Stories from Inside: SCI 2

3. Another favorite patient

              Even working in prison, or maybe especially, a doctor has patients that just become pets.  This one was a favorite.  I’m absolutely terrible at remembering names and have no idea at all what his name was, so I’ll just call him DW.  He had HIV and I took care of him for about 18 months before he was released the first time.

              HIV treatment is a prison medical success story.  Many of these guys don’t show up for treatment on the street, so the only time they actually take their medication is when they’re incarcerated.  We get to watch their viral loads go down and their CD4 counts go up as they respond to treatment.  DW was one of those who frequently didn’t take his medication when on the street.  HIV patients have to take it regularly; they can’t afford to miss a dose, and inmates, out of prison, are not generally the most reliable of people. 

              I don’t generally watch the local news.  The weekend that DW came back to us, he was on the news all weekend and I missed it.  He came in to see me all excited: “Dr. Burns, Dr. Burns, did you see me on the news?  That wasn’t how it happened!  They called in carjacking and kidnapping!  It wasn’t like that at all.  Do you remember Stephanie?”  The only place we had women at SCI was in work release.  DW had gone to our work release program (our nurse practitioner took care of the patients there) before getting out and met Stephanie there.  Apparently, he was pimping for Stephanie and the john refused to pay her, so DW went in to beat him up.  The man pulled a knife.  “See, these are defensive wounds!” and he did, indeed, have defensive lacerations across both palms.  But he got the knife away from the man.  Well, then he had a knife and a really angry man in front of him, so he stabbed him.  “But I didn’t steal the car.  If I had stolen it, I would have taken it to a chop shop.  I just borrowed it ‘cause I needed to get away from the scene.  I left it on the street with the keys in it so he’d get it back!”

              The district attorney offered him a plea deal.  They would drop the assault charge if he would plead guilty to grand theft auto.  He refused.  He hadn’t stolen the car, and he wanted it known that he took care of business; this man had tried to cheat him and he took care of it.  So the DA said, “OK, plead guilty to assault and we’ll drop grand theft auto” and he agreed.  Then they showed the pictures of the victim to the judge.  Apparently, he had beaten him pretty badly.  The judge gave him 9 years on the assault; with grand theft auto he might have gotten away with two years. 

              With all that was going on in his life on the street, DW had stopped taking his HIV meds.  When he came back, his CD4 count was in the teens (above 400 is normal, above 200 would have been OK).  This meant he was close to the end of the line unless it bounced back with medication.  Sometimes the CD4 count rebounds; his didn’t.  Nine years was going to be a life sentence.

              Then Stephanie told him she was pregnant.  First he was elated, thinking he had fathered a child; then he was irate, thinking it must be someone else’s.  I think I was the only one worried (the nurses probably were too, and I wondered if Stephanie was) that maybe he had given Stephani the HIV, but she was tested on her first prenatal visit and she was negative.  The elation wore off and he was just angry at her all the time, thinking she had cheated, (not sure where the pimping for her fits in this? neither was I!) till the baby was born.  The DNA showed that DW was indeed the father!  And you couldn’t find a prouder father!  He showed those pictures to everyone!

              He just couldn’t stay out of trouble though.  This was one of those times (we had several while I was there) that DCC was overcrowded.  They were building a new pre-trial building, to relieve the situation, but at that time there were 32 inmates sleeping in the gym and 13 in the canteen.  Finally the new building opened.  At first, it would be used to relieve the overcrowding, gradually becoming a true pre-trial building as new inmates came in from the street.  But first the ones from the gym and the canteen were going to be transferred.

              DW was in the canteen and led the only revolt (mini-riot) we had in my nine years there.   He and the other inmates in the canteen refused to come out to go to the pre-trial building.  It happened on a Saturday.  I wasn’t there, but I got lots of phone calls.  “Dr. Burns, they’re bringing in the dogs!”

              “Has anyone been bitten yet?  Call me if they are and I’ll come in.”

              Our warden wasn’t stupid.  He simply waited them out.  The inmates held out for thirteen hours, then ended it peacefully and they went to the new building.  Except for DW, of course, who went into disciplinary segregation as the ringleader.  The whole thing made no sense, of course.  The only thing I could figure was maybe they had a drug stash in the canteen that they knew wouldn’t get past the strip search on the way into the new building, so they held out until the drugs were used up. 

              Or maybe they just refused for the sake of refusing.  When I first started in prison, I thought there wouldn’t be any "no shows".  I was wrong.  In prison, you can’t choose where you are housed, you can’t refuse an order from an officer, but you can refuse medical care.  A lot of inmates would refuse simply because they could, and there wasn’t much else they had any choice about.  Control issues are a big deal, and medical care was about all they could control.

              The next time I saw DW, he was still in disciplinary segregation and he was refusing his HIV meds.  When you are in seg, everything is taken from you and has to be earned back.  He said they had taken his bible, and he wasn’t going to take his HIV meds until he got his bible back.  I told him the Department of Correction didn’t care if he took his HIV meds.  He seemed surprised.  I asked him if he cared if I took my blood pressure medicine; if I said I wouldn’t take my blood pressure medicine unless he took his HIV meds, would he take them?  He didn’t dignify that ridiculous proposal with an answer.  I told him it was the same thing.  The powers that be at SCI didn’t care if he took his HIV meds.  Heck, I didn’t even care if he took his HIV meds.  The only person who should care if he took his HIV meds was him.  I’m not sure I convinced him.  Many of the inmates are total narcissists.  They think the whole world is about them, so why wouldn't SCI care it he didn't take his meds?  I often said I went into medicine so I would know the end of the story, but I didn’t always.  He was transferred up to DCC to a higher security level and eventually died of his HIV while still in prison. 

4.  Top bunks; bottom bunks.

              The bunk beds are always an issue.  Many of them have no ladders.  The guy in the lower bunk doesn’t want you putting your foot on his bed to get up and down, so you might have to jump up then pull yourself up.  The issue of whether someone needs a bottom bunk or not is one of the most contentious in any prison system.

              In one of our overcrowded periods, I had an old man, a new intake, come to see me.  “Dr. Burns, I’ve been here before.  I thought I was going to have to come see you to ask you for a bottom bunk memo, but I’m on the floor under the bottom bunk!  Can I get a memo that says I have to be on it?”

              Anyone who comes in intoxicated or is at risk for DTs in the first two weeks or has a seizure disorder or a major medical problem gets a bottom bunk memo.  The annoying one is back pain or a bad knee.  When does an orthopedic problem need a bottom bunk?  Actually, the main ortho problem that actually needs a bottom bunk is a frozen shoulder!  Sometimes an inmate is given a bottom bunk memo but doesn't take advantage of it.  I was called in one night for a 75 year old man who came in drunk and had been assigned to the bottom bunk.  But there was someone in the bottom bunk, and the officer didn’t make him move so neither did the inmate.  The inmate then fell out of the top bunk and hit his head, lacerating a small artery in his temple.  That was one of my most fun suturing adventures.  It took me about an hour and half to get a clamp and a tie to hold on that little artery, but finally I did, and closed the wound.  When I asked the man why he’d climbed up to the top bunk, he said the man in the bottom bunk was drunk and he didn’t want to disturb him!

              I HATE bunk beds.   Right after my residency, long before I worked in prisons, I was working the ER at Germantown hospital, when a mother brought her 6 year old daughter in.  The mother said we knew bunk beds were dangerous, so my husband took them apart and we made twin beds out of them.  Her daughter had run a clothesline from one headboard to the other and tried to tight rope across it.  She fell and hit her mouth.  She had a through and through laceration of the lip, and they usually heal OK, and none of her teeth wiggled, so I thought she was OK, till her mother said “You don’t understand: until ½ hour ago, she had buck teeth and lisped (the woman may have save a fortune in orthodontist bills)!”  Even taken apart they’re dangerous!  There are over 6000 major injuries seen each year in emergency rooms from bunk bed falls.

              At SCI, I had two inmates with major injuries.  Since there were no ladders, some of them would use the boxes they had to put their things in to climb up to the top bunk.  That meant the boxes were left sitting out in the aisle instead of under the bottom bunk.  These two inmates fell off the top bunk, had their feet hit the box and their heads smack down on the concrete.  Both had significant brain injuries.  So I gave out way too many bottom bunk notes.

5.  I know where you live.

              There are disadvantages to being the prison doc who lives in the area too.  I only had one patient seriously threaten me though.  I was treating FF for hypertension, and he decided to refuse all treatment.  His blood pressure was in the 250/150 range.  I hated to argue with him about it, because I knew it would just drive it higher, but it was a treatable condition, so I thought maybe it was worth it.  He said he just wanted to die.  I said he probably wasn’t going to die; he was going to have a stroke and be left handicapped before he died.  I can’t remember at what point he lost it and said: “I know where you live; I know who your children are and where they go to school.  I have friends on the street who will take care of it for me”.  It didn’t occur to me to report it.  Fortunately one of the nurses let the officer know.  The patient was not allowed a phone call before being transferred up to maximum security.  Unfortunately, he did have that stroke and lived several more years with a paralyzed arm and leg.

              Not all those who knew where I lived were a problem, but each one startled me.  The first pizza delivery by Dan, another of my favorite HIV patients, was a surprise.  He became our regular pizza delivery man and knew both my children.  The man who came to clean our gutters knew me from the prison.  It was a bit scary to be walking across Walmart’s parking lot in the dark and have someone yell, “Dr. Burns, remember me?  It’s QD!”  My least favorite was having a work release inmate come up behind me at dusk, when I was standing alone at an ATM machine in front of a closed bank, to ask me a medical question! 

              The fun part: grocery shopping at the beach with my best friend: I was 1/2 an aisle away when she asked what kind of baked beans I liked.  I replied I didn’t care as long as they weren’t like those awful ones at the prison.  Amazing how quickly the aisle emptied out.  My older daughter also got a kick out of having her JROTC instructor ask, in front of a new batch of students, “So, Diane, is you mother still in prison?”

6.  The Suits

              I had been in private practice for 12 years, worked in an emergency room for 2, an institution for the mentally retarded for 1 year, and the Delaware prison system for 2 years and never had a malpractice suit.  Then the Delaware State Legislature in its wisdom decided that inmates who were indigent, i.e., had no money on the books in the prison, could file suit without paying the $125 filing fee.  I was sued 36 times in the next 8 years.

              I always thought that if I got sued for malpractice I would feel so terrible that I might not be able to practice any longer.  I did feel bad about the first suit.  An inmate sued me for refusing to send him for a hernia repair.  The policy in prison medical at that time was that, if a hernia could be easily reduced (put back in place) the patient could not be referred for surgery.  I showed each one how to push it back (it never stayed) and said if he ever couldn’t push it back he needed to see medical.  This particular patient had a large, indirect inguinal hernia (indirect means it bulges out in front of the groin) that over two years in prison became a direct hernia (bulged down into the scrotum).  It was always easy to reduce, but since it extended downward, our hernia belts didn’t help keep it back at all (actually I’m not sure those hernia belts helped anyone.  My grandfather had bilateral inguinal hernias and wore a truss for years: a heavy metal and leather thing, fitted to him, that did keep the hernias reduced.  Our little elastic and plastic jobs weren’t strong enough to help).  In the suit, the patient said I treated him like a dog.  I did feel bad about that.  The patient was released shortly after filing suit and didn’t follow up.  I think he might actually have won something.

              Most of the rest were absolute nonsense suits.  One said I lied to him when I told him he was positive for hepatitis C.  On that one, I sent a copy of the test results to the judge, who dismissed the suit for lack of basis in fact!  The attorney the company had hired e-mailed me and said he would like to tell me that that one was resolved, but the patient had filed an appeal!  How do you appeal a lack of basis in fact?

              One of the inmates who sued me also sued the DOC because his chicken soup slopped over onto his tuna sandwich, which was on the plate with the soup.  He said soup bowls shouldn’t be put on the plate with the sandwiches and filed a suit.  That’s how ridiculous things got.

              One of the most creative briefs was hand-written by an inmate who was supposedly an attorney.  He had been drinking and was in a motel in Rehoboth when he called 911, saying he needed an ambulance.  When the ambulance arrived he told the EMTs he needed a massage.  They told him they didn’t do that and left.  The second 911 call from the same person came over the radio before they even got back to the ambulance.  There was a police car in the area, so they took the police back with them.  The patient maintains that the ambulance attendants strapped him to a gurney and the police then beat him up.  He sued everybody: the mayor of Rehoboth, the police department, the ambulance and EMTs, me, medical at SCI.  Specifically I was sued for failing to document his bruises on intake.  If I’d seen some, I would have documented them.  If I failed to, the nurses on intake would never miss bruises.  The fact that I didn’t mention them and the nurses didn’t either implies to me that there weren’t any bruises to begin with.

               One patient sued me and the orthopedic surgeon I referred him to, for things that happened in the ER before he was incarcerated.  When I asked him why, he said he didn't know the name of the ER doc, so he put down the two doctors names he did know, even though we weren't there.  The orthopedic surgeon then called me and asked me not to refer any more inmate patients to him.  Everything has consequences.  Lost another ortho doc; it was getting hard to find doctors who would see my patients.

              Not one of these lawsuits ever went to court.  I never even did a deposition for any of them.  They were all dismissed by the judge.  But there is a cost to all this.  Most of the suits were pro se – the inmate filing the suit without benefit of an attorney.  But the company with the medical contract had to have an attorney to file the paperwork for my defense, so each lawsuit cost the company, and ultimately the tax payer, $4000 to $5000 to make each of these cases go away.

7.  JR

              You all know someone, that person that you think you have bent over backward for, and they just don’t see it that way.  That was JR.

              JR had multiple medical problems: 7 years before I got to SCI he had carcinoma of the tonsil, treated with radiation and chemo.  He also had frequent kidney stones, and had had a number of lithotripsies.  He had a standing order for Tylenol with codeine.  The nurses would complain that he would pick up the pain meds, take them, and walk off laughing and chatting with friends. But on x-rays he always had stones, and I defended my decision to renew his pain medication regularly, for most of the 9 years I followed him.

              Prior to radiation therapy for oral cancer, most patients have their teeth extracted.  The long term effects of the radiation make teeth deteriorate.  JR didn’t have his teeth extracted.  The dentist who saw him said his teeth were good and could be saved.  Wrong.  Seven years later his teeth were multiply infected.  I sent him to 3 different oral surgeons.  They all said the same thing: they could not pull his teeth until he had hyperbaric oxygen treatments to strengthen the jaw bones.  Otherwise, the maxilla and mandible would simply crumble when the teeth were extracted.  Problem was, there was no hyperbaric oxygen chamber in the state of Delaware.  I called hospitals, vascular surgeons, dive shops; you’d think that a seashore area where people scuba dive would have a hyperbaric chamber.  Nope!  I talked to the Delaware National Guard, Coast Guard, Dover Air Force Base.  No hyperbaric O2 in Delaware!  The nearest unit I could find was at the University of Maryland in Baltimore. 

              It took a year of paperwork and phone calls and discussions with the warden to get permission to take an inmate across the state line for medical care, but we finally got it worked out.  The treatments had to be daily (except weekends and holidays, of course) for 45 straight days.  He had the treatments, plus milk shakes and burgers at McDonald’s on the way back, courtesy of our officer.  Then he had his teeth extracted and things went fine.

              And then he sued me!  I was so pissed.  I’d given him narcotics, because I believed he needed them when other people disagreed; I’d pushed to get his oxygen treatments and gotten his teeth extracted, not to mention treating his hypertension, and he was suing me!  Then I read the suit: it was carefully thought out and well-written; I don’t know who helped him, but I was so well done I would have been proud to have written it myself.  JR filed a pro se suit for non-treatment of hepatitis C, and tried to extend it to make it a class action suit, on behalf of all inmates who had not been treated for their hepatitis C (apparently there is no such thing as a pro se class action suit, but good try!). 

              Hepatitis C treatment was new back then: the treatment was interferon, given by injection 3 times per week, plus ribavirin, 3 tabs twice a day.  Inmates for the most part were not being treated.  Litigation is the only thing that really changes anything in corrections.  This was the third suit for non-treatment of hepatitis C.  So the company set up criteria and we started treatment, just one or two patients at a time.  The patients who sued were the first to be treated, a case of the squeaky wheel getting the grease.  Patients’ liver functions had to be deteriorating, showing that the hepatitis C was causing cirrhosis.  Red and white blood cells and platelet levels had to be high enough to tolerate the interferon and ribavirin, which would have to be stopped if the counts dropped too far.  Certain other diseases would keep the patient from being treated.  JR was a cancer patient, so he would not be a candidate for treatment anyway.  Fortunately, his liver function tests were good, so he didn’t need treatment.  But, as the third lawsuit over the same issue, he did help to get others treated.   

Those are the stories I can remember tonight.  There might be more on another day!