or those with a medical contraindication

17. Review Of Pertinent Literature • Removal of glandular adhesions should be done carefully, with frenulum on the ventral surface to be avoided • Up and down motion with straight hemostat prevents frenulum damage • I performed more side to side motions

18. Review Of Pertinent Literature • Gomco size 1.3 was accurate, no mismatch between bell and baseplate • Risk of bleeding? 1.0% (similar to Plastibell and Mogen techniques) • Most risk related to mismatching device parts

19. Review Of Pertinent Literature • After stem of the bell and foreskin are maneuvered through the hole in the baseplate, but before the device is clamped and tightened, the amount of penile shaft that remains below the clamp must be symmetrical and not stretched too tightly • This crucial step was likely misjudged because there was too much foreskin taken off from the ventral surface

20. Conclusions • When performing a circumcision, be careful around the frenulum and always check below the clamp! • If bleeding complication occurs, use Surgicel/Surgifoam, aluminum/silver nitrate, and worst case scenario, a suture (but obviously get help from Pediatrics/Neonatology unless you’ve done it before!); consider bleeding disorders for resistant cases

21. Adverse Events & Outcomes

22. Factors Contributing To Adverse Outcome

23. Root Cause Analysis: Fishbone Diagram Resident Circumcision Gomco vs. Plastibell

24. Root Cause Analysis: Fishbone Diagram Improved technique Practice makes better Either method can create complications No death

25. Comments & Discussion