Stories from Inside: SCI

              After a year at Delaware Correctional Center, the contract changed, and Prison Health Services, the new medical contractor, let me switch to Sussex Correctional Institution as their medical director and only physician.  SCI was 14 miles from my house; I had been driving 43 miles each way to DCC.  I was there for 9 years, with three different employers on four different contracts.

              Delaware is one of two states in the US that have no county jail system.  All prisoners, pretrial or sentenced, go to one of the 10 state facilities.  So our new intakes came straight from the street, with alcohol and drug withdrawal issues.  We had a 5 or 6 (sorry, guys, it’s been a few years) bed infirmary.  One cell had 3 beds, the others had one each.  The room on the end was a suicide room with a molded plastic bed bolted to the floor, and a hole in the floor for a toilet that flushed from outside the cell. 

              SCI then, was my local facility.  I was amazed at how many people I already knew, and I don’t mean employees.   I had been in practice in the next town over for 12 years.    If I didn’t know the inmates, I knew their mothers or grandmothers or sisters or aunts (as the only woman with a family practice, a lot of my patients were women).   Prison inmates can be your friends and neighbors! During my time at SCI, I did prison intake physicals on 5 people that I had done kindergarten physicals on.  Some of them had poor parenting, but some had strong families and good parents. 

              Most of what I did was standard out-patient internal medicine: hypertension, diabetes, heart disease.  There was a lot of paperwork to get an outside appointment, and sometimes a significant wait, but patients with cancer, kidney disease, serious heart disease, and major orthopedic problems eventually got diagnosed and treated. 

              I thought, when I told my grandmother that I was taking a job in the prison, that she would be upset or opposed to it.  She simply looked up and smiled and said “Job security!”  Dr. Robinson, when he interviewed me, said working in a prison was usually safe, and that’s true.  Most of the inmates just want to get out in no worse shape than they came in.  They tend to treat the doctor OK.  Even if I was saying No to something they wanted, they would be nice, hoping I would say yes the next time.

              When I was 16, I wanted to be a veterinarian and I worked for one for two years.  I found that there was sometimes a conflict of interest between what the client (the one paying the bill) wanted and what would be best for the pet medically.  When I decided to go to medical school instead, I found the same issue in pediatrics (for instance, parents who refuse vaccines).  I decided I was fine with adult medicine.  If you want to drink or smoke yourself to the edge of the grave, and I knock myself out to keep you from taking that last step into it, and you get better and decide to go back to smoking and drinking, that’s OK with me.  It’s your life.  I do my job, and I will tell you what would be medically best for your health, but if you decide otherwise, I’ll still take care of you (The doctor whose office I worked in for a time would expel patients from his practice if they wouldn’t follow his directions.  I saw that as their choice).

              Having refused to deal with a two-way conflict of interest, in prison I found myself with a five way one!  There was 1.  What the prison/ Department of Correction wanted: which was medical care to the community standard, done cheaper, with minimal transports out or hospital time, and not to be sued.  2. What the company I worked for wanted: which was the same but cheaper still.  3.  What the inmate wanted, which frequently had nothing to do with health care and more to do with comfort issues: a better mattress, a better pair of shoes, an excuse from work, an exemption from a drug treatment program, something for pain.  4. What good medical care would dictate, and 5. What, in all of this, I was able or willing to make happen.  It was this conflict of interest that made the job endlessly fascinating to me.   The constant challenge of correctional medicine is deciding whether something is a medical issue or a comfort issue.

              The other surprise was the impact that granting the simplest, most reasonable request, can have on your practice.  For instance, an HIV patient with anemia asked to have an afternoon nap.  He was in a residential drug program, with activities all day, but his request was reasonable considering his physical condition, so I wrote the order.  The next day 16 patients had requested to see me about naps.  The prison administration wants to treat everyone exactly the same.  Medicine wants to treat each person differently.  Inmates want whatever the other guy has.  I took to discussing all unusual requests with our health services administrator, who had worked corrections longer than I had, and could see the implications of granting a request that I overlooked. 

              I was also glad that I went into corrections after a year at Stockley Center.  I spent a year at an institution dedicated to maximizing the potential of a group of people who had very little potential for contributing to society, except perhaps for giving that society a chance to demonstrate good intentions.  Now I was in a series of institutions that didn’t care at all about maximizing anyone’s potential, with a resident population that had great potential for doing something good, but hadn’t done so. 

              The best stories I can remember from SCI:

1. My favorite story: the handcuff key

              The inmate was 22 years old.  The court sentenced him to 53 years (I don’t know what for).  Someone in the courtroom (the officers could all produce theirs, so presumably not an officer) slipped him a handcuff key.  In that little bit of confusion after sentencing, he unshackled his feet and ran.  The bailiff and one of the correctional officers brought him down, but in the process, he swallowed the handcuff key!

              We got an x-ray, which showed the key in his lower esophagus.  I spoke to the gastroenterologist at the hospital who said the key was small, so why not just let it pass.  Next thing I knew, two men came over from maintenance to bolt a metal plate over that hole-in-the-floor toilet in the suicide room.  The warden then appeared with the inmate.  He gave him a bucket and a batch of tongue depressors and told him he wasn’t getting out of the room until he produced the key. 

              I saw the infirmary patients every day that I was there.  He complained of a little constipation (the GI doc had said not to give him laxatives; it would pass on its own), a little gripey abdominal pain.  A week went by without the key.  I thought we should repeat the x-ray.

              This was happening at a bad time for us.  We usually had x-ray in house through a company that sent a tech with a portable x-ray machine, but a week before this started, our tech was fired for molesting an inmate at the women’s prison, and he had not been replaced yet.  So we would have to send him out to the hospital for the x-ray.  We did.  Oddly enough, the key was still in the same spot in the lower esophagus.  So back in the suicide room with the bucket he went.

              Another week went by without producing a key.  The warden said he was not sending him out for another x-ray; he could just stay there.  Another week went by and still no key.  The warden agreed to the x-ray on Monday.  We sent him out to Beebe hospital.  The key was still in the same place.

              I spoke to the gastroenterologist.  He said he could endoscope him and retrieve the key, but he couldn’t fit him in the schedule until Friday.  We would send him to x-ray first, and if the key was still in the esophagus or stomach, he would retrieve it. 

              The officer who usually did our medical runs had been doing them for nine years.  When inmates went out, their ankles were cuffed together with enough chain between for careful walking, but not running.  A chain ran up from that chain to another fastened around the waist.  Wrists were cuffed tightly together in front and fastened to the waist chain.  For an abdominal x-ray, the waist chain had to come off.  So his hands were cuffed together, but not fastened to anything else.  The officer separated the ankles and fastened one to each side of the x-ray table.  So, after the film was taken, he felt comfortable leaving the room with the technician, so he could grab the x-ray and carry it up with the patient.

              The x-ray tech picked the film up from the developer, threw it up on the lighted x-ray reader to see if it was good enough and said, “There’s no key here!”

              The officer looked at the film, looked at the tech and said “Go, hide!  I swear I’m gonna shoot this guy!”  In nine years of medical runs, he had never unholstered his gun, but he drew it this time. 

              He ran back into the room.  The patient was sitting up, key in hand, and had just managed to get his feet unhooked from the table.  He hit the ground running.  Our officer and his partner (takes two for a med run; the other was usually just whoever was available) brought him down and, in the process, the inmate swallowed the handcuff key again. 

              So they took him up to the GI lab, and the gastroenterologist snared the key, cleaned it off and handed it to the officer.  The inmate sat up, looked at the officer and said: “Well, it’s about time.  I’ve had to recycle this thing 4 times!”

              The inmate had short, kinky hair, and each time he recovered the key he hid it in his hair for the trips out to the hospital.  There was supposed to be an officer supervising the inmate and his tongue depressor looking through the bucket of stool for the key.  The officer didn't care for the smell, so he had supervised from outside, through the window.  On the first x-rays, when the inmate realized he wouldn’t have a chance to escape, he swallowed the key again, which is why it was always in his esophagus.  On the last trip, he took the chance, knowing he wouldn’t have another.  I never saw him again.  He was taken from the hospital up to maximum security at DCC, and I suspect he spent the next 25 of his 53 years in solitary. 

              If only some of this determination and creativity and willingness to take risks went into doing something good!

2.  Trust but verify.  Well, mostly verify.

              A. We got a call that the officers were coming from court, bringing us a patient with chest pain.  Why they didn’t just take him to the hospital, I will never understand, but they brought him from the court in Georgetown to SCI medical.  The patient was an older man, (I’ll call him A.S.), who was clutching his chest, moaning, and thrashing around on a gurney.  He said that morning he was lying on a table, having his groin shaved for a cardiac catheterization, when two Delaware State Police arrived, took him off the table, and brought him up to court in Delaware.  He had been arrested in Florida five days earlier and sent to their local hospital with chest pain the day he was admitted. 

              It was a great story.  However, his ECG was normal, except for his increased pulse rate, which could have to do with all the thrashing around, and despite the moaning, he was not diaphoretic.  So I figured I could take the time to make a few phone calls. 

              I called the hospital in Florida.  They had no A.S. scheduled for cardiac catheterization.  He had been admitted there five days earlier and discharged two days earlier with a diagnosis of non-cardiac chest pain.  There were no plans for follow-up.

              So I called the jail in Florida.  They said, yep, they had admitted him and sent him out the same day with chest pain, getting him back 3 days later and the officers from Delaware had picked him up there early this morning.  They recommended that we not fall in the same trap. 

              I told the patient what the hospital and the jail in Florida had told me, that he was discharged from the hospital two days ago and no cath was scheduled.  He simply rolled his eyes and said “Two days ago, today, in all the confusion it’s hard to remember!”  We did not send him to the hospital.  He did fine.

              B.  Might as well call him B.D.  He came in from the street, an African -American man in his early 20’s, very thin and looking sick.  He told me that he had sickle cell disease and colon cancer.  He named a local hematologist-oncologist as his doctor and said he was being treated at a local hospital.  They were planning to do a bone marrow transplant on him, and he was on dilaudid for pain. 

              BD certainly looked ill.  He even had a chemotherapy port in his chest.  I bought the whole story, until I examined him.  His only scar was from an inguinal hernia repair.  I asked if they hadn’t done surgery for the colon cancer.  If he had said no, that they’d just done a colonoscopy and removed a polyp that turned out to be malignant, I still would have bought the story.  But he pointed to the inguinal hernia scar and said “Oh, they just went in from there.”  So I got suspicious.

              I don’t know why these guys think I’m not going to pick up a phone and verify their stories.  Maybe they wouldn’t lie so much then.  I hate to say it, but some inmates are like some politicians, the sign that they are lying is that their lips are moving.  Some couldn’t tell the truth even if it was to their benefit.

              First person I called was the oncologist, but I had to leave a message for him to call me back.  So I called medical records at Beebe Hospital.  They faxed me 8 ER visits and hospitalizations.  Apparently this patient had, not sickle cell disease (SS – two genes for sickle hemoglobin), but SC disease (one gene for sickle hemoglobin, one for hemoglobin C – SC disease doesn’t have the same profound anemia or severe, frequent crisis pain as SS disease, though SC patients commonly have mild anemia and a few minor crises each year, and are prone to severe chest infections and infarcts in the retina).  Every ER visit ended with “We don’t understand why he has such severe crisis pain with a hemoglobin of 12 ( normal in a man is 14 to 17; a hemoglobin of 6 or 7 is not uncommon in a sickle cell disease patient), but given his past history and the fact that he has a chemo port, we will admit him on IV morphine for pain and discharge him with a prescription for dilaudid.” 

              The oncologist called me back while I was reading all this.  I told him the story the patient told me.  He just laughed hysterically.  He had followed the patient from birth.  He never had a crisis pain till he was admitted to the hospital at age 19 for pneumonia and discovered the joys of narcotic pain medication.  He then started making frequent visits to the ER.  During one of those visits, in which they were having great difficulty finding a vein for an IV, a passing surgeon said “Let’s fix this once and for all,” took him to the OR and put in a chemotherapy port.  Now BD had a tap to the legitimate narcotics cow!  There never was any colon cancer or any bone marrow transplant planned.  I’m not sure why the patient decided to enhance his story.  It was that part that created the doubt in my mind.

              By the time I got all this information, the patient’s intake had been finished and he was placed in an infirmary cell.  I was also getting ready to leave.  The evening nurse, who had heard the story, said “But what should we do if he starts complaining of crisis pain?”  I said, blithely, “Give him two aspirin and call me in the morning!”.

              BD was discharged about three days later.  About 6 weeks later, I was walking through the infirmary section back to my desk and I overheard “I have sickle cell disease and colon cancer and they are planning to do a bone marrow transplant”.  I walked around the table to where the inmate could see me and cleared my throat.  BD looked up and said, “Oh, you!” and buried his head in his arms.

              He got out again that time but returned later with a sentence of some years.  During the years we cared for him at SCI he developed chest syndrome and damage to his retina, both of which were diagnosed late, largely because of the number of times this patient cried “Wolf” over the years, in his never-ending quest for pain medication. 

              There are more stories, but I don’t want to make the blogs too long, so I’ll post this one.  More to come if anyone is interested.