A Bloody Mess

By John “Lucky” Meisenheimer, MD and John Meisenheimer, VII

There are scores of prescription anticoagulants out there. I have lost track of how many, but there is a boatload. You add this on to the vast number of over the counter products that also “thin” the blood such as aspirin other nonsteroidal anti-inflammatories and then throw in things like ginseng and garlic and fish oil. It would seem that just about every patient over the age of fifty is on at least one or more anticoagulant type of medicines or supplements. America is now the land of easy bleeders and this bleeding frequently affects the skin.

As a Mohs surgeon doing skin cancer surgery all day long, the anticoagulant bandwagon, of course, creates what I refer to as a bloody mess. Almost all of my patients, having surgery, are of the age range where they are taking some form of anticoagulation. When you ask a patient if they are on anything that might “thin” the blood, if it was not prescribed, the answer is usually no. You think to yourself, great, finally someone not on a blood thinner, this case will be easy peasy. When the next question asked is, are you taking aspirin or a NSAID? The invariable answer is “yes, but that’s for my heart, joints, muscle aches, etc.” Many patients are not aware that these OTC drugs “thin the blood.”

The question may arise, well, why don’t you stop the anticoagulants before procedures, and medically this would make a lot of sense on the surface. Cessation of the anticoagulants certainly would make the surgeries go smoother without having to deal with so much bleeding. I used to do this routinely when I had the blessings of the prescriber of the anticoagulant.

However, sometimes medical practice is influenced by the judicial system. Courts have determined, in California anyway, that if you stop an anticoagulant even with the permission of the prescribing cardiologist, if there is a temporally related cardiovascular event, you can also be sued and lose. The justification is that it is much better to deal with bleeding complications of skin surgeries a hundred times over than having one major cerebrovascular or cardiovascular event. When you think about it, this does make some sense.

I try to remind myself as I am sopping up blood and doing continuous cautery on vessels that do not seem to want to stop bleeding, that it is all for the better good of the patient. I’m sure this debate will rage on over the years by folks much wiser than me, but in my practice, for the last several years, I typically don’t stop anticoagulants started by other physicians. I deal with the bleeding and move on. So far, so good! No major cerebrovascular events or blood transfusions needed. Below are photographs of different skin findings you will see when people are on blood thinners and various expressions of bleeding into the skin.