An Inauspicious End to My Forty-Year Career

              The end started about a year and a half before my actual retirement.  I had no idea this would be the beginning of the end.  We had what is euphemistically called a “drug diversion”.  Someone was stealing narcotics.  One of the nurses noticed that a new card of narcotics had been signed out of the locked narcotics cabinet for a patient who almost never took his pain medication.  We had a double record system.  All the back up supply cards of controlled drugs were kept in a locked cabinet.  When new cards of controlled medication came in (there were individual cards for each patient, usually containing 30 tabs in bubble packs), they were signed into the narcotics book and locked in the cabinet.  Signing narcotics in and out took two signatures, a nurse with another nurse as a witness.  When a patient needed to start a new card, the card was signed out of that narcotics book, including the destination (med carts A or B), and signed into the cart book.  There each card would have a page, and the pills would be signed out, one or two at a time, as given to the patient.  There were supposed to be spot checks done, to make sure this was all done correctly.  This patient’s card had been signed out of the narcotics book, but the nurse couldn’t find where it had been signed in to either of the carts, so he took it to his supervisor.   

              That was on a Friday.  The health services administrator (HSA) was on vacation, so the nursing supervisor and some of the nurses reviewed the books over the weekend.  I was going to a diabetes conference on Monday.  I talked to the administrator and knew that they had found more cards missing, going back as far as February (it was now the end of October).  During the conference, I got a call from my boss, the company’s medical director for our contract, among others.  He asked how I was and I replied “Fine”.  He said “Well, I wouldn’t be fine, if I were you!  Don’t you realize all those drugs were ordered on your DEA number?”

              The final toll was 127 cards missing, with 30 pills in each.  It had been going on for 10 months, with increasing numbers stolen each month.  The sign outs from the narcotic book each had two different signatures, but they had been forged.  It was carefully done and had been very successful.  The police and the DEA had been called.

              I waited and worried and waited to be interviewed by the DEA or the police.  I never was. I waited to be fired.  They didn’t fire me.  Not that I had anything to do with the drug diversion, but in contract work, when something like this happens, the contractor has to do something to show their client that they are taking it seriously.  That usually means firing someone.

              Since the HSA had been on vacation when the discovery was made, the company chose to fire her.  They didn’t permit her to come back to work.  They cleaned out her desk and sent her personal belongings to her home.  We all knew that she had nothing to do with the diversion either, but she was the person in charge of the employee who did it, and since they couldn’t say for sure who that person was, they fired her. 

              Except of course, they didn’t, which made me feel a little better about the whole thing.  They fired her from that contract and hired her for an administrative job at the company’s central office. There wasn’t enough evidence to bring charges against the person we suspected actually did the diverting.  That nurse quit, moving on to another nursing position. But this was the first time I felt really vulnerable, like I might be fired.  Suddenly the job seemed much more stressful.  I actually ended up in counseling.  I would go once a month and talk about how afraid I was of being fired.  In the end it seemed to be a self-fulfilling prophecy.

              With all this stress, I had started to think about retiring.  I was approaching 66, which would be my full social security eligibility age.  A year before I had gone to a retreat, entitled “Retirement as a Spiritual Journey”.  I had a long conversation with the psychologist who ran the seminar, who pointed out that I had always been a caregiver, not only for patients, but children, and mother and father and grandmother and now grandchildren.  He doubted I would be able to retire.  I was afraid of that too.  I had known physicians whose retirement only lasted a few months, and who in their 70’s and 80’s and even 90’s were still doing locum tenens work (filling in for other physicians, on vacation or sick leave, or between full-time hires).

              I sang in two choirs at our Episcopal church: the traditional choir on Sundays and a special choir for special holy day services.  We sang for Christmas services, and then for the special Lenten services: Ash Wednesday, Holy Thursday and Good Friday.  We met once a month for a 1 ½ hour rehearsal followed by a covered dish supper.  We started working on the Lenten music right after Christmas.

              On Holy Thursday, I needed to be at the church at 6:30 pm for warm-ups, with the service starting at 7:30 pm.   I was just getting ready to leave the jail at 5 pm, when one of the nurses brought me a large box filled with papers.  I only went to this part of the jail once a week.  They had a nurse practitioner three other days. Most of these papers should have been reviewed by her, but the nurses had been throwing them in a box with my name on the side.  A week’s worth of paper. 

              I was hoping it was stuff I could put off till tomorrow, but the first paper I picked up was the medication renewals.  Meds had to be renewed (or reviewed and not renewed) when their order expired.  We tried to do renewals on the patients’ regular visits, but the dates didn’t always coincide.  The first order at the top of seven pages of renewals was for an asthma inhaler.  When I pulled up the patient’s record on the computer, the order, which needed to be renewed, had already fallen off the medication list (was no longer listed because it had expired).  I knew then I would have to do these renewals and the rest of the box.

              Our choir had worked on this music for four months and now it looked like I wasn’t going to make it to the service.  So I sent out an e-mail, complaining about how the med renewal was handled (or rather not handled).  Then I did the med renewals and picked up the next piece of paper, an x-ray result to be signed off.  Several sheets below that was an x-ray result labelled “ABNORMAL” in large letters diagonally across the report.  You would think that anyone who saw that would know it needed to be seen that day by the nurse practitioner, not thrown in a box for a doctor who wasn’t going to be there for a week (and all the nurses knew my schedule.  There were 4 facilities in the system and I visited each one once a week and had one day set aside for paper work, chart reviews etc.).  This patient had fractured his big toe a week ago.  When I pulled up his record, he had not been seen after the x-ray report.  Buddy taping, cast shoe, crutches: none of the usual care for a fractured toe had been done.  So, while I was waiting for him to be brought down from his housing unit, I sent out another angry e-mail, to even more people. 

              Got him fixed up and continued on with the box.  By now it was after 6:30, so I knew I wasn’t going to make the Holy Thursday service.  One of the evening shift nurses brought a patient in to see if it was OK to take him out of isolation for his shingles.  They caught me ranting and raving!  I explained that it had nothing to do with them, but I was just so angry, angry at missing a chance to sing in the choir, which I love to do, but even more angry at the shoddy medical care that all of this reflected! 

              It was after 7:30 when I made the real find.  There, in the bottom of the box, was a hospital record.  The patient had come to jail directly from the hospital, so the record had been requested and apparently arrived a week ago.  According to the record, he had had a stroke, with dysphagia (trouble swallowing) and aphasia (inability to talk).  He had been discharged from the hospital on multiple medications for high blood pressure and congestive heart failure, plus aspirin to decrease the risk of another stroke.  When I pulled up his record, he was on no medication, regular housing, no special diet.  So I got him down from his housing area.  He had lost 30 lbs in 30 days!  His prison intake listed answers to all sorts of questions, but apparently they were all asked as “yes or no” questions, so he could just shake his head.  No one on intake ever asked him a question in which he had to verbalize a response.  No one noticed that the man couldn’t talk!

              I wanted to transfer him to the infirmary, but that meant going to a different facility and the patient didn’t want to go.  Inmates can refuse medical care, but they can’t refuse housing, so I could force that.  But the patient, whose communication skills had gotten a bit better over the month, had men on his pod who were looking out for him, and didn’t want to switch.  Having friendly support in a housing area might be more important for his welfare than a stay in the infirmay.  His blood pressure was a bit high, so I got him back on his medications, and added some soft food to his diet.  He would now be seen regularly to make sure he was doing OK.

              By then it was 9 pm.  I was tired and hungry (I hadn’t had dinner yet) and angry (and probably “hangry”).  I was also shocked by so much poor medical care in a facility that I was responsible for, so I was even angrier.  So I wrote one last e-mail, telling everything I had discovered and saying “I swear, the next time this happens I will kill somebody.  Unfortunately, it probably won’t be the person responsible.  It will probably be just the next person through the door!”.  And I hit the “send” button!

              In my defense, you have to understand that I am old.  When I was a child, people threatened to kill you all the time!  My mother certainly did, but she let me live to grow up.  Ralph Kramden used to threaten to send Alice to the moon every week on the Jackie Gleason Show “The Honeymooners”.  Everybody just laughed.  Nobody thought too much of it.  This was before much awareness of domestic violence, before postal workers started shooting up their place of employment, before 9/11, and before all the school shootings.  I just didn’t think about how seriously that threat is taken.

              I didn’t even think of it the next day when I got a message asking me to report to the Health Services Administrator when I was finished seeing patients at the end of the day (I didn’t get to the Good Friday Service either!).  I finished with the patients about 5:30 and went to her office.  There was a representative from HR there.  I was asked what had happened the day before.  I told the story.  I thought they were upset that I had lost it in front of one of the inmates (I was sure that would be a story going around the housing pods).  I was asked to write it up and sign it.  I did and was then told I was on administrative leave until the case was reviewed.  The HSA thought that would be done Monday, and she would call me Monday afternoon.

              Well, she didn’t call Monday.  One of the physician administrators of the company did, and it was only in the conversation with him that I realized that it was that “death threat” that was upsetting everyone.  I really didn’t even think about it.  I was just that mad!

              The HSA did call on Tuesday to let me know I’d been fired.  Well, there I was, 66 years old, with a too big house and a too big mortgage, with one child still living home, and not enough saved for retirement, ‘cause I didn’t think it was going to happen just yet.  I mean, I knew retirement was coming: I had some retirement savings, I had had a realtor look at the house and had started some of the needed fixing up.  Now I wouldn’t be able to afford it all and would have to sell as is, getting the house on the market as soon as possible. 

              The next day, I got a call from that doctor at the company again.  Dr. K had called him and reminded him of a different letter that I had sent about a year earlier, telling them I would have to look for another position, because my chronic fatigue was kicking in.  I went through a period of getting a lot of phone calls at night.  I had sent them my phone bills to document that sometimes I would go a week without having more than 1 ½ hours of unbroken sleep, due to phone calls from the jails.  I was on call one week out of three, but the other two weeks the nurse practitioners were on call, so I was their back- up.  I didn’t get a lot of night calls those weeks, but I still got some.  She said they “hadn’t done me any favors” and she felt they owed me; they had never done anything to fix the situation, and I had hung there and done the job.  So he asked me to come in and interview.

              What they wanted was someone to do “Telehealth”, to fill in where physicians were needed at distant facilities, seeing patients over video-conferencing equipment.  They particularly needed this in Pennsylvania and Arkansas.  Problem was, any physician seeing patients over a video from another state had to be licensed in the state the patient was in.  They had never hired anyone specifically for this job because it took months to get a PA license and frequently a year to get an Arkansas license, and they thought, if they could only offer part time work until then, the physician wouldn’t stick around.  So was I interested?  I could do physician peer reviews part-time until the licenses came through.  Sure, why not?  Better than being precipitously unemployed.   And maybe this would let me control the timing of my actual retirement.

              I started the license applications.  Arkansas was a stickler.  I had those 36 lawsuits (I explain about the suits in the blog: Stories from Inside: Sci 2).  Arkansas wanted the initial complaint and the court’s final disposition papers on all of them, so that took some time.  Meanwhile, I did odd jobs for the company. 

              I was asked to go evaluate the problems of a jail we had picked up in November.  This was a private jail, run by a company that usually did its own medical care.  This time, they decided to try contracting it, to see if it could be done cheaper.  The nurses, aides, and clerks would still work for the private prison company.  Only the Health Services Administrator, the doctor, the dentist and the ophthalmologist would work for the contractor.  I was told things weren’t going well and asked to check it out.  It was a small jail with three nurse practitioners, so the MD medical director only needed to go once a week.  They asked if I would take it on.  Our administration saw the problems as being the other company’s issues. 

              So I went to the jail, a 2 ½ hour drive away.  I spent 5 hours interviewing people: the HSA, nurses, nurse practitioners, the warden, even a few inmates.  I went back to my company and told them it was our fault, not the other company’s.  We had taken over the contract in November, walked in, looked around, said “you’re doing a fine job; keep it up” and left them with a new HSA, a doctor once a week, and no guidance or supervision. 

              The first thing that worried me was that they were not following any alcohol withdrawal protocol.  Alcohol withdrawal, unmonitored, can be fatal.  I had lost two patients during my10 years in Delaware prisons.  Both had been on the alcohol withdrawal protocol, getting Librium regularly, but were going to be released and so were taken over to the intake area to wait for their rides.  The rides were later than expected.  Each inmate had a seizure and respiratory arrest in the bathroom at intake.  CPR was ineffective.  We changed our protocol so that medical would take the Librium over to the intake area until the patient was actually released.

              This jail did not use an alcohol withdrawal protocol.  The nurse checked a box on the intake sheet that marked “At risk for alcohol withdrawal”.  The inmate was then put in general population, not monitored, and if he had a seizure was given IM Dilantin, which doesn’t work for alcohol withdrawal seizures.  They did not stock injectable Ativan, which did work.  I was told to take our protocols to the jail and implement them.

              I took the protocols down, and met with the nurses (remember, they work for the other company, the one that runs the prison), only to be told “No, we can’t do that”.  It seems that in the 8 months that we had had this contract the other company had not gotten around to approving any of our medical protocols.  I went back to my boss, who said they would take it up at the next meeting.  After two weeks I had heard nothing; no protocols had been approved yet.  I went to my boss again and said that I could not be medical director at that facility.  Why, at the end of my career, would I be responsible as medical director in a place that would not do what I knew needed to be done for the patients?  I was to say “This patient needs to be on the alcohol withdrawal protocol, having vital signs checked and getting Librium if he develops symptoms” and, when the nurses told me they couldn’t do that, I was just to say, “Oh, that’s OK.”  I wasn’t going to do that.

              By then, my Pennsylvania license came through.  They sent me up to a prison in Pennsylvania for a week to learn their computerized medical records system.  While I was there, I saw an inmate in medical clinic, an older man who had not had his blood pressure medicine in a month.  He showed me a note from medical saying he was out of medication and needed to make an appointment to be seen.  He claimed that when he tried to make an appointment, they gave him one three weeks away, and said they couldn’t renew his blood pressure medicine till he was seen.

              When I saw him, his blood pressure was 225/150.  He was not having symptoms.  The nurses (in Pennsylvania, the nurses in the prison work for the state, not for the contractor that the doctors work for) insisted that they had no stock blood pressure medicines for emergencies.  They had to have cards with his name on them.  The nurse that I was speaking with thought he might have some cards on the med cart, but the cart was out in one of the housing areas.  A nurse would be sent to check.  I left him in the waiting area with orders for medications to be given now, and his blood pressure to be monitored for several hours.  I saw my next patient then went back to the waiting room to check on him.  He wasn’t there.  Despite my orders, he had been taken back to his housing area in another building for count time.  I asked if he had gotten the medication I ordered.  None of the nurses in the clinic or pharmacy could tell me whether he had or not.  I went to the HSA.  She could not get an answer to my question either, so she called the medical administrative person who worked for the state.  She came and talked to the nurses and said yes he had gotten the medicine.  I asked if they had taken his blood pressure again.  If they had, it would be in the med book but that was on the cart, which was over in the housing area.  All I could get was that “yes” answer, that he had gotten his medicine, but no documentation or blood pressure reading.  That was my last day there.

              I went back to the company and told them I was not doing telehealth.  If I could not be sure that a patient was adequately cared for when I was actually on the premises, seeing him live, how could I possibly give orders for a patient from another state?  Again, I would be responsible for the patient but would have no way of knowing whether my orders were being carried out!

              I was then asked if I would take my old job back.  It seems they had not been able to fill it.  I said no, but I did agree to do the review of 20% of the nurse practitioners charts, a review that was required by state law, until I had a replacement.  I did this for two months from home.

              I found working from home difficult.  There were many more interesting things to do at my house than chart reviews.  But I ran into the same problem.  I was retrospectively reviewing what the nurse practitioners had done, but I was not meeting with the NPs.  If I disagreed with what they had done, I was still accepting responsibility for it, while having no input into it. 

              Reading all the above, it makes me sound like a control freak.  I had no problem in private practice, giving advice and medication to a patient, only to have him decide to ignore them.  That’s his choice, with his life.  But when you take some of those choices away in a prison system, it changes the situation.  For the patient to refuse to take the medicine is fine; his choice.  But not to get those medications when he is willing to take them, that is a system problem.  A major part of the medical director’s job is to make sure the systems work and to fix them if they don’t.  In each of these situations, I was unable to fix the systems.  It was time to retire.   So I did.