MORBIDITY &
MORTALITY
RAHIL “The Man Who Doesn’t Need To
Shave To Look Good” SHAIKH, MD
Northeast Iowa Family Medicine
July 23rd, 2014
Sponsors
Chief Complaint
1 day old M with unwanted foreskin.
HPI
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
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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)
PMH, PSH, FH, SH
• Nothing significant
Review Of Systems

Goal in life was to urinate on Dr. Shaikh
multiple times
Medications/Allergies

None

NKA
Physical Examination

Completely normal, healthy baby boy
Assessment & Plan
1) Routine newborn cares
2) Bottle feed
3) Circumcision
Timeline Of Events
DATE
CLINICAL STATUS
04/29
Birth at 20:48
Fed well, urinated, passed stool, VSS
04/30
Circumcision performed at lunch hour, preparations began ~ 12:30
Circumcision note signed at 14:15
Called in ~ 15:00 for bleeding circumcision site to the L of the ventral
frenulum that was refractory to Surgicel
Tried multiple variations of Surgicel and Surgifoam but bleeding
wouldn’t stop
Attending evaluated and used silver nitrate and then aluminum
nitrate with temporary relief ~ 16:00
After family was with baby again, bleeding resumed
Resident used Surgicel and Surgifoam technique assisted by
Neonatologist to stop bleeding; baby was monitored by resident for 1
hour and hemostasis was once again temporarily achieved
Called in ~ 19:00 for bleeding from same site refractory to multiple
Surgicels
Decision was made to re-do Surgicel/Surgifoam application and
leave baby in warmer without diaper to have hemostasis achieved
and maintained
Timeline Of Events
DATE
CLINICAL STATUS
05/01
Checked in on baby ~ 05:30 and hemostasis had been achieved,
same application of Surgicel that had been applied since the
previous night was not soaked through with blood
Discharged baby ~ 13:00 in great condition (no problems with
urinating, feeding or vital signs)
05/02
Followed up in office, doing well, remnants of aluminum nitrate
(black) still present but otherwise baby was in solid shape
Did I do this?
Was there something
wrong with the way I
performed the
circumcision?
Was it too early as
well?
Review Of Pertinent
Literature

World Health Organization: Manual For
Early Infant Male Circumcision Under
Local Anaesthesia, 2011
Review Of Pertinent
Literature
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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
Review Of Pertinent
Literature

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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
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
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
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
Adverse Events &
Outcomes
CASE
YES
Unexpected death
Medical or surgical complication
NO
X
X
Delay in care
X
Delay in diagnosis
X
Prolonged medical care in setting of poor prognosis
X
Other
X
Factors Contributing
To Adverse Outcome
FACTOR
YES
NO
Communication: ex. inadequate handoffs, incomplete
clinical information
X
Coordination of care: ex. involving multiple servies and/or
care sites
X
Volume of activity/workload: ex. increased clinical volume
and/or perception of workload
X
Escalation of care: ex. delay or failure to involve more
senior physician or nurse
X
Recognition of change in clinical status: ex. delay or
failure to recognize changing clinical signs +/- symptoms
X
Other: surgical technique
X
Root Cause Analysis:
Fishbone Diagram
Resident
Circumcision
Gomco vs. Plastibell
Root Cause Analysis:
Fishbone Diagram
Improved technique
Practice makes
better
Either method can create
complications
No death
Comments &
Discussion