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

Jan 14, 2016

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MORBIDITY & MORTALITY. RAHIL “The Man Who Doesn’t Need To Shave To Look Good” SHAIKH , MD Northeast Iowa Family Medicine July 23 rd , 2014. Sponsors. Chief Complaint. 1 day old M with unwanted foreskin. HPI. - PowerPoint PPT Presentation
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Page 1: MORBIDITY & MORTALITY

MORBIDITY & MORTALITY

RAHIL “The Man Who Doesn’t Need To Shave To Look Good” SHAIKH, MD

Northeast Iowa Family Medicine

July 23rd, 2014

Page 2: MORBIDITY & MORTALITY

Sponsors

Page 3: MORBIDITY & MORTALITY

Chief Complaint

1 day old M with unwanted foreskin.

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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)

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PMH, PSH, FH, SH

• Nothing significant

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Review Of Systems

Goal in life was to urinate on Dr. Shaikh multiple times

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Medications/Allergies

None NKA

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Physical Examination

Completely normal, healthy baby boy

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Assessment & Plan

1) Routine newborn cares

2) Bottle feed

3) Circumcision

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Timeline Of EventsDATE CLINICAL STATUS

04/29 Birth at 20:48Fed well, urinated, passed stool, VSS

04/30 Circumcision performed at lunch hour, preparations began ~ 12:30Circumcision note signed at 14:15Called in ~ 15:00 for bleeding circumcision site to the L of the ventral frenulum that was refractory to SurgicelTried multiple variations of Surgicel and Surgifoam but bleeding wouldn’t stopAttending evaluated and used silver nitrate and then aluminum nitrate with temporary relief ~ 16:00After family was with baby again, bleeding resumedResident 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 achievedCalled in ~ 19:00 for bleeding from same site refractory to multiple SurgicelsDecision was made to re-do Surgicel/Surgifoam application and leave baby in warmer without diaper to have hemostasis achieved and maintained

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Timeline Of EventsDATE 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 bloodDischarged 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

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Page 13: MORBIDITY & MORTALITY

Did I do this?

Page 14: MORBIDITY & MORTALITY

Was there something wrong with the way I

performed the circumcision?

Was it too early as well?

Page 15: MORBIDITY & MORTALITY

Review Of Pertinent Literature

World Health Organization: Manual For Early Infant Male Circumcision Under Local Anaesthesia, 2011

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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

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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

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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

Page 19: MORBIDITY & MORTALITY

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

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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

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Adverse Events & Outcomes

CASE YES NO

Unexpected death X

Medical or surgical complication X

Delay in care X

Delay in diagnosis X

Prolonged medical care in setting of poor prognosis X

Other X

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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

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Root Cause Analysis: Fishbone Diagram

Resident Gomco vs. PlastibellCircumcision

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Root Cause Analysis: Fishbone Diagram

Improved technique Either method can createcomplications

No death

Practice makes better

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Comments & Discussion