There are many days when I feels satisfied to have chosen primary care as my field. I can brush off questions like "are you JUST a family doctor?" and "aren't you going to specialize?" with ease and even a touch of primary care pride. However, feeling like any medical ailment COULD be within my domain also causes a bit of anxiety for this newly minted family doc attending. Of course, there are limits, but in prison I might be the only doctorly eyes that see a patient for sometime.
Uncertainty in medicine has always bothered me. I want to know the answer to every question, even the mundane ones. I'm beginning to make a list of the scourges of humanity, problems which plague my patients and, therefore, are plaguing me because I can't answer them with a snappy diagnosis. White lines on your nails? Excessive hair loss? Numbness "everywhere"? Dizziness? Eyelid twitches? Well, that's clearly... hmmmmm... Don't sweat the small stuff, right?
Prisoners also often try and cram as many vague and random complaints as possible into a single visit to avoid being charged for multiple visits, which is not unlike patients on the outside. I have to set limits with the number of things I'm willing to address but that doesn't always go over so well. A lady earlier in the week got huffy because I wouldn't refill her prilosec or talk about her GERD after we were wrapped up her visit on pelvic pain. She was bad mouthing me all the way out the clinic. Why battle over prilosec? Well, I don't want to, but you can buy it on canteen -although pricey- and the visit was over by the time she brought it up. I felt my usual chocolate heart turning a bit stony. Perhaps I should attend the upcoming Swedish CME about maintaining empathy...
Wednesday, January 26, 2011
Tuesday, January 25, 2011
Plotting my escape
A great way to remind yourself that you're not actually in prison is to take a weekend trip to Seattle. My friend Alyson was flying in from Boise for a baby shower so I decided to join her for a weekend getaway to our former stomping ground. We enjoyed a fabulous weekend catching up with our friends and trying restaurants I missed while living in the Emerald City(Hi-Spot, Harvest Vine) plus some new ones (Cheeky Cafe). We even went out for more hours on Friday night (9hrs!) than I worked on Thursday (8 hrs). Who doesn't enjoy some Capitol Hill bar hopping, junk food munching, and karaoke singing with a bunch of doctors? We also stopped by our favorite markets and only needed our rain jackets one day!
Then Monday morning...back to prison. The lockdown was still in effect, so I only saw two patients yesterday. Today was a "modified lockdown," so the medical clinic was open for business. I don't know if any more shanks were found, but I hear some hooch was found in a coffee pot. (Homemade hooch is popular prison contraband...I'm told it can even be made out of metamucil...blech!) We have a lot of medical appointments to make up, so the rest of the week should be busy.
I also heard a piece of depressing news today: our best nurse has put in her 2 weeks notice. She is my go-to nurse, the most reliable one, the only whose judgment I value most. And she looks after my schedule. I think current nurse drama has a lot to do with her departure. I also am plotting my next career move and have had a few interviews at a Denver community health center. I like the prison work overall and am beginning to see improvements in diabetes control, results of labs/studies I've ordered, and am learning alot, but the early and icy commute to Pueblo is wearing me down. As much as I enjoy collecting La Quinta points (to be used to stay in a hotel near the slopes soon), it would be nice to see my apartment walls for longer than the time it takes me to repack my suitcase. And Matt. I like him too.
The pros of this job: 3 day weekends without call, autonomy, and a relatively light clinic schedule. The cons (other than the ones staying here): no peds or ob patients, the commute, and being gone 3 nights a week. Break even trade offs: patients can get all meds, imaging, and consults within reason without having to pay for it, tempered by having to wait a fairly long time and me having to get permission from the insurance company and pharmacy committee.
I will keep you posted if I make a permanent break for Denver.
Then Monday morning...back to prison. The lockdown was still in effect, so I only saw two patients yesterday. Today was a "modified lockdown," so the medical clinic was open for business. I don't know if any more shanks were found, but I hear some hooch was found in a coffee pot. (Homemade hooch is popular prison contraband...I'm told it can even be made out of metamucil...blech!) We have a lot of medical appointments to make up, so the rest of the week should be busy.
I also heard a piece of depressing news today: our best nurse has put in her 2 weeks notice. She is my go-to nurse, the most reliable one, the only whose judgment I value most. And she looks after my schedule. I think current nurse drama has a lot to do with her departure. I also am plotting my next career move and have had a few interviews at a Denver community health center. I like the prison work overall and am beginning to see improvements in diabetes control, results of labs/studies I've ordered, and am learning alot, but the early and icy commute to Pueblo is wearing me down. As much as I enjoy collecting La Quinta points (to be used to stay in a hotel near the slopes soon), it would be nice to see my apartment walls for longer than the time it takes me to repack my suitcase. And Matt. I like him too.
The pros of this job: 3 day weekends without call, autonomy, and a relatively light clinic schedule. The cons (other than the ones staying here): no peds or ob patients, the commute, and being gone 3 nights a week. Break even trade offs: patients can get all meds, imaging, and consults within reason without having to pay for it, tempered by having to wait a fairly long time and me having to get permission from the insurance company and pharmacy committee.
I will keep you posted if I make a permanent break for Denver.
Wednesday, January 19, 2011
Shank you very much
Wikipedia defines a shank in several ways, including a poor golf shot or a cut of meat, but in prison, a shank is a makeshift knife fashioned by prisoners. Because of these shenanigans, all of an offender's property is meticulously catalogued by the property department. All medical supplies like wrist braces or hearing aids must be inspected and then engraved with the prisoner's ID number. Shanks and other contraband are taken very seriously, and due to the past month's events including the discovery of a shank, we were placed on a full lockdown today.
For me this meant, that all of my patients were cancelled, which caused me to squeal in delight. (Yesterday a nurse saw my schedule and basically told me to brace myself.) Instead, I got to catch up on some chart reviews and chase down missing consults. I did see two emergency visits...one vomiting teenager and one woman who had, as they say in Spanish, fallen pregnant. Oops. Apparently she became incarcerated during the fall and had a few negative pregnancy tests at a county jail, reportedly. Then she was transferred to our prison and had not been seen in the medical clinic since she arrived. Her growing abdomen roused her own suspicion, but denial is an extremely powerful force, as I learned in residency with another pregnant patient. It's been a while since I've gotten to do prenatal care so I enjoyed trying to remember what to do with a 31 week pregnant lady. Basically, she will be transferred out of our facility as swiftly as possible and will deliver at a Denver Hospital. On the bright side, at least she did not become pregnant while in prison. I've heard that has happened and that is, well, frowned upon.
While I was seeing my two patients today, the inmates underwent strip searches looking for other contraband. The entire facility is being searched from top to bottom. I hear the lockdown may last for sometime. Emergency medical visits only.
Our Warden stopped by the medical staff meeting today. She is a dynamic, no-nonsense woman who spoke about the "evolution of the prisoners" and how prisoners are becoming more brazen. She reminded us that the offenders are not our equals and that we must not become complacent. It is a good reminder to stay vigilant, which is probably the biggest difference in working in prison compared to the outside.
The most humorous exchange of the day was between me and a new agency nurse, who is studying to become an RN. I asked her if she had given the tylenol and the phenergan to the vomiting teenager yet. She had not, so I said, "you can probably just give those tonight, prn." She looked bewildered and replied, "I don't think I can given a suppository through the cell window." Apparently, she thought I had meant "PR," which is per rectum, instead of PRN, which means as needed. It reminded me of some medical jargon misunderstandings of my own when I started my clinical rotations in med school, which I know caused a few chuckles and smirks on rounds.
For me this meant, that all of my patients were cancelled, which caused me to squeal in delight. (Yesterday a nurse saw my schedule and basically told me to brace myself.) Instead, I got to catch up on some chart reviews and chase down missing consults. I did see two emergency visits...one vomiting teenager and one woman who had, as they say in Spanish, fallen pregnant. Oops. Apparently she became incarcerated during the fall and had a few negative pregnancy tests at a county jail, reportedly. Then she was transferred to our prison and had not been seen in the medical clinic since she arrived. Her growing abdomen roused her own suspicion, but denial is an extremely powerful force, as I learned in residency with another pregnant patient. It's been a while since I've gotten to do prenatal care so I enjoyed trying to remember what to do with a 31 week pregnant lady. Basically, she will be transferred out of our facility as swiftly as possible and will deliver at a Denver Hospital. On the bright side, at least she did not become pregnant while in prison. I've heard that has happened and that is, well, frowned upon.
While I was seeing my two patients today, the inmates underwent strip searches looking for other contraband. The entire facility is being searched from top to bottom. I hear the lockdown may last for sometime. Emergency medical visits only.
Our Warden stopped by the medical staff meeting today. She is a dynamic, no-nonsense woman who spoke about the "evolution of the prisoners" and how prisoners are becoming more brazen. She reminded us that the offenders are not our equals and that we must not become complacent. It is a good reminder to stay vigilant, which is probably the biggest difference in working in prison compared to the outside.
The most humorous exchange of the day was between me and a new agency nurse, who is studying to become an RN. I asked her if she had given the tylenol and the phenergan to the vomiting teenager yet. She had not, so I said, "you can probably just give those tonight, prn." She looked bewildered and replied, "I don't think I can given a suppository through the cell window." Apparently, she thought I had meant "PR," which is per rectum, instead of PRN, which means as needed. It reminded me of some medical jargon misunderstandings of my own when I started my clinical rotations in med school, which I know caused a few chuckles and smirks on rounds.
Tuesday, January 18, 2011
Having a Fit
There must be something in the water because the number of patients having seizures in the last two weeks is out of control. Almost daily, it seems that the nurses are called on the radio to go to the scene where an offender is seizing. This causes the nurses to grab the crash kit and hop in the golf cart "ambulance" and take off speeding. Several of these folks have been taken to the ER in a real ambulance....Then they come back to me later in the day with no records, a patient education hand out for "neck pain," and a prescription for some narcotics we can't fill. Neat. I think last week they loaded up a "seizing" patient with some drugs because she was so groggy and hypotensive when she came back that I transferred her to the infirmary at another prison. (God bless that infirmary doctor, who lives in a Winnebago, for accepting the transfer.) I had to call him today to transfer another seizer who I can't get under control. He then traded me back the first lady who hadn't seized at all while she was there. I'm not surprised because her description of her seizures was vague and didn't quite compute ("I called the guard and said, 'hey i'm having a seizure!'...[insert fully body shaking])
Did I miss all of the lectures and didactics in residency about primary care management of epilepsy? I've been trying to read up and consult more experienced prison docs but don't feel that confident in the fine tuning of anti-epileptic drugs regimens. I did order my first EEG recently on another possible epileptic who is "seizing in her sleep" and wakes with "sore tongue and gums." We'll see what the EEG reveals...most of the imaging studies I have ordered have reported normal findings, save for a few arthritic joints and two cases of osteoporosis in relatively young women. I guess that's a good thing.
Things to look forward to: Mexican pot luck with the nurses tomorrow and my first trip back to Seattle this weekend!
Did I miss all of the lectures and didactics in residency about primary care management of epilepsy? I've been trying to read up and consult more experienced prison docs but don't feel that confident in the fine tuning of anti-epileptic drugs regimens. I did order my first EEG recently on another possible epileptic who is "seizing in her sleep" and wakes with "sore tongue and gums." We'll see what the EEG reveals...most of the imaging studies I have ordered have reported normal findings, save for a few arthritic joints and two cases of osteoporosis in relatively young women. I guess that's a good thing.
Things to look forward to: Mexican pot luck with the nurses tomorrow and my first trip back to Seattle this weekend!
Monday, January 17, 2011
On the Bright Side
It's always a little hard to make the early morning trek to Pueblo after a fun weekend in Denver. Inevitably, the 4:40 am alarm comes too early. Compared to last week's bone chilling sub zero temps (which made me think I was locums'ing in Alaska), the lovely 50 degree weather made my commute down I-25 easy breezy. I also enjoyed the sunrise over the Colorado plains. It's getting lighter at night, so when I leave the sun is setting over the foothills. Here's the Pueblo downtown Riverwalk looking pretty
Other high points of today include getting paid time a half for working on MLK day and an interesting mix of patients. From osteoporosis to HIV and refractory seizures, these patients are keeping me on my toes. Too many patients told me I was nice today, which always raises a red flag that they might be after something. Flattery will get you no where in prison! Not even with the chocolate heart doctor.
In other breaking prison news, 15 tylenol #3 tabs were stolen from the clinic med room over the weekend. No one knows how this theft occurred, but an empty baggie was found in the dumpster. There has been a big to-do in clinic about the missing T3s (the only narcotic we have). When anything goes wrong, the poor "agency nurses" become the scapegoats since they have limited experience at our facility. This theft prompted the Warden and Associate Warden to drop by and offer some observations. (They are both women, and the Warden is a nurse who worked her way up the ranks.) The mystery of the missing pills continues...I'll be on the look out for tylenol toxicity...
Other high points of today include getting paid time a half for working on MLK day and an interesting mix of patients. From osteoporosis to HIV and refractory seizures, these patients are keeping me on my toes. Too many patients told me I was nice today, which always raises a red flag that they might be after something. Flattery will get you no where in prison! Not even with the chocolate heart doctor.
In other breaking prison news, 15 tylenol #3 tabs were stolen from the clinic med room over the weekend. No one knows how this theft occurred, but an empty baggie was found in the dumpster. There has been a big to-do in clinic about the missing T3s (the only narcotic we have). When anything goes wrong, the poor "agency nurses" become the scapegoats since they have limited experience at our facility. This theft prompted the Warden and Associate Warden to drop by and offer some observations. (They are both women, and the Warden is a nurse who worked her way up the ranks.) The mystery of the missing pills continues...I'll be on the look out for tylenol toxicity...
Tuesday, January 11, 2011
Prison Runway
One of my patients today is the prison seamstress. She is responsible for crafting all of the fashionable prison "greens." A typical prison outfit is comprised of a dark green top and pants --very similar to scrubs. Each outfit is emblazoned with the offender's name and DOC number. Prisoners also sport bright yellow t-shirts, gray sweatshirts, and carhart jackets.
However, if an offender is in trouble, she is taken to the seg unit in an orange jumpsuit, which is also the outfit of choice if she has to be taken off the prison grounds to the ER, for example. When people are out of seg but still in trouble, they wear orange pants with their green tops, similar to a scarlet letter.
Prison footwear leaves much to be desired, especially for the slew of people I've seen lately with bunions, MTP arthritis, and plantar fasciitis. Most people are given a pair of black boots, but it is possible for the offenders to buy New Balance sneakers. Today I tried to order a wider pair of shoes for an inmate...we'll see how that goes.
Just because personal expression may be limited by fashion doesn't mean the offenders don't go all out with eye shadow. They have some of the best applied eye shadow I have ever seen. I could use some smoky eye pointers. Many kinds of make up are available on canteen for purchase. Some ladies had the great foresight to have make up tattooed right on before they came to prison, eliminating the need for pesky eyebrow pencil.
I learned on one of my first days in prison that, although incarcerated, prisoners still want to look nice and feel good about their appearance. One lady broke my heart when, during her asthma visit, she asked if her "face would always be like this." She developed Bell's Palsy a year and a half ago and still has some noticeable motor deficits in the left side of her face. My heart broke when she started crying after I told her that she probably wouldn't see much more improvement. I definitely take cranial nerve VII for granted.
However, if an offender is in trouble, she is taken to the seg unit in an orange jumpsuit, which is also the outfit of choice if she has to be taken off the prison grounds to the ER, for example. When people are out of seg but still in trouble, they wear orange pants with their green tops, similar to a scarlet letter.
Prison footwear leaves much to be desired, especially for the slew of people I've seen lately with bunions, MTP arthritis, and plantar fasciitis. Most people are given a pair of black boots, but it is possible for the offenders to buy New Balance sneakers. Today I tried to order a wider pair of shoes for an inmate...we'll see how that goes.
Just because personal expression may be limited by fashion doesn't mean the offenders don't go all out with eye shadow. They have some of the best applied eye shadow I have ever seen. I could use some smoky eye pointers. Many kinds of make up are available on canteen for purchase. Some ladies had the great foresight to have make up tattooed right on before they came to prison, eliminating the need for pesky eyebrow pencil.
I learned on one of my first days in prison that, although incarcerated, prisoners still want to look nice and feel good about their appearance. One lady broke my heart when, during her asthma visit, she asked if her "face would always be like this." She developed Bell's Palsy a year and a half ago and still has some noticeable motor deficits in the left side of her face. My heart broke when she started crying after I told her that she probably wouldn't see much more improvement. I definitely take cranial nerve VII for granted.
Monday, January 10, 2011
Strike?
How do you know when the roads are "too bad" to go work? Do doctors ever get snow days? After 5 years of receiving emails reminding me that I am "essential personnel" and must find a way to get to work even during the apocalypse, I have a hard time throwing in the towel due to bad roads. Would a foot of snow in Denver and a unplowed highway make good excuses? The usual 1 hr 40 minute early A.M. drive to Pueblo took me 3 hrs and was harrowing to say least. (Matt suggested I pack some snow shoes in case I got stranded). Thankfully, only one stop to clean the windshield was required, and I didn't end up in a ditch. I would say the day was a success. If I could only finagle a way for the prison to pay me for my drive time...
Today in prison, I had some nice patient visits. My first patient was a lady in her 50s brought in from the "seg" unit, where she spends 23 hrs/day in her cell. She had a black eye and was wearing a seg unit uniform - the orange jump suit. She had also been on a "hunger strike" for a week. I guess the purpose of hunger strike is to make some kind of statement. After seven days of striking, she was eating a grilled cheese sandwich in the exam room. (The nurses have protocols for all kinds of medical evaluations...including the hunger strike. I think it involves daily weights, vitals, urine dips and measurements of fluids.) This patient has severe hypertension, and I wondered if she was also on a "medicine strike" since she took her blood pressure pills 8 out of the last 30 days. Not advisable when you've already had 2 heart attacks. We actually had a productive visit where she set goals of "eating" and taking her pills "29 out of 30 days" this month. Ambitious for someone who maybe took that many doses over the last 3-4 months, but I am cautiously optimistic.
I also saw a teenage medical mystery for follow-up. Last week, he had his boot camp physical and other than hypertension and slightly large liver, he was quite well with no pertinent past medical history. Then, over the weekend, he developed redness on his arm and, later, on both feet and ankles as well as ankle swelling. The on call doc ordered labs and treated him for cellulitis, which seems totally reasonable, but it just didn't seem like cellulitis. He never had a fever and had a normal white count. Apparently he looked a lot better today, but still had purplish feet, a vasculitic looking ankle rash, and pedal edema. His only lab abnormalities were an elevated AST and slight proteinuria. Today the proteinuria had resolved, and his blood pressure had improved. I am chasing down a rheumatologic rat with more lab work, but I imagine this might be a wild goose chase.
Today in prison, I had some nice patient visits. My first patient was a lady in her 50s brought in from the "seg" unit, where she spends 23 hrs/day in her cell. She had a black eye and was wearing a seg unit uniform - the orange jump suit. She had also been on a "hunger strike" for a week. I guess the purpose of hunger strike is to make some kind of statement. After seven days of striking, she was eating a grilled cheese sandwich in the exam room. (The nurses have protocols for all kinds of medical evaluations...including the hunger strike. I think it involves daily weights, vitals, urine dips and measurements of fluids.) This patient has severe hypertension, and I wondered if she was also on a "medicine strike" since she took her blood pressure pills 8 out of the last 30 days. Not advisable when you've already had 2 heart attacks. We actually had a productive visit where she set goals of "eating" and taking her pills "29 out of 30 days" this month. Ambitious for someone who maybe took that many doses over the last 3-4 months, but I am cautiously optimistic.
I also saw a teenage medical mystery for follow-up. Last week, he had his boot camp physical and other than hypertension and slightly large liver, he was quite well with no pertinent past medical history. Then, over the weekend, he developed redness on his arm and, later, on both feet and ankles as well as ankle swelling. The on call doc ordered labs and treated him for cellulitis, which seems totally reasonable, but it just didn't seem like cellulitis. He never had a fever and had a normal white count. Apparently he looked a lot better today, but still had purplish feet, a vasculitic looking ankle rash, and pedal edema. His only lab abnormalities were an elevated AST and slight proteinuria. Today the proteinuria had resolved, and his blood pressure had improved. I am chasing down a rheumatologic rat with more lab work, but I imagine this might be a wild goose chase.
Wednesday, January 5, 2011
Back from Hiatus
After a lovely trip to Ohio for the holidays, I am back in prison. I can't say that I'm glad to be back at work, but I'm working on my attitude as part of my new year's resolution. Some prisoners did remind me yesterday that I "was free" and should have had a great new year's, which I did.
I think the trifecta of a bad day for me in prison is the intersection of difficult patients, less than ideal nursing staff, and computer problems. I've hit 2/3 of those daily this week...but not the dreaded 3/3...yet...thankfully. (I'm sure there are many more serious things that could go wrong, but I'll just fret about the mundane, annoying things for now). There has been a shortage of nurses lately due to people quitting, being sick, and just not showing up, which leaves "agency nurses" (the locums of nursing, or travel nurses) and new prison nurses in training. This week is an exercise in patience.
Things improved a bit once my computer got fixed....just in time for the drill sargents to bust into the clinic yelling at the 9 youthful offenders I had to examine. I usually split the exams with a nurse practitioner, but she wasn't in. Today I learned several things: the average pulse of a youthful offender is about 102. Secondly, I can reduce the overuse of "ma'am, yes ma'am" by telling the offenders to cut out the ma'ams at the beginning of our visit. Simple, but brilliant! It also seemed to quiet the guards during my exam, making our interaction feel more clinical and less tense for me and the patients. (As soon as they left the exam room, the guards would start up again with the "stop eyeballing me! Toes to the wall!") I can't help but feel bad for those kids, even if they are hardened teenage criminals.
I was pleased that a teenager on dialysis didn't show up for a physical today. I heard he is still coming despite many attempts to prevent him from the YOS program. Dialysis? Boot camp? I just don't think those are compatible. Next month I'm going to have a fit if I see a kid in a yellow jumpsuit with a canteen over his head and a palpable thrill in his arm...
I think the trifecta of a bad day for me in prison is the intersection of difficult patients, less than ideal nursing staff, and computer problems. I've hit 2/3 of those daily this week...but not the dreaded 3/3...yet...thankfully. (I'm sure there are many more serious things that could go wrong, but I'll just fret about the mundane, annoying things for now). There has been a shortage of nurses lately due to people quitting, being sick, and just not showing up, which leaves "agency nurses" (the locums of nursing, or travel nurses) and new prison nurses in training. This week is an exercise in patience.
Things improved a bit once my computer got fixed....just in time for the drill sargents to bust into the clinic yelling at the 9 youthful offenders I had to examine. I usually split the exams with a nurse practitioner, but she wasn't in. Today I learned several things: the average pulse of a youthful offender is about 102. Secondly, I can reduce the overuse of "ma'am, yes ma'am" by telling the offenders to cut out the ma'ams at the beginning of our visit. Simple, but brilliant! It also seemed to quiet the guards during my exam, making our interaction feel more clinical and less tense for me and the patients. (As soon as they left the exam room, the guards would start up again with the "stop eyeballing me! Toes to the wall!") I can't help but feel bad for those kids, even if they are hardened teenage criminals.
I was pleased that a teenager on dialysis didn't show up for a physical today. I heard he is still coming despite many attempts to prevent him from the YOS program. Dialysis? Boot camp? I just don't think those are compatible. Next month I'm going to have a fit if I see a kid in a yellow jumpsuit with a canteen over his head and a palpable thrill in his arm...
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