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