The week in snaps

This is a nice kite I got in the mail from my friend Molly last week. Much nicer than the prison kites. And this week, we'd have to replace "head" with "lower extremity." People with foot, knee, and hip pain have been limping in all week. So I went on a bit of x-ray binge. After being so conservative with x-ray ordering in my last clinic (since my patients usually were paying for all of their expenses out of pocket), it's nice to have that diagnostic tool available...plus it makes me feel like I am "doing something" for their pain other than just ordering ibuprofen, giving them sheets of exercises, and handing them tissues when they are in tears due to pain. Occasionally, the x-rays are actually helpful.

I spend a fair bit of time thinking about freedom since I've been working in a correctional facility. On my way out of work, I walk through the parking lot to my car. Just 50 feet away, the inmates are returning their living units. It kind of amazes me that a simple chain linked fence separates me from all of the prisoners. Not because I feel threatened, but just because of thinking in terms of probability. I often wonder about my chances of being on the other side of that fence.

Working in prison makes me feel very grateful to have a nice family, a good education, and a La Quinta to come home to at night. This month, I have appreciated the fine Christmas decorations in my hotel.



Maybe I should have put up some garland in the prison clinic? One offender told me it was her first Christmas away from her kids, and she cries when she hears Jingle Bells. Some people have "an old number," that is, their department of corrections number has 5 digits instead of 6 and starts in the 50,000's. Some of those folks have spent their lives in and out of prison, while others have been locked up for a long time. One delightfully cheerful and funny patient today told me she been in was diagnosed with hypertension when she got to prison. When I asked her how long she'd be in, she replied 22 years! That's a lot of prison Christmases.



This beautiful tree would have fit right in at my tacky Holiday party last weekend!



Matt and I with our ice sculpture.

Can I take your order?

I've always thought I learned a lot about my current career during my days as a young waitress at Bob Evans. Basically, people don't like to be kept waiting, they appreciate when you are nice to them and they expect you to get them what they want. I used to have nightmares about having tables of people that I forgot about. On occasion, I have similar dreams about patients being left in the exam room while I run late. Ironically, now I spend lots of time counseling about the side effects of the products I used to push: country fried steak and french silk pie. I may not wear a blue apron and dowdy clip-on tie anymore, but I still have to provide plenty of customer service. And as a chocolate heart, I can find it hard to say no to things that seem like no big deal "on the streets."

Stuff for which people have requested I write medical orders:
A snack
A release from wearing her bra (she had shingles...and bras are required by the department of corrections...although wearing two bras does not require an order)
A lower bunk bed
A release from a previous lower bunk bed restriction
An extra pillow and blanket (for a prison aerobic teacher with an injured meniscus)
To cancel her "Pueblo healthy living diet" and then to reorder the diet (by the same offender in the same week)
An order to move back to a living unit close to the "chow hall" (for her bad arthritis)
An order to prohibit working more than 4 hrs/day
An order to get rid of the fruit cocktail on a diabetic food tray
An EKG for my boss who was having chest pain

Lockdowns and Shakedowns

I enjoyed a lighter patient load at prison this week due in part to the usual stuff--patients canceling or no-showing, for which they are charged $3. However, a few patients were also cancelled as a result of a lockdown on Wednesday afternoon. Apparently when fights break out or there is some sort of mayhem, the "shift commander" (boss of daily operations) issues a lockdown, and the offenders must stay where ever they are until it is clear. In this instance, two women from unit 2 got into a brawl. I guess there was quite a weight class differential because when they brought up the ladies for an "anatomical" (full body nursing assessment in the medical clinic), the lightweight was missing a chunk of hair and had some abrasions, while the heavyweight contender didn't have a scratch. I hear of a few catfights in the women's prison, but the serious fights happen in the men's prison. These can have fatal outcomes.

When prisoners break rules or get in trouble, depending on the seriousness of the offense, they are brought to the "seg" unit. In this area, they are in their cells for 23 hrs/day. I made a trip to seg in my first week at prison to accompany our nurse practitioner as she gave a breast cancer awareness and self breast exam lecture. (Nevermind that teaching self breast exams is a USPSTF category "D"...the prisoners seem to really enjoy health education.) Anyway, imagine about 20 prisoners trying to watch this talk while looking through the 5 inch wide windows on their cell doors. I had to walk around with the self breast exam poster to each of their cells so they could take a quick look. The seg cells do have a small window to the outside world, which I think would preserve my sanity. Often as I leave the prison at night, I see prisoners in the medication line adjacent to seg signing to their friends who are locked up.

By some stroke of luck, I am on a list serve for a men's prison and get emails with the daily "incident report." These contain reports by officers detailing a wide range of topics --from unruly prisoner behavior to malfunctioning equipment on the campus. These objective descriptions can be quite hysterical at times. ("I, Officer H, witnessed offender #(insert 5-6 digit number here) place a brick of cheese in the kitchen on the underside of a metal cart. I later asked him what was in his pocket and located the brick of cheese.") Many of the reports have to do with illegal tattoo equipment seized during searches and shakedowns. I am still trying to learn what a "shakedown" is, but I think it is a cell search after a piece of contraband is found. Apparently, you can dismantle a radio and use it as a tattooing machine. Don't expect me to come home for Christmas with "prison doc" with a heart around it on my bicep.

Pleasantville

I had a very pleasant day at the prison today. It's amazing what having a few motivated, reasonable patients on my schedule will do for my job satisfaction. Instead of copping an attitude when I declined her request for "bottom bunk restriction," my anorexic patient with a history of a controlled seizure disorder actually thanked me for my "thorough evaluation." (DOC has pretty strict criteria regarding who can have a lower bunk because EVERYONE wants one. She didn't qualify.) I also had a good visit with an diabetic amputee whose sugars are much improved since tweaking her insulin regimen almost weekly over the past 2 months. She also said she was feeling much happier as a result of achieving better diabetes control, so that was encouraging. In the afternoon, I saw a few ladies who were eager to manage their hypertension and high cholesterol. One lady excitedly told me she had lost 40 pounds and recently had gotten her cosmetology license, both of which had improved her confidence. (I REALLY need a hair cut, but don't think I'm ready to have the inmates tend my tresses...yet)

To top things off, I found out about 6 of my requests for specialist consults or imaging studies had been approved (including a few MRIs I didn't think had a chance). It's like a Christmas miracle!

Could that breakfast burrito with Pueblo green chili have been just the ticket to start my day off right? FYI the chili is both a pepper and a type of stew/gravy used to smother sandwiches ("sloppers"), recently featured on Food Wars. I can't say they look pretty, but the taste is growing on me.

http://www.youtube.com/watch?v=h49_G5JWejc

Livin' La Vida Pueblo

While working in Pueblo four days a week might not have been exactly what I had in mind for my first job in Colorado, I am enjoying it. Who wouldn't love a piping hot Belgian waffle every morning? And who wouldn't want to drive 2 hrs south on Monday morning at 5:30 am to enjoy one? Ok, probably next to no one. The delightful waffles are the high point of the Pueblo breakfast as the case may be. Tomorrow is "Dress Down and Breakfast Burrito Day," and you can be sure I have pre-ordered my breakfast burrito. They apparently come with something called "Pueblo green chili," a local treat I am eager to try. I asked someone how the prison guards could dress down and was informed they can wear jeans with their prison uniform shirts. (Furthermore, I got a mass email stating, "you may dress down but you still must act like a professional." Thanks for the clarification.) I will be sticking to dress clothes.


My evenings in Pueblo are simple, but I really haven't gotten too bored. Between trips to Target and the Dollar Tree, the treadmill, knitting projects, The Girl Who Kicked the Hornet's Nest, and dinners with a few new nurse friends, I have managed to stay occupied. One night I came upon this sign outside the La Quinta conference room:


I peeked in the class room and saw a big "Join the NRA Today!" poster. Although I didn't attend that time, you never know after a few more months in Pueblo...A nurse reminded me last week that "this is a red state." I reminded her that I moved to the blue part.

Pueblo's major employers historically were the steel mill and the state mental hospital, formerly known as Colorado State Insane Asylum, established in 1879. A city of about 100,000, Pueblo boasts a downtown River Walk and two Walmarts! If that wasn't exciting enough, I am pleased to let you know it is located in a "banana belt," which is a region that enjoys warmer weather than the surrounding area, especially in winter, apparently. Today was sunny and 50, so I believe it's true.

I'll take two tickets to paradise....I mean Pueblo.

Making a run for it

An excerpt from a prison staff email:

"Exercising on your lunch hour can offer many health benefits and is a wonderful way to eliminate stress. If your chosen exercise is running, then please notify the Main Entry staff BEFORE you run out of the parking lot and onto the roadway. Seeing someone running out of the parking lot tends to cause stress on the staff members who are manning the armed posts."

I think I'll save my running for the La Quinta treadmill after work.

Wearing Thin

Perhaps it is the six weeks of driving to Pueblo and lugging my stuff in and out of the hotel or maybe it's the ever growing number of chronic pain patients on my schedule, but this week is wearing on me. I'm seeing about 14 patients a day, which pales in comparison to the 22+ I'll see if I take a job in a Denver community health center. The bottomless basket of charts "to review" is a welcome relief from the patient visits at the end of the day. And tomorrow I have to see my least favorite patient: a 40 something yr old who is convinced something is seriously wrong with her and derails all of my attempts to take a history with her tangential thought processes. I am just waiting for her to file a grievance against me and call her lawyer (which I heard she has done in the past).

Depending on your view of musculoskeletal medicine, the prison population is either a treasure trove or your worst nightmare. (For me, more of a nightmare.) There are very limited means to treat chronic pain here, so I end up telling everyone to exercise, lose weight, and take NSAIDs. Luxuries like PT, massage, accupuncture, and pools are not an option. (Even social support is hard to come by.) Occasionally it seems like a brace would be helpful, but the inmates have to buy these from "canteen" with the money they earn working in prison. Often, they say can't afford what I recommend and it's usually true because I can see how much money is in their account (one funny difference compared to medicine "on the outs.")

There are a wide range of jobs in prison including "porters" who clean the offices, cooks in the kitchen, harvesters on the "farm crew," and the "pusher" who pushes the wheelchair of a diabetic with an amputation, plus many more. Nearly all of the MRIs and outside consults I have requested to orthopedists or podiatrists have been denied by the prison insurance company. Which leaves me with, as I recall hearing in medical school, "the most powerful tool in modern medicine...the human hand." (Being an osteopath would be extremely helpful!)

Today I attempted a knee injection and a ganglion cyst aspiration. Hopefully they'll fare better than the lady whose trochanteric bursa I injected a few weeks ago. She had no improvement and was tearful and frustrated yesterday. I think I absorbed all of her frustration right into my trapezius. Six weeks in prison have left me feeling like I have fibromyalgia. At least I can soak in the La Quinta hot tub and sleep on a decent mattress, so I'm grateful for that.

Just one more day of work this week and then I'm off to "headquarters" in Colorado Springs for a provider meeting on Thursday.

Fountain of Youthful Offenders

Once a month, a batch of new teens/young adults arrive at our prison to start the Youthful Offender System (YOS), a program that focuses on education. Completion of this several year, multi-phase program will shorten the prison sentence for offenders age 13-21. (The vast majority of the inmates in my prison are women, but some youth and adult males are in a separate area of the prison for a short term.) The first month of YOS is a boot camp, and day one of boot camp includes a military-like welcome and subsequent parade through the medical, dental and psychiatry clinics. My boss warned me that "there would be a lot of yelling in clinic" when the youth came for their medical exams. I would never have made it in the military.

Just after noon, seven teenage boys in yellow jumpsuits enter the clinic scooting along the hallway walls with canteens over their heads while drill sergeants yell and, at times taunt them. Meanwhile, one woman with a video camera follows them around documenting everything. (My only guess is that this is to ensure the tough love/breaking in is humane and follows some kind of standard?) My job is to basically do a sports physical on the youth to ensure they are cleared for the physically rigorous boot camp, all the while trying to keep a straight face when they answer "ma'am, yes ma'am!" and "ma'am, no ma'am!" to my medical questions. I had one kid today say "ma'am, no ma'am to 8 question in a row, and when I tried to ask an open ended question, he said "ma'am, none ma'am!" (Another funny moment: me "have you seen your tongue? does it always looked like that?" Youthful Offender "ma'am, yes ma'am!" It was the strangest tongue I've ever seen!)

All the ma'am responses drive me a little crazy, and I gave one of the drill sergeants a dirty look for scolding one of my patients when he just answered "yes." And don't be the kid who says "ma'am, no sir" to a drill sergeant, because that does not go over well.

Coming up tomorrow, there will be a multidisciplinary debriefing and potluck, where the staff discuss each offender's medical, psychosocial, education, legal, and gang background before the youth go to the yard for their "exercises." The debriefing last month broke my heart. Most of the kids never even had a chance. Hopefully, they can get through YOS and get their lives on track. And until they do, I will keep tending to the broken noses and busted up lips from the fights that break out at the main YOS campus down the hill.