Richard Johnson

Richard Jacobson is a thirty six year old man. He is currently living in a homeless shelter because he lost his job about two years ago. He previously worked as a construction worker, however, when a piece of the machinery fell and his brain was left permanently damaged, he was let go. Ricky, as he likes to be called, is functioning at about a sixth grade level. He is brought into the ER by the police after he is found wandering around the park one evening in nothing but his underwear. Ricky is known to the ER as a frequent flyer. He is an uncontrolled diabetic and his blood sugar levels typically reach astronomical values before he winds up back in the ER.

This particular evening is a January night in Chicago where is has recently snowed fourteen inches of snow. When Ricky is brought into the ER, he is only wearing only underwear, a hat and a tattered pair of shoes. The shoes are ones that the hospital gave him only a week prior to this current admission. As he is admitted to the ER, the nurses begin working him up, hooking up IV’s, and beginning a drip to lower his glucose levels. As they begin to pull away at the shoes that are frozen to his feet, they notice the intense frostbite in his feet. After Ricky’s blood sugar is brought down to normal levels, he is assessed by the attending in the ER using the mini mental state examination to determine if Ricky is competent to make his own medical decisions. Ricky is able to complete the exam scoring a 27, well within the limit for cognitive competency. Upon further examination, the attending in the ER also decides to call a surgical consult because even after rewarming, Ricky’s toes do not all return to normal states and are looking progressively dead.

Dr. Jablonsky is the surgical attending on call that evening and after an examination of Ricky decides that he is in need of surgery to remove the dead toes. This surgery has been deemed time sensitive but not necessarily immediate because the longer the team wait to remove the dead toes, the greater the chance that the team will have to remove the entire foot because of death in the bone or the muscles of the foot. However, as Dr. Greene, a resident under Dr. Jablonsky, is talking with Ricky about the surgery, he notices that Ricky is adamant that he does not want to lose his toes. He says that because he is homeless he needs his toes. He can’t live without his toes. Dr. Greene explains that if they don’t remove the toes he will lose one if not both of his feet. This doesn’t seem to impact Ricky, he just states again that he will not go into surgery and allow them to remove his toes. Dr. Greene brings this concern to Dr. Jablonsky, whose only response, is “consent the man or he will lose a lot more than his toes.” Dr. Jablonsky goes and talks with Ricky and returns with a signed consent form. However, when Dr. Greene talks with Ricky, he is concerned that Ricky might have been bullied into signing the form by Dr. Jablonsky.

When Dr. Greene suggests involving Dr. Rowland, the psychiatrist, in order to assess Ricky’s ability to make his own medical decisions, Dr. Jablonsky refuses stating that “Rowland is not a competent professional; she works so slowly that Mr. Jacobson will need his leg amputated before she clears him for surgery.” He also states that because of the mini mental state examination he is clearly competent to make medical decisions. Upon further investigation however, Dr. Greene discovers that Dr. Rowland and Dr. Jablonsky once had an intimate relationship that recently ended badly and he has been avoiding her since the breakup. Dr. Greene is concerned that Ricky is not aware of the consequences of his decision and will soon sign out AMA and eventually lose his foot or his leg due to gangrene. As Dr. Greene, how do you proceed?

--Written by Kate  Sulkowski

Amy and John

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Amy and John are a young couple with a five year old daughter Abby. Amy also has a nineteen year old son, Brian, from a previous relationship. They had planned on having a large family. Abby was diagnosed with leukemia when she was two years old. She has had three surgeries and is currently on the transplant list for a bone marrow transplant as well as a new kidney. A bone marrow transplant would most likely put her in remission enough to receive a new kidney. Abby is on dialysis six days a week and spends most of her time in the hospital. Abby has never been to preschool and hardly plays with children her own age, except for in the hospital daycare, when she is well enough to go there.

            Neither Amy nor John are blood matches for Abby. Brian left home when he turned eighteen, has not been tested as a possible donor, and has not made contact with the family for four months. No other close relatives are match for Abby.

            Prior to Abby getting sick, Amy and John discussed having another child. Now however, Amy and John approach Dr. Johnson, a fertility specialist, to help them have another child. They want to select various aspects of the fetus. Specifically, they want to select for a child that would have the same blood type as Abby in order to use the cord blood from the birth as a marrow transplant for Abby. They also hope that the new baby will be able to donate its kidney to Abby at a later date. During her initial meeting with the couple, Dr. Johnson notices that John does not talk much and when asked direct questions he tends to direct them towards Amy or answers with one word answers.

This concerns Dr. Johnson and she decides to sit down with Amy and John separately. When she talks with Amy, she can tell that this is their last option to save Abby’s life and Amy is clinging to the only hope she has left. Amy is well within child bearing years and having another child would pose no immediate health risks to her or the potential baby. Amy wants to begin this process as soon as possible and wonders exactly when they can begin. However, during her discussion with John, Dr. Johnson has to ask him a lot of questions before he finally blurts out that he is not alright with designing a child to be used to save Abby. He was raised a staunch Catholic and he believes that every life is sacred. He is concerned about the eggs that will be lost in the process and the potential lives they could have been as well as the idea that their new child will be used as a commodity. He states that he knows he and Amy will love the child regardless of the outcome but he is concerned about Amy’s motivations behind having this child. He is too nervous, however, to talk with Amy about his concerns and problems with the creation of their next child because he fears she will leave him if she thinks he is not on board. He is also afraid of the guilt he will feel if he does not do everything possible to save his little girl. However, he swears that he cannot tell his wife about his feelings and asks Dr. Robinson to keep them confidential. Dr. Robinson calls the couple into her office the next day to discuss the options available to the family. As Dr. Robinson, do you offer to help them create a baby with the desired blood type?

-Written by Kate Sulkowski

Brad and Dr. Robinson

Brad is a seventeen-year-old male with advanced cystic fibrosis (CF). Due to the present condition of his lungs, Brad has been given about three months to live. Brad comes into the ER with his girlfriend Jenny. Brad is unable to breathe. Dr. Robinson ascertains Brad’s age, after Jenny unwillingly gives it up, and intubates him. After Brad is intubated, his mother is located and called. When Brad’s mother Janice arrives, she informs Dr. Robinson that Brad has been living with Jenny in an apartment recently. Janice and Brad have recently been in a fight because of Brad’s decision to run away and live with Jenny (and not her). Dr. Robinson pulls Brad’s mother aside and tells her that there is a good chance that Brad will not wake up. His brain was without oxygen for an extended period of time and there is a good chance that he will not recover. Also, the amount of time on the ventilator did nothing to improve Brad’s condition and nothing can be done further to improve it. Dr. Robinson asks Brad’s mother about a DNR order and about her son’s wishes at the end of his life. Because of Brad’s adamancy about not being intubated when he originally arrived in the ER, Dr. Robinson is concerned about going against Brad’s wishes. Jenny also returns to the hospital with a non-statutory advanced directive stating that Brad did not wish for any heroic measures and under no circumstances did he want to be put on a ventilator unless it would improve his condition. Janice says she is not ready to lose him and says to intubate him again if necessary. Dr. Robinson looks at the advanced directive that Jenny brought in. Although this is a non-statutory advanced directive, and thus has no legal authority, Brad is extremely clear with his words. Brad wrote that he has watched numerous friends with CF die both on ventilators and on by choking to death on their own saliva and he never wanted to be in that situation. He never wanted to be on a ventilator and he wanted to spend the last days of his life with Jenny. He also wrote that his mother could not understand his feelings because she was blinded by her love for him and her fear of losing her only son. Dr. Robinson is concerned about doing what is best for Brad. Brad has a 2% chance of waking up to even a semiconscious state according to the neurologist’s assessment. He will continue to deteriorate on the ventilator and he will require ANH and a central line infusing his body with medication to control his pain. Taking into consideration the wishes of Janice, Brad’s legal guardian, and the advanced directive Brad wrote prior to his hospitalization, how should Dr. Robinson proceed?

--Written by Kate Sulkowski

Mrs. Klein and Baby A

A very premature baby, Baby A, has been under your care since birth. Her mother, Mrs. Klein, was forced into an early cesarean delivery because of the baby’s condition.  Baby A was born with a very severe form of hydrops fetalis, a condition that causes her to suffer from breathing problems, risk of heart failure, total body swelling, extreme anemia, and bruising all over her skin. She has been on many medications to prevent heart failure and is on a ventilator to manage her respiratory problems. However, even after having oxygen delivered to her body, she shows no signs of improvement and her oxygen saturation levels remain low. Furthermore, because she was born premature, the lung tissue is underdeveloped, and her lungs cannot provide enough oxygenation. You, as the physician, are concerned of causing oxygen toxicity by administering more oxygen and causing more harm than benefit to Baby A. Also, since her condition is worsening, you will have to administer more medications to prevent heart failure, brain damage, and lessen the respiratory complications, but you also know that combining many of the medications and treatments has shown to result in more pain and poorer quality of life. The prognosis is very bleak, but her parents insist on treatment in spite of the lack of improvement and the chance of furthering the child's suffering.
During a meeting with Mr. and Mrs. Klein, you explain to them the burdens of the treatment. However, Mrs. Klein interrupts you.
“We want everything done to keep our baby alive,” Mrs. Klein urges. “We come from a religious family, and we believe that God created human life. It is not acceptable to take away a life that God has created. You have to do everything that you can as a doctor to save people’s lives, not end them.”
What should you do?


-Written by Kiran Singh

Mr. Busey

Your patient, Mr. Busey, is a 77-year-old man who has been on a treatment for AIDS known as HAART, highly active antiretroviral therapy. However, because he has not been taking his medication daily, the HIV has become resistant to the combination of HAART. He has missed many of his regular check ups with you. One day he showed up and informed you that he does not want to pursue any more treatment. He plans to live the rest of his life without any concerns about his health. However, he also informed you that he has a new girlfriend, Ms. Cleary, that he met at the senior home. He also informs you that he has not told Ms. Cleary about his AIDS. You feel a little uncomfortable, but you ask him if he is sexually active. To your surprise, he responds that he is. You begin to talk to him about safe sex practices, but he interrupts saying “we’re just a couple of old geezers. “It doesn’t matter anyways because we aren’t planning to have children.” He shrugs it off and says that he just wants to enjoy himself for the rest of his life. “Anyways, Ms. Cleary has a lot of other medical problems to worry about. She does not need this on her mind, and it would not affect her health much.” You are concerned of the patient spreading the AIDS, but you also know that informing the girlfriend about his AIDS breaches confidentiality. Also, you research a little more about the medical conditions that Ms. Cleary has, and you realize that the even if she did contract AIDS, it would not affect her lifestyle much. However, you also feel a little uneasy because you realize that she may want to know as a precautionary measure. You do not want to breach your patient’s confidentiality, and you are unsure whether or not there would be a benefit of informing Ms. Cleary of her boyfriend’s condition. What should you, as the physician, do?

--Written by Kiran Singh

Tim L.

You are a pediatrician at a family practice. A father, Mr. L, brings his 12-year-old son, Tim, to your office because his son has had a slight fever and other flu-like symptoms. You are told by the translator that the family emigrated from Vietnam a couple of years ago and are becoming accustomed to their new lives in America. However, in spite of their attempt to assimilate, they uphold and value many traditions from their culture.

During the routine check-up, you ask the son to remove his shirt. You observe bruising in a pattern across his back. You ask the translator to question the father about the bruises, and he explains that Mr. L’s wife, Mrs. L, performed cạo gió on their son. The translator continues to convey Mr. L’s message to you on how cạo gió involves oiling and firmly rubbing the skin with a coin in order to restore balance in the body. He further reveals that the family believes that an excess of “wind” causes many illnesses and how cạo gió, or “catch the wind,” is a method of raising the blood to the surface of the skin and releasing this bad wind. He also explains that this is a common practice in Vietnamese families to improve mental and physical wellbeing.

After discussing these alternative medicine practices with Mr. L, you return to your check up with Tim. When you place your stethoscope on Tim’s tiny back, he winces in pain from the bruises, which concerns you. Should you report the parents to the Child Protection Agency?

--Written by Kiran Singh

Kaela and Dr. Israel

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Dr. Israel is a pediatric gastroenterologist who is treating one of her best friend’s daughters, a young 14-year-old girl named Kaela. Over dinner on Friday, Mary, Kaela’s mom, was talking about how Kaela had been complaining about a stomachache that continues to get worse. Her parents have reservations about her symptoms, thinking that Kaela is faking it, because they believe that she is being bullied at school. Dr. Israel says that she is more than willing to see Kaela in her office on Monday. Kaela is usually really sweet and outgoing, but Dr. Israel notices that she is really reserved today. Dr. Israel starts the examination by asking Kaela why she is here. After listening to Kaela talk about her pain, before the examination, Kaela asks her parents to step out during the examination. Dr. Israel asks Kaela how school has been going and Kaela remains silent. Dr. Israel asks if she wants to talk about anything, saying that what she says is confidential. Kaela begins to tell Dr. Israel that she has been confused lately about her body and her attraction to other people. She has always been a tomboy, but she said that she started to notice that she likes girls more, saying that they are attractive. Dr. Israel explains to Kaela that this is common, since she is at the prime age of puberty; it is common to have a fluctuation of hormones making one have these different feelings. Kaela breaths out a sigh of relief and proceeds to thank Dr. Israel. Dr. Israel invites the parents into the room and says that she wants to run a blood and urine sample as well as an ultrasound. Everyone agrees and Kaela is asked to go downstairs to get an ultrasound. An hour later, Dr. Israel gets a phone call regarding Kaela’s findings. She is surprised to find out that Kaela is actually intersexual, the ultrasound shows that she has testes, which were inflamed and causing the pain. Dr. Israel goes down to see Kaela, to find her asleep in the waiting room. Dr. Israel calls over her parents and tell them the news. The parents nervously look at each other, and Dr. Israel asks if they already knew. The parents begin explaining to Dr. Israel that, when Kaela was born, the OB/GYN delivered the news to the parents, who had to decide if they wanted to pick a gender now or wait until the child grew up. The parents decided that, since she looked like a girl on the outside and had girl parts on the outside, then she would remain a girl. The parents beg Dr. Israel not to tell Kaela, explaining that she is in difficult place already and that telling her this news would place even more stress on her. Dr. Israel has reservations about not telling Kaela, because she knows that Kaela has been confused about her sexual identity, but she promises she will not tell. It is clear that Kaela’s parents do love her and want her to be happy, and they think that she will remain happy by not telling her. Would it be overstepping boundaries if Dr. Israel tells Kaela, a minor, about her condition against her parents’ wishes?

--Written by Elizabeth Puzniak

Sarah and Dr. Papke

Sarah has been Dr. Papke’s best friend since they were in grade school.

Dr. Papke is an OB/GYN and today her best friend, Sarah, is coming in for a routine ultrasound at St. Elizabeth’s Catholic Hospital. Dr. Papke is excited to see Sarah, because she and her husband, Brian, have been trying to conceive for years now and it finally happened. Dr. Papke talks to Sarah during her ultrasound, but then becomes quiet when she sees the screen. Dr. Papke asks Sarah if she has had any pain in her lower back and/or pelvic area. Sarah, now a bit frightened that Dr. Papke is asking her this, responds by saying “yes, I have, but I thought that was normal?” Dr. Papke starts a pelvic exam. In doing so, Sarah winces at the tenderness of her uterus and fallopian tubes. Dr. Papke conducts a vaginal ultrasound, she finds no signs of the developing fetus in the uterus.   Sarah notices Dr. Papke’s concerned look on her face and asks if anything is wrong with her baby. Dr. Papke reveals to Sarah that she is having an ectopic pregnancy. Dr. Papke explains that this kind of pregnancy occurs when the fetus is developing outside of the womb. In ectopic pregnancy, the fetus cannot survive, and if Sarah were to go full term and deliver the baby, she has a less than 5% chance of survival after child birth. Sarah is a strict Catholic and doesn’t believe in abortion, and she classifies this as abortion. However, as the doctor you think that she should end the pregnancy now so she doesn’t hurt herself. Would you be willing to risk losing your best friend for a child who is medically already dead?

--Written by Elizabeth Puzniak

Lisa and Dr. Csolak

Just a week after Lisa turned 18, she was involved in a vehicle accident on her way home from school. The paramedics rushed to the scene and thought that there was internal bleeding so they took her to the nearest Emergency Room. She got into the ER and was immediately seen by Dr. Csolak. Her parents arrived a few minutes later and ran to go see her. Dr. Csolak quickly told the parents what had happened, and in front of Lisa, said that she needed surgery right away, thinking that her spleen had ruptured, but would need an MRI to confirm.  Lisa interjects and says that she will not undergo any surgery. Lisa does, though, consent to having an MRI. While at the MRI, Lisa’s parents approach Dr. Csolak and tell her that she has been going through some rough times since her close cousin, Robin, committed suicide. They think that this is Lisa’s way of letting the pain go, by dying of something that can be treated. Dr. Csolak asks Lisa’s parents if anything has changed with Lisa since the suicide. They tell Dr. Csolak that Lisa hasn’t been sleeping, but when she does she has nightmares; she seems uninterested in things that usually maker her excited, such as painting; she hasn’t been eating a lot; and she has been moping and never seems to smile anymore. They wholeheartedly believe that if Lisa was not undergoing grieving of a loved one, she would chose to have the surgery. Dr. Csolak knows that a quick surgery will heal Lisa and that the success rate is extremely high. Her primary obligation is to the patient, but should Dr. Csolak listen to Lisa considering she has her whole life in front of her or should she listen to the parents?

--Written by Elizabeth Puzniak

Jacob and Anya

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Jacob and Anya were high school sweethearts and went to college together.  After college Jacob got a job in marketing, and Anya went on the law school.  Two years after graduating college, Jacob and Anya were married.  They decided that it would be best if they waited to have children until after she completed her law degree.  After finishing law school, Anya and Jacob decided that it was now time to start trying for a family, since they had decided that they wanted to have three children.  They tried for over a year and a half before deciding to consult with a fertility specialist.  Dr. Adams eventually recommended in vitro fertilization, and implanted Anya with four embryos, of which two were successful.  Jacob and Anya were elated; they were finally going to be able to start their family.

            When Anya was twelve weeks pregnant, Jacob’s mother admitted to him that he had an older brother who had died before he was born who had Duchenne Muscular Dystrophy.  Jacob was devastated, and immediately asked for the twins to be tested for the disease using amniocentesis.  The twins were genetically tested for various diseases in addition to Duchenne Muscular Dystrophy.  While neither of the children came back as a carrier for Duchenne Muscular Dystrophy, one of the fetuses came back as a carrier for down syndrome.

            Jacob declared that he believed that they should terminate the child with the down syndrome, because he thought that it was wrong to knowingly have a child who would be significantly affected by a genetic disease.  He further stated that they ought to consider their healthy child who would not get as much attention, if they had to constantly care for their disabled child.   Anya did not know what to do, while she understood Jacob’s argument, she was torn.   However, she eventually decided that it would be better for their family and their future healthy child to terminate the pregnancy for the child with the down syndrome gene.  The physician would have been willing to terminate the pregnancy in the case of Duchenne Muscular Dystrophy, because of the hardships on both the parents and the child.  However, the physician  does not feel right about aborting a child with down syndrome, since he has a child which is developmentally delayed.  Should the doctor preform the abortion on a fetus?

--Written by Amanda Zinger

Deborah

Deborah is a sixty-eight-year-old patient with advanced dementia.  Her appetite has slowly decreased over the past two months, and had a particularly low appetite the past five days.  The care team at the nursing home has offered the option of a percutaneous endoscopic gastronomy (PEG tube) to help provide nutrients she is not getting from oral intake.  Dr. Johnson explains that the benefits are limited in this case with dementia.  He explains that the patients often try to pull out their tubes in their diminished conscious state.  Dr. Johnson leaves the decision up to her children, Robert and Ann, along with her sister Betty.  Robert and Ann agree that the feeding tube should not be placed, stating that their mother is gone, she is no longer the tough woman they know to be their mommy.  Robert states that it would be best to simply let nature take its course, if she is meant to die.  Betty is outraged at their decision.  She yells how can you let your mommy starve to death, she is a fighter would not want to die.  Betty argues that Deborah is a devout Catholic, and that her sister would have wanted the feeding tube, because she believed all life was precious.  No one can argue against Deborah’s belief that she valued all forms of life, which was clearly indicated by her strong stance of supporting pro-life movements.  However, her children still believe that the feeding tube should not be placed, because they believe their mother would be harmed more than she would benefit from the feeding tube.

            Before Deborah entered the nursing home, her children lived several hundred miles away and only got to see their mother several times a year, during holidays and birthdays.  During these times, Deborah refused to discuss her opinions about the early signs of dementia, and her health, stating she did not want to ruin the fun memories, and dampen the event.  However, Deborah and Betty have always been particularly close.  The two of them went to mass twice a week for the past ten years leading up to Deborah’s placement into the nursing home.  The past three years, while Deborah has been in the nursing home, Betty still made it a priority to visit her sister several times a week, especially on Thursday nights for bingo.  Betty also has seen how much Deborah has enjoyed the programs the nursing home puts on during the week, along with spending time with her friends at the nursing home.  Should Dr. Johnson place the feeding tube?

--Written by Amanda Zinger

Andrea

Andrea is a fifteen-year-old patient recently diagnosed with reflux nephropathy, a condition where the kidneys are damaged by the backwards flow of urine into the kidneys.  Over time the kidneys can be scarred and damaged.  With her recent diagnosis, the medical team recommended that she be placed on dialysis, while a donor kidney was found.   However, Andrea and her family are part of a religious sect, Shinto, which does not believe in organ transplantation.  Shinto, a Japanese religion, states they want to keep their bodies pure for God, and do not want impure substances entering their bodies, including other people’s organs.   Andrea’s parent’s, Joel and Carol, state that they have done their research and believe that Andrea could beat the renal disease with a healthy diet, drinking ionized water, and taking herbal supplements.  This treatment plan was formed with help of the family’s pastor, who supports the idea of dialysis as well, but does not condone the idea of a possible transplant, even if the transplant was from a family member. 

            Dr. Wilson, her nephrologist, suggests that Andrea see a psychiatrist to determine whether she understands the treatment options presented to her by the care team and her pastor.  The psychiatrist is also supposed to determine if Andrea understands the requirements of dialysis.  The psychiatrist tells Dr. Wilson, that Andrea understands the burdens and benefits of dialysis, and comprehends that she would be on dialysis the rest of her life, if she did not get a transplant.  Andrea states that she would prefer if she could just “go home” with hospice, stating “It’s all right if I die, I’m not scared of death, I get to go home to God.  I’m just afraid my pastor, and parents would feel that I am just giving up.”  Her parents argue that going home and dying is against their beliefs, and that they could not possibly think of a life without Andrea.  Joel and Carol state that Andrea needs to start dialysis, because she can still have a life with dialysis, even if most of her life would be hooked up to a machine.  Dr. Wilson is torn, while is primary responsibility is to his patient Andrea, he does not know if he can go against her wishes and subject her to years of renal dialysis, which might cause her years of suffering.  Should Dr. Wilson place Andrea on dialysis?

-Written by Amanda Zinger