Stories from the Inside: My first year.

              Apologies: These are the stories I tell when people say “I bet you have a lot of stories from working in prisons”.  Nurses that I worked with will soon realize that the nurses are never mentioned.  It’s not that you were unimportant, or unappreciated by me.  Many of you are what made the day to day working tolerable, and even fun.  But I can’t tell anyone else’s stories.  These are my stories, adventures of inmate/patients.  You have to tell your own.

1. The Death Penalty

              My first day in a prison was not what I expected.  I spent it reading two thick binders.  It took the entire day.  One was the rules and regulations of the prison; the other, the policies and procedures of Correctional Medical Services, the company that had the contract for inmate medical care.  The part that took me most by surprise, just because I hadn’t thought about it at all, was about the death penalty.  CMS was clear, we were to have absolutely nothing to do with the death penalty, not even to pronounce a patient dead if asked.  The reason made perfect sense.  We were here to take care of patients.  The doctor-patient relationship requires a certain amount of trust.  That trust is on shaky ground at best in prison.  How could they trust us at all, if we were also involved in any way in putting prisoners to death?  I hadn’t thought about it, but I was relieved to read the policy.

              The next day I started seeing patients in the infirmary.  I was told that one patient in particular would be assigned to me, to solve a problem that had been going on for 6 weeks.  JC (I will call patients by initials or nicknames to protect their privacy) was in the infirmary with an NG tube, being tube fed.  He was only in his 30s.  He had told the medical staff that he was unable to swallow and lost significant weight, so a naso-gastric (NG tube – nose to stomach) tube had been inserted.  No work up had been done to find out why he couldn’t swallow. 

              JC was scheduled to be executed the next month.  I was told that he had been adopted as a child.  He was in and out of trouble with the police during his teen years, and his parents always bailed him out when needed.  When he got in serious trouble in his 20’s, they had not bailed him out, or had not been able to.  He was sentenced and served 10 years in prison.  He had been heard many times to say he was going to kill his parents for leaving him in jail.  When he got out, he immediately went home and did what he said he would, killed his parents.  He got the death penalty for that.

              JC had waived his appeals, saying he just wanted to get it all over with, but as the time for execution approached, regretted his decision.  What appeals he was then able to make were denied.  From some things he read or that other inmates told him, he concluded that they would not be able to execute him if he were sick.  He had to be healthy to be put to death.  Mostly, he seemed to think that, if he had to have an NG tube, he couldn’t be executed.  I was told that it was my job to separate him from that NG tube.  So much for not having anything to do with putting a patient to death.

              Not that others hadn’t tried to separate man and tube.  I mean, the stupid things are falling out or getting pulled out all the time.  How hard could it be?  But the one time the nurses removed the tube on the doctor’s orders, JC reached under his bed, pulled out a new tube, and inserted it himself!  They should all be so easy to get in.

              Not that he was actually using the tube for its intended purpose.  He would have to be hooked up to the drip bag of tube feeding for some hours each day.  But JC was up, walking around, with the end of the tube carefully pinned in his pocket.  He walked around the infirmary.  He went out to the yard to smoke (smoking was still allowed in Delaware prisons at that time).  He couldn’t possible be getting enough nourishment to keep him alive through that tube.

              One day a nurse saw him take a hot dog off another inmates plate, and an offices saw him scarf two bowls of fruit cocktail.  I was sent to confront him.  JC smiled and batted his baby blue eyes at me and said, “Dr. Burns, I guess I just don’t understand.  I thought I was supposed to try to eat, just to see if I could.”  He still insisted that he was unable to swallow and needed the tube.

              My turn to insist: I insisted that we had to do some tests to find out why he was unable to swallow.  He needed to have a barium swallow and perhaps a video fluoroscopy, or upper endoscopy, to see what the issue was.  Finally since he said he was unable to swallow for the first two studies, he was scheduled for an upper endoscopy, in which a gastroenterologist would pass a tube with a light and a scope into his esophagus and stomach to see if there was a mechanical obstruction.   I explained that the NG tube would need to come out at least 48 hours before the study, so that the findings would not be confused by the trauma of the tube in the esophagus.  He then let me remove the tube.

              He had his endoscopy, which was negative.  While he was gone, we searched his cell and retrieved his stash of replacement tubes.  He had already proven to us that he could swallow just fine, so when the test was negative, he was returned to death row and executed two weeks later.  I would have felt much worse about my part in it, if I had not been an adoptive parent myself.  So much for having nothing to do with the death penalty.  The ethical issues of working in prison were going to be much more complicated than I had thought. 

2.  Why I tried never to ask or know what a patient was in prison for.

              M. was an older man.  I was seeing him for a routine follow-up for hypertension and COPD when he started to talk.  He was coming up for parole.  “I’ve been in here 20 years.  I should be paroled.  I would go around and tell men they shouldn’t do the things I did.  They shouldn’t do them because awful things happen if you go to prison for this.  These days, if that five-year-old had vandalized a house, they would have wanted to charge her as an adult.  I treat her like an adult and I get 20 years in prison.”  He went on to say that he had been sexually molested as a child and thought that it was a good thing that had happened to him, and it was a good thing that he was doing for the children he molested.

              M. clearly wasn’t ready for parole and was not paroled.  He went on to develop lung cancer and died in prison.  I took care of him for several months, and every time I looked at him I remember him saying “that five year old”.  I had one of those at home, a five year old, which made him my worst nightmare.  It was difficult for me to treat him, and I realized it was important that I not know what my patients did to land in prison.

              It is so easy to google patients these days.  Because of this patient, I was determined never to do that.  I broke my rule twice, years later, but those are stories for another day.

3.  Love

              That actually was his first name: Love.  I could imagine a mother holding him as an infant, saying “Isn’t he a little love?”  He was still young, in his late 20’s.  I didn’t know what he had done to land in jail.  What he was doing now though, I was pretty sure, was faking paralysis.  He had had a seizure, which I thought was real.  He had a history of them and was on medication.  After the seizure, he was unable to move his left arm and leg.  There is a condition called Todd’s paralysis, which is a temporary paralysis after a seizure.  Todd’s doesn’t usually last for more than a few hours, but Love’s paralysis was not getting better and was lasting for days.  Except when he slept: his left arm and leg moved fine while he slept, and for the first few seconds after waking him, till he realized that he was awake and someone was watching him.  Then they couldn’t move.

              I had to give him good marks for persistence.  He kept this up for 6 weeks!  He told me that he had an aunt who was paralyzed after a seizure, but her paralysis went away the same day; his didn’t.

              Finally I decided he would have to be evaluated by someone other than me.  The nurses and I documented daily that his arm and leg moved fine while he was sleeping or if he thought no one was watching, but I thought I might need some documentation from a neurologist, so I made arrangements to send him out for a consult. 

              For the trip out to the neurologist, he had to be shackled in a wheelchair and transported by van.  I guess the shackling confused him.  When he got to the neurologist, he couldn’t remember which side was supposed to be paralyzed, so he told the neurologist he couldn’t move his legs but his arms were fine!  The neurologist laughed and sent him back with a note for the chart.  When the officer unshackled his feet from the wheelchair, Love kicked him in the groin, so he was whisked off to disciplinary segregation, and I never saw him again.

4. Earl

              Earl was 75.  His wife was 73 with severe arthritis.  With her medical bills, (Medicare has a deductible and doesn’t pay everything) they were unable to make ends meet on their Social Security so they decided to do a drug run for a local dealer.  They got caught.  Earl’s wife received a suspended sentence because of the arthritis, but Earl got a year.

              He was hoarse when he arrived, and when the hoarseness didn’t resolve, I did an indirect laryngeal exam, with a tongue depressor taped to a flash light and a dental mirror (sometimes practicing in prison is like practicing in a third world country), and I didn’t like what I saw.  Earl had laryngeal carcinoma.

              I went in and sat down to explain what his treatment would entail.  He would have to have his teeth pulled so he could have radiation therapy.  With radiation and chemotherapy, the narrowing of his airway would get worse before it got better, so he would need to have a tracheostomy and a feeding tube.  I told him I could get him out on a medical release and he said “NO!  PLEASE!  Then we would have my medical bills too.  That’s how we got into this mess in the first place.  Prison is God’s way of making sure I get medical care for my cancer!  Don’t send me home!”

              So we didn’t.  Earl had his trach and his feeing tube, and went out to the hospital every day, shackled to a wheelchair, to get his radiation and chemotherapy.  By the end of his year in prison, treatment was finished and we were able to pull his trach and feeing tube.  He was able to eat a soft diet and went home with visiting nurses to follow him.  And once a month he would call prison medical to thank us and tell us he was still doing well.  Sometimes we did good work!

5.  Three quick ones, not necessarily mine

              My first escape: I wasn’t really involved in this, except for being locked down until the inmate was found.  Inmates sometimes torture each other.  The missing prisoner only had two months left on his sentence, but his cellmate and “friends” decided to tell him that his wife was cheating on him.  He decided he had to get out immediately and settle the issue.  When he was missing at one of the routine counts, the prison was locked down.  Everyone, including employees, had to stay in place.  When the inmate was not found after a thorough search of the premises, the prison officials considered what vehicles had left after the previous count.  The only truck that left was a trash truck.  They called the company and had the truck sent back.  The inmate had indeed climbed into the trash truck.  Unfortunately, it was a trash compactor and the inmate was dead.  All because people he trusted lied to him.

              Before I started at my first prison, the chief of security there was walking across the yard one day when an inmate planted a shiv in his belly and pulled up.  He was brought to medical with his intestines spilling out.  I wasn’t there when that happened but I was there when the security chief came back to work again and walked across that yard.  He taught us later that, when called to an emergency in the prison, never enter until security says the scene is safe, and then, know that the scene is never safe.  I admired him greatly for having the courage to walk across that yard. 

              One more story, not mine (breaking my own rules again, but too good not to tell): Marilyn, one of the nurses, stopped for gas near the prison and saw an inmate that she had treated in prison the previous week standing at a pump.   “Earle (a different Earle from the above story), did you escape?”

              “No, Miss Marilyn, I maxed out (finished his sentence)!" 

              “How long were you up, Earle?”

              “30 years, Miss Marilyn, and I am so glad to see you!  How do you pump gas?”

              Lots of things change when you’re incarcerated for 30 years.

The stories above were all from my first year at DCC.  The contract changed after that, and I was given the chance to switch to my local prison: 14 miles each way instead of 44.  So I switched to SCI and from Staff MD to Medical Director.  But that will be the second installment of stories.