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Let me explain...my dad had an appointment with the PA at the dermatologist office to discuss the possibility of another surgery on his nose. The doctor who did the original treatment moved and a new dermatologist took his place. When my dad went to his appointment he was informed that because of a cancelation they could do the procedure immediately. I believe he made the decision to comply only because he was blindsided. This was done at the office on a 90 year old man who is on Plavix and aspirin (he has three carotid artery stents, along with other medical concerns). Four hours later he was told to leave and was fine to drive himself home. My mom with dementia was home alone for over five hours. After three hours dad had to return for an emergency visit to receive more stitches since he was bleeding profusely. I knew nothing of this until I called to do my morning check with my parents. My brother took him in for the emergency visit....but that's another vent. Dad has a follow up on Monday....I will take him and voice my concerns but I think the doctor was negligent.....I feel this should have been done in an environment equipped to handle emergency's and proper arrangements should have been made prior to surgery. His entire face is black and blue and eyes are nearly closed due to bruising. In addition he was given Oxy for pain relief. Anyone's thoughts on this will be appreciated.

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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,
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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?
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Abby2018 Sep 17, 2019
GA...Moving forward....all Dr.'s visit for dad.....he and mom will be on equal footing. Supervised... so there will no longer be the unknown of "subject to interpretation". : )

I'm finding out this caregiving journey is one of never-ending challenges. "Lessons learned" are filed away for future reference.....an arsenal of life experiences to help us get through the next crisis (along with this all important site). As always, thanks for your concern.
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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.
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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.
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Abby2018 Sep 16, 2019
Mom's doctors feel it's okay to leave her for short periods of time. A typical visit with the dermatologist with travel time is about an hour. He was there only for a consult.......he was blindsided by the offer to do the surgery then and there. I stated that even though he is competent he does get confused when processing information to make split second decisions. I agree....dad should have called....but under the circumstances he also should have been questioned by staff if a family member should be contacted.

Dad has bleeding issues with or without plavix......his vascular surgeon made it clear that not under any circumstances should procedures be done while taking the plavix/aspirin combination (including anything above the shoulders). I don't feel any medical establishment should put the very elderly in a compromising situation.
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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.
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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.
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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.
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NYDaughterInLaw Sep 16, 2019
I agree.
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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?
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Abby2018 Sep 16, 2019
I'm not looking for a lawsuit here.....it would be a long shot at best. I just feel the entire situation was handled poorly and the consideration expected towards the very elderly were ignored. I intend to file a complaint against the surgeon since I feel his interest was with filling his quota for the day as opposed to meeting my dads best interest. Even being of sound mind he does get confused when having to process a lot of information under stress. He has other health issues that should have been considered as part of the equation before rushing into surgery.
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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.
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Abby2018 Sep 16, 2019
I typically do.....but I had my 18mth old granddaughter on that particular day and wasn't able to go with him for the consult. Dad is astute and I trusted him to get the information, weigh our options and then make a decision. I would have never let him have a procedure done alone.

After pressing my dad further, Mohs was the surgery performed. From what I was able to gather from researching Dr. Google, it is a painstaking and tedious procedure.....but the gold standard for Basal and Squamous cell cancers. I'm curious as to why your mom was sent to a hospital environment as opposed to an office setting?

I am going today for his follow up and hope my questions are answered.
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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.
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Abby2018 Sep 16, 2019
Thanks GA.....I just spoke with dad and was informed that he doesn't have an appointment .......they will see him as a walk in. Not sure if he'll even see the surgeon at this point.
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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.
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Abby2018 Sep 15, 2019
Alvadeer.....Let's face it a law suit would be just a long tedious affair and emotionally and physically draining for all involved...if an attorney would even consider it. And yes....I do need to get an apology for a terribly mismanaged event. And so it goes....I just hope this young Dr. takes to heart that the human element is just as important as the mechanics and bottom lines of medicine.

And I love the thought that we have expectations of holding our medical professionals to a higher standard than the retail giants......and sometimes this is sorely misplaced. Thanks for that....puts things in perspective :)
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Contact your state DPH. Not your local APS. The PA and doctor both have licenses. Let the boards determine sanctions. I did something similar for a wrong prescription with double the dose. The state informed me what they required of the pharmacist after an investigation.
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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?
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Abby2018 Sep 15, 2019
He drove himself.....which he does all the time. He's actually quite competent and alludes to others that he is really very astute. We have found no reason as yet to take away his shrinking freedoms......but at times he does get confused when presented with too much information at one time.
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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.
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Abby2018 Sep 15, 2019
I agree....and we most probably would have went ahead with the procedure since the first surgery did not get all the cancer cells. I would have liked to have known all options considering his age and health issues....and stayed with him during surgery as well as making arrangements for someone to be with mom.
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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.
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Abby2018 Sep 15, 2019
When this was explained to me (by dad), it was out of the PA's hands.....the dr. had the cancellation for surgery and since my dad was scheduled for a consult for a possible future procedure, the dr. made the call. He was the inexperienced one here......new to the practice replacing my dads original dermatologist. In my estimation, due diligence was ignored.

But to the idea of a medical history folder....great advice. Too often we rely on inner office/hospital info to be all inclusive and up to date in the patients bio.
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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.
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Abby2018 Sep 15, 2019
Dad's appointment was with the PA to discuss a future procedure. He was not convinced to get this done as it could get pretty invasive. He went to find out his options and we (family) were to discuss which would be the best choice for him. The Dr. informed my dad that there was a cancellation and the surgery could be done immediately. I don't believe the PA was involved at all.

Local anesthetic

Mohs procedure done....removing layers of skin with pathology done at each section to make sure all cancer cells are gone.....typical time is three hours.

I will see the discharge papers tomorrow..... My brother said the incision site was bleeding and my dad's shirt was covered in blood. I didn't see my dad post op since I was not informed until after the fact.

Dad bleeds very easily and takes a long while for even a minor cut to clot. There was no reason to do an elective surgery on zero notice while being on Plavix and a daily dose of aspirin. Right now I blame the Dr. for being too aggressive and ignoring due diligence. He has been with the practice for just a few weeks....and very young and a very short resume. I question his experience with the very elderly.

Agreed...arrogance will get me few answers. Thank you for your advice.
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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.
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Abby2018 Sep 15, 2019
Actually...yes I have DPOA for both parents. It is on file for mom, but with dad only for his PCP.
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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.
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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.
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Abby2018 Sep 15, 2019
Oh Barb....you know I totally agree and that was one of the first things to come to mind. My dad has taken a downturn since caring for mom over this past year and it's been a rollercoaster for my sister and me. I worry that the worse possible will happen to shut this down and we can move them to a safe environment. I understand the desire to stay in place, but I question the logic (whatever that might be at this point) behind it. As always, your advice is much appreciated.
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Abby,
The bruising may be normal.
However the bleeding from the suture site was not.
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gladimhere Sep 15, 2019
The bruising is normal. I had basal cell removed from my nose. I looked like I had been beat up for about two weeks!😓
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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.
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Abby2018 Sep 15, 2019
Sadly, no. My brother was called and he took him back to the physicians office after hours to control the bleeding. The ER would have been the better choice for documentation. I will take him for follow up tomorrow and will request the necessary lab work. Thanks for the suggestion.
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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.
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Abby2018 Sep 14, 2019
Yes....I'm with you....stress aside.....This young buck needs to be aware of the empathy and knowledge necessary to deal with the very elderly since they have their own set of considerations. He ignored this in totality.
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Absolutely....documentation is paramount. Thank you.
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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.
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Abby2018 Sep 14, 2019
Mom managed through somehow.....and to think my dad's PC expressed concern over doing the procedure to begin with. Dad is the same.
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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?
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Abby2018 Sep 14, 2019
No.....my brother brought him back to the dr.s office. I am livid..if I have been contacted I would have brought him to the ER.
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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.
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Abby2018 Sep 14, 2019
My thoughts as well...from my understanding he his young and most probably inexperienced. On the job training is a poor excuse for competency.
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Speaks to lack of proper consideration of his medical records. I'd be furious at their handling of this.
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Abby2018 Sep 14, 2019
Thank you...I am in complete agreement.
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Take pictures.
Doctor was negligent, speaks to informed consent as a start.
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