Circumcision again ~

Well... up to today, I've been through 3 times of circumcision events whereby my very first exposure was during my early 2nd semester (Block 1.4). My tutor who is an urologist was involved in a mass circumcision at Klaten (if not mistaken). I still remember vividly that on that particular day, after my tutorial session, he asked if anyone of us were interested in following him to a circumcision event. Of course, all of us were very excited and raised up our hands almost instantly. I can still recall that, I was so anxious as I did not bring along my lab coat on that day which was deemed to be necessary (which ended up not being used at all!). I was lucky that Wen Mei did have her friend lab coat with her and willing to borrow me, at that particular time... I would not have forgive myself if I were to miss this opportunity simply because of that !! Anyway, that very first experience of mine being into the field was not very interesting after all as my task over there was just washing the used instruments and being the operator's nurse. I was not given any chance to be the first assistant as anyone else, except Laili, as a CO-ASS's assistant, right before we left the site. (She was the only one who stayed and helped out the operator among us)


The second one was held by BEM (Badan Eksekutif Mahasiswa) of UGM at Graha Sabha Pramana. We were required to register with a payment of Rp 15k, to BEM, and were promised to be assigned as first assistant on that particular day (22th of November 2009). Special lecture on circumcision (12th of November 2009) and selection (15th of November 2009) were being conducted prior to the event, so-called to prepare us for the day. I must say that their management was real sucks as first, they demand to have another day for briefing, even after the suggestion from doctors in-charge to settle it on that day itself (we were told to attend a meeting with the doctors and will be brief on the flow of the event, which turn out to be a chit-chat forum, as things discussed were who to prepare the drugs and wound management, how to set up the room, which obviously, none of our business, but the BEM!!), second, the so-called briefing which was "postponed" from the first meeting, on purpose (for their preparation) was delayed by 1 hour !! That's not the worst part as even with the postponed and delayed, we were still not being assigned to which table that we should perform the operation on !! And, we don't even know how the flow will be like, despite the fact that, the day after that was the circumcision day !! You call this management ??!!! All that we got to know from that time-wasting briefing was the outfit for the day. Oh god, what a great briefing !! Well, guess what ??!!! That was still not the worst part as when the day finally came, which is 20th of November, we, who were told and assured that WILL BE FIRST ASSISTANTS turn out to be.... OBSERVERS !! What the.... and, some of my friends who passed the selection were not having their names on the bed numbers !! This is what you get from BEM, a body that has full control over all the faculty activities and as chief of the student committee? No wonder this faculty never did anything great nor show improvements.


Well, as that was my 2nd time as an observer, I was very focus and concentrating on how they perform the circumcision. To my surprise, the operation room was full of yelling and crying which I barely remember that I had experienced that during my first exposure. As far as I could remember, the cries only came from injection (of anesthetic). I supposed that they were not competent in injecting the lidocaine after all, and tend to ignore the pain suffered by those pitiful children. Furthermore, operation which should takes approximately 15~20mins was prolonged to 30~45mins !! The effect of anesthetic will subside okay, my fellow doctors and CO-ASSes !! Please either speed up or give another dose of lidocaine to reduce the pain suffered okay? They do not deserve all these !! What got on my nerve was that, some "empathy-less + heartless" doctors even played with the wound and saying that it was not painful at all but the children were panic and could not differentiate tactile and pain (lidocaine will cause painless but will not remove the tactile sensation. Hey, docs, it was very obvious that it was an unbearable pain, instead of sense of touch okay? The child never cried even during injection and half way of incision. Furthermore, the body language shown was clearly indicating that he was under intense PAIN !! Why would he do so when he can actually stand the pain of injection and show no sign of pain at all during incision? Think again, OKAY??!!! I guess this 2nd exposure of mine was merely to demonstrate what should not be done and why should one speed up, as fast as he/she can (of course, with safety precaution and consideration) during the procedure.


The third one, which is the most recent one, happened on the 27th of December 2009, held by MER-C, was the most successful and yet fruitful + meaningful one, though this is also the most expensive one :p costing me Rp 400k for the whole process, which were minor surgery & circumcision lecture plus with selection on the day itself (13th of December 2009), circumcision event (27th of December 2009) and lastly, control of circumcision candidates (30th of December 2009) where we remove the bandage applied, inspect for possible infections, management of infections, if any and, education for further wound care. Well... this is my very first time become an assistance cum operator, and as well my very first time feeling so depressed and had made myself looked real terrible......


For this and only for this event, let's go abit detail on it as it really means alot to me and I would not have forget what happened throughout this event. On the 13th of December, a lecture on minor surgery and circumcision was conducted at Radiopoetro building, 1st floor lecture hall. We were provided with a CD (contain video of circumcision and lecture slides) and a booklet about minor surgery and circumcision. I find it particularly useful as those materials contain lots of information which were not taught during Skills Lab and previous circumcision lecture (held by BEM). In addition, the lecture and practical session were both conducted by urology residents or urologist, instead of general practitioner as in the previous one. They are, of more skillful and knowledgeable than a GP, of course. Lecture, was not much a difference than the usual one, BUT, the practical session was a total fruitful one. Perhaps it might be due to the fact that I have yet to attend a minor surgery and circumcision Skills Lab sessions, on that particular time, I found it exceptionally fruitful and yet meaningful. I was under the instruction of Dr Akhmad, who is a urology resident, during that practical session. Well, I guess I was too confident towards myself and had been overestimated my ability on circumcision, I tend to focus on minor surgery which will not be assessed for selection. I had not been practicing it, for even once on a manikin, for my entire life (on that particular time), before being assessed by my instructor. Yup, I can say that I was the only one who able to master all of the minor surgery skills taught, but also at the same time, screwed myself up in circumcision skills, unaware. I have totally forgotten that 'doing it' is totally different with 'seeing it'. I was not able to perform simulated circumcision in proper manner and within the time frame. I was so tense by that particular moment and the feeling just gone worse when hearing that they will only select the best 10 candidates for the up-coming event as a result of lacking candidates to be circumcised. Wow... I'm really screwed !!


However, to my surprise, I received a message from Syifa, committee member of the event, on date 22nd of December, stating that I've been selected as the best 10 out of around 50 candidates. Honestly, I was like, how should I describe it? The feeling was something like winning a lottery. For me, that was an event that I would never wanna miss, and yet, I have succeed !! I could never imagined what would I feel if were to told that I've failed, though they did promise that for those who did not manage to join the event will be prioritize in the coming event. I was so so so lucky !! But yet, I did not perform well during the event. This fact really killing me, even until today. The feeling of depressed still remains deep within me...


On that day, 27th of December, we gathered at the headquarter of MER-C, waiting for departure, early at 7am. The journey took around an hour to reach an house estate, where we could see lots of kids waiting just in front of a mosque (our operation room), with the company of their parents, facilitators and... Spongebob and Minnie !! Cool~ After settled down, we got our hands washed and be prepared for the operation. I was the first assistant to a doctor who performed the first operation, as a live demonstration. Then, it followed by me, being the next operator. I swear that I was paying full, 100% concentration when being the assistant, but somehow, I failed to do the anesthesia. I had directly caused the kid to have suffered from unnecessary infiltration method of injection (as my blocking method failed). Furthermore, such a failure had also caused the lost of opportunity of my groupmates to perform anesthetic for following candidates. It was then follow by yet, another mistake where I had mistakenly cut the prepuce too laterally !! Second chance were given but yet I still can do such a silly mistake !! Well... it's time for the doctor to take over and I'm, again, becoming his first assistant. What the heck was I've been doing?


It was over and over again, I've been seizing the chance to have hands-on experience again, by being others' first assistant, hoping that one of them would give me a chance to hold the scissor or even... the needle. But, none of them were to give me such a chance, except the last girl, my senior of Inter Program. That was also due that I've been asking for a chance to sew the wound (anyway, the girl was really a nice person as she was wondering when will it be my turn to be operator as she aware that I've not been operating at all. She might have lost her chance to be operator if I were to be the operator when she was actually asking if I wanna take over the kid, not knowing that that kid was the last one). Well, I can't blame anyone, can I? It was my fault to have made so many mistakes and even though this have not been happened, I don't think I will give others to take over my role as an operator simply like that. This is a chance that not many people would have possessed !! BUT, even that, I still could make another mistake by cutting off the thread at the frenulum part mistakenly !! I was told to finish up the left part of the penis, both excision and closing the wound, AND BEWARE OF CUTTING THE THREAD at frenulum. I'm really a total failure !! I guess the doctor must be really tense and disappointed for what I've done, after being given so many chances. Anyway, just to share the feeling of cutting and sewing a real human skin, it was alot harder than I thought, much harder than a manikin. The mucosa was real thin and can be easily pass through by the needle, but not the skin. Perhaps this is of individual and it happens that I was cutting a hard one. Who knows? Except one has been excising skin for few times :p Whew... I guess I was really lucky enough to be under the supervision of those 2 instructors. I guess I did not mention that out of 10 of us, 8 of us were of under Dr Akhmad, and the instructor who supervise us during the event was the only one who gave the opportunity to all 4 of us to perform all the procedure (whereby other doctors were only allow them to sew up the wound or excise prepuce only).


Lastly, is the control event. Interestingly, this is my first time ever travel by ambulance, which was also my first time ever pushing a vehicle, first time ever pushing an ambulance, and first time ever seeing an ambulance break down :p Such event took place at another mosque nearby where we were given the task to remove the bandage applied 3 days before and inspect if any infections suspected. Though the procedure seems to be quite an easy one, but can be really difficult when doing it as the kids now are no longer under anesthesia and the removal can be really painful, especially if the bandage is tightly adhered to the wound. I was partner with another guy who was my former groupmate (during the circumcision), and was the second operator. Well... what can I say? I was truly being lucky to be the second as the condition of the first kid was alot complicated than the second one. Most of the bandage was tightly adhered to the wound. In addition, the kid was no giving full cooperation, compare to the second one, who was requesting to keep the bandage as it was due to the intense pain. It eventually ended up with the kid removing the bandage himself, risking his penis to infection as he was not gloved. Ya, another interesting story to share here : My partner actually said that he will use ALCOHOL to disinfect the wound, follow by BETADINE, so there won't be a problem of infection when I requesting him to hand the kid a pincet, instead of using his hand !! What a surprising answer !!! Didn't he know that alcohol can worsen the condition of wound and Betadine will delay the healing process of the wound? Besides, no one can stand being applied with Betadine on one's wound, not to mention, using an alcohol !! Well... just as expected, the kid cried once the Betadine was dropped on his wound (I rejected his request to use the alcohol by handling him only Betadine. Imagine what will happen if the kid was clean with alcohol !!). As for my patient, it was so coincidence that he was my last patient during the circumcision too. Adhesion was not that bad for him and was successfully being removed without much complication, of course, with his full cooperation.


Well... that was basically what happened during my third exposure to circumcision. It's undeniable that I've gained lots of knowledge and experience through this event. I'm definitely need to strengthen my skills in circumcision, as well as in other skills so that pain / uncomfortable sensation could be minimized, besides reducing unnecessary trauma to the patients, as what happened to my very first patient...









personal comment : Way of organizing and managing the event of MER-C was way better than of BEM and due to that reason, I've get myself registered as a MER-C volunteer on the 4th of March 2010 :p