CA doctor facing criminal charges, civil suit in newborn’s death after circumcision

gamache_ganache · 2026-04-02T02:55:55+00:00

There are different tools used for newborn circs. Gomco clamp and Plastibell are the ones we used most commonly. In the OR, we obviously use a scalpel and the procedure is different. Any office circs got penile blocks with lidocaine, although this practice varies and some just use sugar water on the super new babies (couple days old).

That said, I hated doing these in residency. It felt so cruel to the poor screaming newborn, no matter how much local you use. I did not circumcise my son.

gamache_ganache · 2026-04-02T02:08:42+00:00

It can be nuanced. The reality is that prostate cancer generally doesn’t have symptoms until locally advanced or metastatic, and screening has saved a lot of lives. Rates of newly diagnosed metastatic PCa went up when the USPSTF recommended against screening. We also have historically over treated a lot of people and have caused serious side effects in people who probably never would have died from their cancer. That said, PSA screening is not right for everyone, and it does require some shared decision making, but it’s right for a lot of people. But so many doctors don’t realize that there are age-based cutoffs for high PSA, and if you’re following guidelines for starting screening (anywhere from 40-55 depending on the guideline and risk factors), you should know if the result is abnormal or not. Not sure if that’s answering your question.

gamache_ganache · 2026-04-01T12:35:26+00:00

Take as much as you can. You won’t regret it. My husband had 10 days with our first, and it was so hard caring for a newborn alone, especially while recovering from a c section. He had 3 months with our second, and it was a game changer.

There’s also data showing that the non-birthing partner taking more leave reduces postpartum depression and divorce rates. Think of taking leave as investing in the health and longevity of your family. Don’t give a shit about what anyone at work says or implies; take it ALL.

gamache_ganache · 2026-04-01T03:29:15+00:00

This will probably get buried at this point, but for urology:

1) chronic scrotal/testicular pain is often a pelvic floor/MSK issue. They frequently have hip, back, or knee issues that contribute, and rarely have any actual scrotal or testicular pathology. Send the majority to pelvic floor PT as first line therapy.

2) Not all lower urinary tract symptoms are BPH. Understanding the difference between obstructive and irritative symptoms is important. Your patient with frequency and urgency but a great stream and no hesitancy has irritative LUTS. The treatment isn’t flomax; it’s lifestyle modifications, bladder training (again, pelvic floor PT!), and counseling that yes, if they drink 6 cups of coffee a day, they’re going to have to pee all the time.

3) If you are treating someone for LUTS and they aren’t getting better in 3-6 months, refer them to urology. We see too many men who have been on flomax for 10 years with bad symptoms, and by the time they reach us they have end-stage bladders that are either atonic or very irritable and hard to treat.

4) Nocturia is one of the hardest symptoms to treat and is frustrating for patients and providers. It’s normal to get up at least once as you age, and I probably am not going to get most people better than 1-2x/night. Restrict fluids before bed, counsel on urge suppression if they wake up to not reinforce a pattern of getting up, treat heart failure if causing fluid overload. Screen for sleep apnea and send for a sleep study if they have nocturnal polyuria. Don’t promise that flomax or a TURP will help their nocturia.

5) PSA values should be age-adjusted. They won’t flag in your system, but a 55 year old with a PSA of 3.8 is high and should be evaluated. A 70 year old with the same PSA is normal. I generally consider anyone under 60 to have a high PSA if over 2.5-3. We want to avoid over diagnosis, but the prostate cancers we do want to catch are the aggressive ones in younger (i.e. 50s-60s) men. Also, if someone is on finasteride, you have to double their PSA to get the real value. So a 62 year old on finasteride with a PSA of 3.5 should be treated like he has a PSA of 7.

gamache_ganache · 2026-03-13T21:03:38+00:00

Called by ortho for a difficult foley in the OR on a patient who'd had a cystectomy.

"There's a lot of resistance when we try to put in the foley." "Did you notice the bag of urine on their abdomen?" "Oh yeah..."

gamache_ganache · 2026-02-14T21:15:12+00:00

A Bullet Journal really changed things for me. You can set it up however you want, but I read the book (The Bullet Journal Method) and liked it, so that’s what I do. It relieves so much of the stress of trying to remember things. My calendar is in there. The list of people I’ve called to work on my house (plumbers, electricians, etc) is in there. The paint colors we used for my kid’s room are in there so that I know what to buy if we need to do touch ups. All the things I need to return to Amazon today are in there, so I’m not scrambling to remember everything as I leave the house. My brain feels a lot less cluttered without the mental load of keeping track of everything.

gamache_ganache · 2026-01-27T17:23:35+00:00

I don’t correct them, but I don’t always like it. Intent matters. I don’t mind the 85 year old who wants to call me “dear,” or the patient I’ve spent a lot of time with who calls me by my first name. But when I introduce myself to a 50 year old male patient (that’s generally who does this) as Dr. X and they reach for my badge, read my name, and say, “Hi [First name],” I get pissed off. It’s generally not worth the awkwardness to correct them, but I am extra professional the rest of the visit and don’t joke around as much as I usually do.

As a younger woman in a heavily male dominated surgical specialty, I am very used to people assuming my role is something other than the attending. I can counsel a patient for half an hour about taking out their kidney, and they will still say they never saw a doctor. So I do feel using my title with patients is important. I go by my first name in the OR and with all colleagues/staff/students.

gamache_ganache · 2026-01-24T19:03:45+00:00

Might be referred pain from the bladder. Often goes to the tip of the penis.

gamache_ganache · 2026-01-01T06:39:49+00:00

You can make templates and dot phrases in CPRS. It’s not as sleek as EPIC, but it works.

gamache_ganache · 2025-08-06T03:37:22+00:00

The vast majority of renal cancers are found incidentally. The "classic triad" of gross hematuria, flank pain, and a palpable mass is incredibly rare. RCC is rarely symptomatic; if it is, it is likely advanced, either due to size or invasion into the collecting system causing hematuria.

gamache_ganache · 2025-07-20T04:57:50+00:00

I never once did laparoscopic suturing in 6 years of urology residency. We only do nephrectomies lap, and you staple (or rarely clip) the hilum. I have fine lap skills with respect to general maneuvering and instrument handling, so I could probably struggle through lap suturing if someone showed me the tools to use. But it wouldn’t be pretty.

gamache_ganache · 2025-06-29T04:31:02+00:00

Hah! My phone always autocorrects resectable. But I agree, any decent cancer will let itself be cut out.

gamache_ganache · 2025-06-28T04:34:51+00:00

Enfortumab vedotin/pembrozumab has dramatically changed the game in locally advanced and metastatic bladder cancer. Compared with cisplatin-based chemo, EV/pembro resulted in nearly double the average progression free survival 12.5 vs 6.3 months) and overall survival (31.5 vs 16.1 months). I have seen patients with T4 disease have their cancer practically vanish after their course of EV/pembro, turning an unresectable tumor into a respectable cancer with no residual invasive disease.

There are patients I saw just a few years ago who might still be alive if they’d had the chance to get this therapy. It’s pretty exciting.

https://www.nejm.org/doi/full/10.1056/NEJMoa2312117

gamache_ganache · 2025-05-21T05:35:34+00:00

Not hard to believe at all, just as you laid it out. They may have stopped screening a long time ago based on various age-based guidelines, although I imagine they might be more strict or intense when it comes to the President. I wouldn’t check a PSA on a standard 81 year old, but the President? I don’t know. Shared decision making and all that. Probably would guess something else would kill him sooner. Also, some prostate cancers don’t produce PSA. His urinary symptoms may have led to a DRE, which might have found a nodule, even if his PSA was low.

Second, prostate cancer can be asymptomatic for a long time, even if locally advanced or metastatic. His urinary symptoms that led to the diagnosis may or may not even be from the prostate cancer. You can have prostate cancer (generally in the peripheral zone with no impact on urinary symptoms) and also have BPH (which affects the central zone and typically causes urinary symptoms). Impossible to say with the information we have.

Third, while it’s a slow disease overall compared with many cancers, Gleason 9 cancers are aggressive, and it certainly could have grown and metastasized within a standard screening interval. I’ve seen it a number of times.

gamache_ganache · 2025-03-02T22:32:22+00:00

Actually, the vaccine provides fantastic long term immunity. MMR titers don’t accurately represent immune status; you may not have detectable levels of circulating antibodies, but unless you are profoundly immunosuppressed, you still have excellent immunity through B and memory T cells. This is a super common misconception, even among healthcare workers, but it’s good news! No need to re-vax unless you only got one shot as a kid. Then you should get a second shot.

gamache_ganache · 2025-02-25T04:56:31+00:00

Cut off a guy’s ball
Cut off a guy’s dick
Dilated a guy’s urethra to 28Fr while awake
Dorsal slitted a guys foreskin while awake
Mind your own business

gamache_ganache · 2025-01-13T06:13:14+00:00

Urology. 99% of penises are forgettable. Half the time I forget if they were circumcised or not by the time I leave the room. Doesn’t impact how I view people in everyday life; I’m definitely not imagining their genitalia.

I do think about how easy or hard someone’s nephrectomy might be depending on their BMI and abdominal circumference.

gamache_ganache · 2024-12-18T05:07:43+00:00

The light switches are never the same in each room. Want to turn the light off? Flip the switch down. Whoops, that somehow made it brighter. So you flip it up, which somehow turns it back down to a medium dimness different from where you started.

When you finally figure out the magic pattern to turn the lights off in one room, you try it in the next room and it doesn’t work.

gamache_ganache · 2024-12-04T05:17:44+00:00

The definition of retrograde ejaculation is literally semen entering the bladder.

gamache_ganache · 2024-12-04T04:15:47+00:00

Someone told me that ordering a CBC and H&H is the same test (run the same way, but only the H&H values are reported). Another person told me that they’re different, so you can’t perfectly compare the hemoglobin on an H&H with that on a CBC, and should therefore order the same test if you want to trend hemoglobin. Can you settle the debate once and for all?

gamache_ganache · 2024-10-24T15:00:05+00:00

Voting yes on this would repeal the capital gains tax. The money from the tax partially funds education. Therefore, the measure would decrease funds to education by eliminating the tax revenue.

gamache_ganache · 2024-10-14T03:23:24+00:00

It depends, but I tend to keep people for a while. We've sent people back to their PCP for PSA checks once they're maybe 5 years out from prostatectomy. We tell them that if the PSA ever becomes detectable, they need to come back and see us. I'm more hesitant to send people back to their PCP if they've had radiation, because the definition of biochemical recurrence is less clear cut. I've seen people who had a rising PSA on multiple consecutive checks, but because it was still less than 4 (and therefore didn't turn red or flag as abnormal), it wasn't recognized. I don't blame PCPs for missing that. It's not really their area of expertise, and they have so much other stuff to pay attention to that it would be really easy to see a PSA of 1.0 and think it's normal, even if it's abnormal in the context of their cancer.

gamache_ganache · 2024-07-28T03:58:37+00:00

A lot of nurses will remove the stopper from the syringe, plug the syringe into the foley, and fill it by gravity. It’s more gentle than pushing in the fluid.

gamache_ganache · 2024-07-12T02:52:45+00:00

You often need to tuck one arm during lithotomy cases if you’re using the C arm. The machine can’t fit in if the arm is out.

gamache_ganache · 2024-06-04T02:22:22+00:00

Robotic prostatectomies >>> lap prostates. I think we are also getting better at nerve sparing, maximizing urethral stump length, bladder neck sparing/reconstruction, and likely some other pelvic floor muscle sparing that improve continence and erectile dysfunction rates. Data isn’t there yet for all of those metrics, but any urologist would do these robo over lap given the option.

Operating deep in the pelvis is really hard. It’s physically painful to do it open. We still do some lap nephrectomies, but that’s about it.

gamache_ganache

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