Where medicine meets discipline

Medicine on the outside is based upon principles like confidentiality, trust, privacy, and justice. Being a prisoner compromises one's rights, obviously, but when the roll of the clinic staff swings from care provider to disciplinarian, I become uneasy.

Inmates can get "charged" while serving their time for breaking the prison rules. Some infractions can result in being "written up" or "thrown in the hole" (the seg unit) for a period of time until an internal court evaluates the offender's behavior. These violations are then considered when the offender is evaluated for parole. There are many rules to be broken. Inmates are forbidden from touching each other in any way. Hugging is viewed as sexual misconduct. (I doubt anyone would ever give me an accurate sexual history due to concerns for disciplinary action...I ask anyway). Sharing medicine or food is also not allowed. I still haven't figured out where the line is between a patient's right to autonomy and willful noncompliance, which can result in a write-up.

Another interesting charge is "abuse of clinical services." Sending excessive kites or being disrespectful to staff can result in this charge. I have had more than one patient complain about a nurse who has singled them out and written them up for abusing our clinic. At times, I tend to sympathize with the patient, as I have occasionally observed aggressive nurses antagonizing certain difficult patients.

I had my own run in with a difficult patient last week during a diabetes visit. After just a few questions about her peripheral neuropathy, the patient became frustrated and basically went off on me about her chronic pain in a hostile way. I left the room and asked the nurses to show her out. This nurse then wrote the patient up for being verbally abusive. The next day, the same patient tossed her used insulin syringe through the slot in the med window, and now she is in the hole.

While I agree that inmates need to be respectful of staff and it is totally inexcusable for them to be tossing sharps around, I am sure that any therapeutic relationship I might have had with this patient has been destroyed. It's a strange and uncomfortable position to be in. The ethical challenges of prison medicine are tricky to navigate.

All you need is Love...and Candy...and a Heart Biopsy

Happy Valentine's Day! Cupid has nice 50 degree weather for flitting around Colorado this week. I was delighted to drive to Pueblo today on clear, dry roads. Thawed out windshield wiper fluid is a beautiful thing....and so are my Valentine's flowers from Matt. Even the La Quinta left me some V-day treats (despite giving my precious room 120 to a management trainee for the next 3 weeks!)

I arrived at work to meet the usual morning morning ambush. Some of the prison heavy hitters had their typical medical problems and ER visits over the weekend...seizures, chest pain, pseudoseizures...I have been trying to get the epileptic lady under control since Christmas, and I thought we were finally making head way. Apparently not quite yet. The lady with chest pain is a total wolf-crier with the potential to have a heart attack. She does have heart disease and a stent, but each biweekly episode of chest pain yields an ER diagnosis of "non cardiac chest pain" and a script for benzos (which we don't have in prison anyway).

My most interesting patient today was a young woman in her 30s with a history of congestive heart failure. She also told me she had 3 strokes during the same hospital stay "due to stress," which sounded ridiculous. However, she actually did have some past medical records which confirmed her hospitalization for strokes and CHF. Unfortunately, no cause was ever identified for her heart failure at the age of 32, but I suspect many years of meth use might have been at play. She's the only patient I've encountered who underwent a heart biopsy as part of her work up. It's not every day you get a heart biopsy! Gives a whole new meaning to "Take Another Little Piece of My Heart, now baby...." She seemed to be doing pretty well clinically with some minor shortness of breath with exertion. Hopefully her echocardiogram will get approved so we check on the status of her big heart.

The Darndest Things...

The youthful offenders have a lot of scars and tattoos. Today the 5 offenders were all under 20 and had scars from abuse, stabbings, and cutting. One 18 yr old had some peculiar linear scars running down his anterior forearm from elbow to wrist, like faint train tracks. I examined him and inquired. His response? "I was high on meth in Canada and some girl cut up my arm to suck my blood on 4th of July. No one ever believes me." I could not keep a straight face, but I did believe him.

The morale of this story: Don't go to Canada on Independence Day. And meth is bad too.

It's a Lady's Prison

In case there is any confusion, I am definitely working in a women's prison. Our prison also houses boot camp for youthful offenders and a few adult men passing through on their way to other prisons (or waiting for colonoscopies). Nearly all of my patients are adult women age 20-74, with most of the women in their 30s-40s. (The lady in her 70s just showed up last week...I gave my first mini mental status exam in months.) Tomorrow the clinic will again turn into day one of boot camp as another crop of tachycardic teenage offenders arrive at boot camp.

My typical day will include chronic care visits, a few people with various medical complaints (usually pain), and a few procedures a week (skin excisions, joint injections). Since physical therapy is not often approved and getting a brace requires a small army, I will stick a needle in almost anything to inject steroids or to aspirate a joint. My biggest success story so far: uric acid crystals on an MTP aspiration! She's got the gout.


I had never aspirated or injected this joint before, but thought it might give her some relief. By some small miracle, my aspiration actually yielded some clear viscous joint fluid. I smeared it on a slide and slapped on a cover slip. To ship the slide to the lab, I put it in a big test tube. With the slide sticking out and the lid taped on, I was thinking "the lab is never going to accept this." But by a second stroke of luck, the lab did take my sample and spotted some negatively birefringent crystals. Her presentation of gout wasn't classic, so I was quite surprised to get the results. None of this has helped her symptoms yet, but she is following up tomorrow. Stay tuned.

Hotel for Dogs

After more than 12 weeks of living la vida La Quinta, I have finally requested to have the same room each week. I have been trying out different rooms with the same king suite including "micro/fridge." I thought settling on the same room might make my stays seem more homey and ease my weekly battle with the thermostat. (Every room is slightly different, and this white noise addict likes the rooms with the built in fan).

Paradise found? Not so sure...

For you animals lovers out there, the La Quinta is very pet friendly. According to the online pet policy, "pets are welcome at most locations nationwide." (Good thing I'm not working at a prison in Manhattan, Queens, Monterrey, or San Antonio...)

Most weeks I have crammed demands such as "no adjoining door, first floor please, no pets" into the "special requests" field on my online reservation. Guess I had to forfeit those preferences when I put all my chips on room 120. While I did buy milk bones for Audrey the Pomerian who lived downstairs at my last apartment, these pooches aren't getting any treats from me. And they better keep the yapping down.

I am reminded of the experience of the nurse practitioner, who also travels from Denver. "I got sick of those barking dogs at La Quinta, so I moved to the Wingate." (While the nearby Wingate does offer a better breakfast, I found their manager to be less than accommodating when I requested to not have a paper thin adjoining door. I checked out and never looked back.)

Time to bust out the ear plugs and set the fan to high.

The joys of hotel living are still better than living in prison.

Frosty!

Hello from sub-zero Colorado! It was a frigid drive down to Pueblo this week and the 1/4 mile walk from the guard station to the clinic is simply bone chilling. Despite the excellent efforts of the inmates in snow shoveling, the campus is treacherous. They do use some device to clear the path that looks like a cross between a broom and a floor buffer:


Tiny yellow bristles litter the path to clinic...and the twisted ankles and wounded knees from ice injuries are trickling in.

So far in prison, I have basically been an internist with a fairly narrow scope of practice. All psychiatry is handled by the mental health department. The only "peds" I do is the sports physicals on the teenagers. OB patients get shipped to Denver faster than you can say "oops, she's 31 weeks pregnant." And gynecology is done by the gynecologist nurse practitioner, an affable lady who was more than happy for me to come on board to take over the inmates' primary care concerns. For example, she remarked more than once, "I don't want to remove any toenails unless they are up in a vagina." However, while she is out having knee surgery, I will be doing all the paps, colposcopies, and answering kites stating, "I am not buying nothing until I know what is going on down there." It should be a nice change of pace and a good chance to brush up on my gyn skills.