90 year old dad had surgery for basal cell carcinoma on his nose without family being notified because the dermatologist had a cancellation.

Take pictures.
Doctor was negligent, speaks to informed consent as a start.

Speaks to lack of proper consideration of his medical records. I'd be furious at their handling of this.

Absolutely, informed consent requires full understanding of what to expect risks etc.. very careless and arrogant for doctor to prioritise his own schedule & income over your Dads safety.  Would make a written complaint as well & photos.  I hope  is recovering, it must have been very upsetting for him to undergo such treatment.

Lawsuit.
Negligence.
Plavix is a prescription drug that prevents platelets from clumping together and forming blood clots. It helps blood flow more easily and reduces the risk of a future stroke or heart attack. ... Plavix is a blood-thinning medication used to treat coronary heart disease and peripheral vascular disease.

I would go to a different doctor for a second opinion right away.

He went to the E.R. because of this incident?

Drove home, age 90, after local anesthesia and oxy???

My thought would not be printable. Get a background check on this "doctor".

Hoping your Mom was okay, and that Dad is better.

Absolutely....documentation is paramount. Thank you.

Search for: Connecticut Medical Malpractice Laws & Statutory Rules
online.

Obtain a physical exam with EKG (heart) to determine if he is okay.
My response is usually the nuclear option, but there are other options.

One can confront, correct, offer to put a negligent doctor out of business and report to administration, or keep stress at a minimum for you and your Dad.

You have choices here.

Has your dad been seen by his own PCP or ER doc since this happened?

I would get him to the ER for immediate documentation. You want to make sure that your father's platelet level is sufficient for healing, I think.

Abby,
The bruising may be normal.
However the bleeding from the suture site was not.

Abby:

The bigger issue here, one that you have been posting about for several months here, is that this is a clear indication that your parents are, as a unit, no longer competent to live alone.

Did dad think " my demented wife is home alone, what if this surgery goes wrong and I end up admitted to the hospital?" Did he think to consult with anyone about whether this was a good idea to have this surgery without someone accompanying him? Did he think to say to the doc, "I'm on blood thinners, is that okay?" He may have been asked about meds and answered inaccurately.

Use this incident with dad's PCP to force some action. Like informing APS about this incident.

The whole situation was handled poorly and I don’t think Dad should be trusted to go to any appointments alone anymore. However the bruising, however scary looking, is normal. My DH has had basal cell surgery on his face multiple times and always ends up with black eyes. Especially when it’s his nose he’ll have 2 bad shiners that will last for days. But the bleeding from the Plavex is obviously not right and must be addressed.

Abby;

As I recall, none of you has POA. Thus, you have no "standing" to make any changes.

You parents' doctor bears some responsibility here if he knows about this situation (and thus I would sent her/him a certified letter, outlining what happened) there may be reporting mandates in their state.

I've read this entire thread a few times, and may be repeating what others have said in an effort to tie together all of the issues.  So please excuse me if I repeat, for emphasis, points already made.

1.   To confirm, and this is critical:   the intent of the appointment was to discuss surgery, but not necessarily to perform it.  Therefore, your father went unaccompanied, and had not D'C'ed any meds, nor taken any antibiotics in preparation for a surgery.   If this is the case, I do think the PA should have taken these facts under consideration.   

2.  My understanding is that Plavix is an "antiplatelet" and an anticoagulant, sharing some properties of Coumadin.   In my experience, Coumadin is D'C'ed prior to any surgery and substituted by more short acting meds such as Lovenox or Heparin.    Perhaps that should have been considered as well, But is IS a medical decision.

3.   Anesthesia isn't mentioned, so I assume none was administered.

4.   What was the specific reason for the 4 hour wait period before releasing him to drive himself home?  Was there any bleeding then?  

5.   When he returned, where specifically was the bleeding?  From the interior or exterior of his nose?    What was done at the doctor's office, and what advice was he given?   Do you or your brother have a copy of the discharge instructions?  

6.   As to responsibility/liability, did the PA make all the decisions?  Perform the surgery?   Was any doctor present to supervise or inspect prior to and/or after the surgery?   Did anyone else examine your father prior to his being allowed to drive home alone?

7.  Determination of liability and/or negligence is based on legal and medical standards, which have to be evaluated by a doctor in a similar field.   Records would be ordered (very costly) and reviewed by an independent physician chosen by any law firm that might consider taking a med/mal case. 

You can order the records yourself, but your (and any nonmedical interpretation) wouldn't be guiding in terms of negligence.   You might want to consider this, but do NOT raise the issue of negligence or malpractice.   As the basis for ordering the records, use "follow-up treatment", or something generically similar.

8.   Then take them to a med mal attorney (ask if you need advice on how to find one), and definitely not an elder law attorney, for review.  He/She will indicate whether or not there's sufficient cause/grounds for considering litigation, or even just pursuing a claim w/o filing suit, as well as what steps he/she would take next.

9.  Personally, and I'm not a medical person (my family was), I think the surgery should not have been performed (a) w/o D'C ing Plavix and aspirin, using Heparin or Lovenox for a prescribed period of time, and drawing blood for PT/INR before the surgery.

HOWEVER, I don't know enough about how long Plavix remains in the body to know if this would be the appropriate procedure.    And there also might be more sensitivity to bleeding based on other factors.    

10.   Tomorrow, DO NOT approach the PA or any one on the staff aggressively or demanding explanations as that will only put them on the defensive.  Act dumb, confused, and ask for explanations to help you understand what happened (not what went wrong), & how you can help your father now.

11.   Whether negligence exists is not something any of us can determine as it depends on facts listed in Paragraph 7 above, as well as case law in your state, and standard of care for (a) similar situations (b) anticoagulant standards and (c) vulnerable elder.

12. Oxy - I can't offer anything on that level except that I have never taken it even though it's been prescribed.  

If you need clarification or explanation of anything I've written, please feel free to respond.   I hope my thoughts are helpful.

Addressing other issues:

Abby, you raised the issue of an inexperienced PA.   Are you aware of the rigorous educational and practice area screening and course they must take?  My niece is an RN getting her Masters for an NP position; she has extremely rigorous standards to meet, she "rounds" as doctors do.    And as an NP student, she works with experienced NPs or other medical practitioners on DX and treatment.

Before blame is assessed to the PA, think about what other dynamics might exist at that practice.   The supervising doctor needs to be aware of this situation so it can be corrected.  

There may be another issue in that particular practice.


I'm not familiar with your familial situation, but I do agree with BarbBrooklyn that it's time for a reassessment.  Neither of your parents should be seeing medical personnel alone.

And I think a medical history would be important for either you or your brother to take with you when accompanying your father or mother to any medical appointment.

The history should provide the basic personal info, including emergency contacts, but also (a)  all medical conditions, surgeries and history (b) meds and frequency  (c) allergies, to meds and non medical substances, as well as reactions thereto   (d)  pharmacy contact info (e) surgeries, and (f) treating doctors, conditions and contact info. 

Since my family has a history of cancer, I also provide a list of relatives who've had it, the type of cancer, and any cardiac or other major issues.    Some doctors include familial history requests in their records.

I started that when my parents became Winter Texans.  When Dad was hospitalized, he could show the booklet of med info (about 8 - 10 pages!)  to the Texas medical people and they had not only a medical history but emergency contact information.

Hi Abbey. Hope u don't mind my saying, it may be best that they rushed his surgery, cuz basal cells can be very aggressive & his office biopsy May hav revealed a need 4speed. My mother, (& many others in the Dr's waiting room), had lost half their facial features from 'removals' that were let go too long. I tried not 2 be graphic, cuz it got pretty horrible.

Something's been troubling me.   Did your father actually drive himself to the doctor?    Is he one of those people who just can't give up driving?   Or if someone accompanied him, who was it?

He was on plavix. Yes. You are correct. Could have been really a mess of bleeding and trying to reverse it with other drugs. It was a mess up. I am hoping he will admit that to you. I think it is what you need to hear. And it is the truth.
Another truth is that your Dad agreed to it, and no one was there to say "wait, but........." and this is how all this generally comes down.
It is a mess up and happens all the time.
The MD will either be a decent thinking person who is honest, or he will not be. In the one case we already know what he would do, apologize, say there was missing information he should have tried harder to have, what have you.
OR
He will say "I could have had no way of knowing...."
blah
And the fact of the matter is that there is absolutely no recourse in a case like this. There is no suit, there would be no lawyer interested, a letter would be ignored, so would a report to the medical board. Not that any and all of those USELESS actions could not be taken; just they would make no difference.
We expect medical folk to be better than the Nordstrom or Macy's or Target salesperson, but often they know as much about us and have as little time to find it out. And as to recourse? None anymore. Don't get me started on suits, but forget about them. They will not EVER work, and you can Private message me if you need to know why.
So on you go. Nasty that too much bleeding and back to the ER and someone will pay. You. Us. The system. And this is the way of it so often.
I am so sorry. And I am so relieved it isn't a good deal worse.

Abby, thanks so much for taking the time to respond so thoroughly to the many posts, and thanks for answering my questions.   

I can understand someone insisting on driving himself; my father was like that until I took over the driving.  But then my own transit time increased dramatically, although I got to know every one of his doctors.

I see now that the doctor was at fault, unless there was some need for immediate surgery b/c of the state of the cancer.    Still, I think he could have verified his position with the family first; it would have been just courteous, especially for a  90 year old man.

Hopefully you'll get answers to your questions tomorrow.  (A good one might be who he would recommend as a competent alternative to him!).  

Good luck, and best wishes for a better day and some solid answers to this situation.

I wonder why the Mohs procedure was not discussed , it is the most effective technique for treating basal cell cancer and squamous cell cancer of the face. My mother had it done for both basil cell cancer and squamous cell cancer of her face with complete success at Mass General Hospital in Boston, Ma. The procedure is done under local and recovery time is about 48 hours. Her face was bruised and swollen but healed rather quickly. A highly trained doctor performs the Mohs procedures. My mother was taken off her Aggrenox, but continued to take her low dose aspirin. No bleeding issues. Sorry that happened to your dad. I think he should have a family member with him when he has doctor visits. Hope your dad is doing well.

When my basal cell was removed it was done in an outpatient surgical center, not the office.

Maybe there is an outpatient center adjacent to the doctor's office?

Dad made the decision to have this done, and he is competent, it would be interesting to know if an attorney would even accept it. What were the damages?

Abby, if he had Mohs surgery, that’s why the procedure took so long. That’s what my DH has (in his dermatologist surgeons surgery room). The smallest area and depth of affected tissue is removed, and perimeter skin cells are examined right then in their lab to make sure all cancer is removed. The patient waits during this. If it’s found that more needs to be removed, the doctor keeps taking and examining small amounts until they are assured there’s no remaining cancer. DH is there for hours and now I understand your Dads long time in the office as that is typical. It’s an ordeal, but it saves the doctor from cutting out huge hunks of skin “just to be sure” and return trips. So the good part of your Dads experience is that the cancer is gone, and this is just over sooner than you expected, if you want to look at the bright side.

But, my question to the doctor, how did they miss he’s on Plavex? Every doctors office I’ve ever been to reviews my medication list with me right off the bat at the start of the visit. Did they not review meds, or was your Dad confused about it or deny being on it? That’s the question I would want answered.

We understand that you couldn’t make this particular appointment with him, and you think he’s usually astute, but I think this is a wake up call that he might not be as clear thinking or able to advocate for himself as well as he seems. So I’m not sure I’d put this episode entirely on the doctor. Except for the Plavex part.

I think your decision making process in moving forward is one of those awful instances in which something awful could have happened, but fortunately didn’t, combined with whether Dad is still able to make split second decisions about his own care, and deal with the fallout himself after his decisions are made.

Unless you intend to imply that Dad is not capable of taking care of his own decisions, you will have to anticipate that in this situation, there is really no change you can make, because no actual harm resulted to either your dad OR your mom, although clearly, there could have been awful consequences.

How you decide to proceed going forward is the horridly delicate dance that all of us wind up undertaking out of love for our loved ones when they reach the stage at which we simply can’t be absolutely sure what we NEED to do and what we SHOULD do, to keep them totally safe physically.

It sounds as though you’re there. If your dad has NOT been assessed as being cognitively incompetent to handle his own affairs, the the default assumption becomes .......so he IS competent, and therefore, for what ever reasoning he applied, he decided to go ahead and take the cancellation appointment.

Maybe no one is actually “wrong” here, but rather each of the individuals involved was functioning with all the information that was available at the time of the decision making.

Please understand, I’m NOT justifying the medical decision that was made. My comments come from my own attempts when my LO was at the beginning stages of cognitive failure, and the awful indecision that confronted me knowing that she might not be able to drive in traffic, or live in a house that was riddled with “fall risks” or ultimately, the point at which she was, or would be, unable to make difficult decisions on her own.

I did some things that were right, some horribly wrong, and some that I’m still not sure about. In the long range, her safety became paramount, but however difficult it was to challenge her failing sense of independence, the challenges ultimately were made when her safety was at risk.

A very difficult call for you to have to make for all concerned. Hoping you can find your way through this complex stage to a solution that brings a measure of safety and comfort to all involved.

Abby, thanks so much for the updates; they really add more to the whole story.  I understand much more clearly now what happened.

But just a quick comment - "walk-in clinic" - to me that changes the dynamics of the whole situation.

I also doubt you'll get to see the surgeon, but there's another way to address the issues.

I've noticed that LLCs are investing in Veteran owned businesses, providing capital to Veterans so they can purchase a franchise.   More and more I'm finding, as I do background research on companies, including some medical facilities, that LLCs are also involved, as are larger corporations purchasing hospitals.

This changes the dynamics and monetary focus.    My last employment was with a firm that handled LLCs, some of which included medical personnel.  It stands to reason that the LLC would then invest in something like a clinic.   I'll bet there are medical people on the ownership end of this, and these are people who WOULD understand the issues of potential negligence, reputation, repeat customers, etc.   Better yet, they'll understand and feel it in their pocketbooks if clientele declines b/c of poor medical treatment.

And they also understand the premium dynamics of medical malpractice liability insurance.  

So, one thing you might ask is about the ownership of the clinic, then research that ownership.   Contacting them might be more effective than the front line medical workers.

I hope today provides some relief for you and your family, and I hope your father is healing well.

Your father left your mother with Alzheimer's home alone, drove himself to the doctor's office and gave consent. If anyone was obligated to notify you it was your father and, in my opinion, you are angry at the wrong person/people. There is no indication to stop Plavix or aspirin for minor skin surgery.

Thank you everyone for your input and best wishes. Dad is doing well and other than bruising and black eyes the surgery went well. I was a little apprehensive this morning when dad said it was a walk in visit, but he was seen promptly by both the nurse and the doctor. I voiced my concerns over the way this was rushed through and the disregard this was done while dad was on Plavix. I was told it was because the procedure was above the shoulders. Odd because his PCP told dad to stop Plavix one week prior having his teeth pulled for dentures. Before taking Plavix and aspirin dad had significant issues with his blood clotting. Regardless, the surgeon apologized profusely and claims he wasn't aware of the underlying circumstances. The office did have my number on file, but chose to call my mom periodically to check on her rather than to contact me. I just feel at this juncture the ball was dropped on so many levels....yet I am grateful for the outcome.....the procedure was successful, mom is fine and dad is recovering nicely. My take away: Although the oath is at first do no harm, I guess no harm, no foul has it's own significance.

Abby, I applaud your adaptable attitude, and accepting the fact that even though the procedure wasn't handled appropriately, there's not a lot that can be done, other than make the managers or owners know of the problem so that procedures can be instituted for more thorough background development before surgery.

Thinking about this, I think it's a "lessons learned" situation, but also one that offers insight, personal growth, and the opportunity for alternate planning, if such a situation ever occurs again. 

E.g., how will your father's appointments be handled in the future, will his solo driving be addressed, and what other actions can be taken to protect him in the future?

So glad your Dad is doing well which is all the most important thing, Good that you raised the issue and were heard, will feed into better care and attention for someone else.  Its a real juggling act  keeping it all together !!, Good wishes on your new plan,