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    What is the standard of care when taking critical information from patients?

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    Dr. Surgery performs surgical procedures every day in his office. He recently performed a large excision and failed to ask his patient about medicine intake.


    David Goldberg, M.D., J.D.
    The patient did not take any prescription blood thinners, but he did take high daily dosages of garlic and ginkgo. Unfortunately the patient had progressive postoperative bleeding, which led to volume loss and an ultimate CVA. A lawsuit was brought against Dr. Surgery. Will he lose this case based on negligence?

    History highlights

    Clearly, a medication history is important for possible agents that may impair platelet function and increase risk of bleeding. The most common prescription agents that increase risk of hemorrhage or inhibit platelet function used on an outpatient basis include warfarin, low-molecular-weight heparin, fondaparinux, idraparinux, aspirin, clopidogrel, ticlopidine and dipyridamole.

    Prescription and nonprescription nonsteroidal anti-inflammatory drugs are common and they also inhibit platelet function. The intake of herbal and vitamin supplementation is common as well.

    The four G's — garlic, gingko, ginseng, ginger — and vitamin E are commonly used agents that have been implicated in increasing bleeding risk. A recent review, however, showed that ginger, ginseng, gingko, saw palmetto and St. John's wort had little effect in increasing bleeding risk when platelet number, fibrinogen, prothrombin time (PT), partial thromboplastin time (PTT), thrombin time, bleeding time and a platelet functional assay were done.

    However, the study authors note many case reports of catastrophic bleeding on many of these agents, and further evaluation is probably necessary. The controversy remains. Should Dr. Surgery have asked about the intake of such medications?

    Negligence factors

    Complications from bleeding may or may not have legal significance. If the aggrieved patient is convinced his physician has been negligent, legal action may be taken against the dermatologist.

    Any analysis of physician negligence must first begin with a legal description of the elements of negligence. There are four required elements for a cause of action in negligence. They are duty, breach of duty, causation and damages. The suing plaintiff must show the presence of all four elements to be successful with such a claim.

    The duty of a physician performing cutaneous surgery is to perform that procedure in accordance with the standard of care. Although the elements of a cause of action in negligence are derived from formal legal textbooks, the standard of care is not necessarily derived from some well-known textbook. It is also not articulated by any judge.

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    GoldbergDavid.jpg
    David J. Goldberg, M.D., J.D.
    Dr. Goldberg is Director of Skin Laser & Surgery Specialists of New York and New Jersey, Director of Mohs Surgery and laser research, ...

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