Is anyone still reading this?

Wow, I haven't blogged since OCTOBER?! Doubtful that anyone still reads this, but here is an a recollection written from the depths of the hospital at 4 am!

I rounded on a 76 yr old female this morning who showed up for her EGD and
colonoscopy yesterday a bit delirious so was admitted to us. The bowel
prep might have caused insomnia and dehydration; her head CT
was normal. With a little fluid and rest, she was back ot her effusive
self.

Here is an except of what I understood while she talked for 10-15
solid minutes, all the while holding my hand or wrist:

You are such a young doctor. It is wonderful that you speak two
languages, mi muchachita. My doctora also speaks Spanish but she left
to have her bebita. I brought her baby a present. She has
taken care of me and husband for so long. It's so great that you take
care of people. Do you have children? [No] Oh you are getting married?
That's good because the Biblia says it's not good to be alone and my
son in California had brain cancer. One day, I went to pick him up
from school and some kids were beating him over the head with a sports
trophy. He was confused and went to the hospital. Then years later
they found a cyst or a tumor and operated. He married a crazy lady who
wasn't very good. I told him he should move in with me, but he said
all of his doctors and medical records are in Califonia. It's not good
to be alone, hija. You has to have understanding of your partner. All
men have faults. You have faults too, but it's nice to be together.
You are just so young [kisses my hand]. Bring me a picture from your
wedding!

(I think I may have missed the message of her story, although I'm fairly
certain she was lucid and any misunderstanding was due to my lack of
geriatric Spanish comprehension. But I'm also fairly certain that
someone got beat up by an athletic trophy.)

Button up your lip no more

As my Granny once said before my family took a cruise to Alaska, "button up your lip, and buy a new hat." It's Granny's version of if you can't say anything nice, don't say anything at all. I've tried to keep my blog from becoming Negative Nancy's Pity Party @ blogspot.com since I started my job almost 5 months ago, but I'm done buttoning up my lip! (Not done buying new hats, however...)

My sunny, optimistic last blog makes me laugh. Every month at my job has presented new challenges, a steep learning curve, and bipolar-like swings on my job satisfaction scale. First I had to adjust to seeing more patients per day than ever before. This has given me time to reflect on my cushy schedule in residency and in prison (10 patients/day? Ha!) as well as a new skill set -- cutting people off. All too often, patients, with laundry list of ailments in tow, try to derail my 20 minute appointment. I'm improving my ability to interrupt and suggest they schedule a follow-up. I feel bad about this, but it's a reality in my 17.5 patient/day world.

Just when I thought I had a handle on clinic, I started taking inpatient call and doing OB at a community hospital with about 100 beds. My call schedule is quite variable in terms of calls/week. I also do some medicine only calls and some medicine/OB calls. Most of our inpatient service is moms and new babies, with about 1-3 medicine patients at a time (so far anyway...the winter is sure to increase our census, and winter arrived in Denver last night in case you've been watching the news.) While this may sound like a manageable feat, and occasionally it is, OB overrides everything. It's tough to take care of the medicine patients when I'm tied up assisting in multiple C-sections. I am missing my intern to help divide and conquer the work!

One of my biggest gripes is the fact that my clinic expects us to carry on with our clinic schedule post call, no matter if I have a normal "8" hr clinic day (read 10) or 12 hr clinic day (usually 13ish) afterward. I've been struggling to figure out how the other docs maintain this schedule or how they work around it. Sometimes I wonder what planet I'm on altogether. (Do these people really think it's reasonable to work 36 hrs without sleeping?! I'm a basketcase after 24 hrs on.) I have one day a week off, so apparently this is supposed to make up for working nights and weekends. However, my Monday fun day doesn't really soften the blow of a brutal post call Wednesday, unfortunately.

Which basically brings the blog up to speed with the present day. Yesterday I had a 24 hr med/ob call where I delivered 6 babies and was up all night. While I had high hopes of a quick 2 hr 4 am nap, the morning ended in the worst post partum hemorrhage I've ever managed. The patient had a large tear from her delivery, which I repaired, but she continued to have brisk bleeding. I called the obstetrician to come in and help, and we spent an hour or more in the operating room trying to stop persistent vaginal pulsing and oozing. She lost about half of her blood volume. I think she will recover well, but it was terrifying. Then I changed out of my bloody scrubs and put on some clinic clothes. My misery peaked when I had to rescue my Subaru, discovered in the parking lot with the help of automatic key clicker as Scarlet was entombed in 7 inches of ice and snow. Turns out wear clogs wasn't a great choice for the first day of winter. I didn't last through much of my clinic day, but I did hear some neat comments like "you look so tired" and "oh, your hair is different." Indeed the red rimmed eyes and post call frizzy ponytail were, at best, unbecoming.

To avoid the aforementioned NNPP blog, I'll end on a positive note. The only patient on our hospital service right now is my own - a 40 ish yr old guy with moderate developmental delay and low potassium due to a month of diarrhea. One of the nurses must have told him I delivered a baby because when I checked on him later in the night he said with genuine awe, "You delivered a baby? Wow! That's AMAZING! I'm so proud of you! Wow! You do EVERYTHING!" I was touched and will try to keep in mind that my job is full of special, privileged moments, despite its demands.

Hopefully my next blog won't be so delayed!

New Directions

Hello from week 2 of orientation! After some much enjoyed time off visiting friends and family in Cincinnati and Seattle, I have returned to the land of the working. My new clinic is part of federally qualified community health center organization that runs 4 clinics just outside of Denver. From humble beginnings with one provider in a small house with a curtain dividing the living room, our clinic has grown to provide over 170,000 patient visits yearly. About 40% of the patients are uninsured, 40% have medicaid, 15% have medicare, and a few have private insurance. I was surprised to learn that 98% of of our patients are below 200% of the federal poverty level. The clinic's mission is to be the medical provider of choice for low income people in our service area.

All new providers go through a 3 week orientation before being turned loose. This orientation includes 12 training sessions with my sworn electronic health record enemy, NextGen. I used this system for a year and a half in residency and made a little promise to myself that I wouldn't ever take a job that used NextGen. Alas, that promise has been broken, and I'll have to get over it. The real boon of NextGen is that you can use it for billing and data generation, despite its lack of user friendliness. (Click, click, click...Epic, I miss you...sniff, sniff.)

The first day of orientation, I had a skype meeting with our clinic scheduler who happens to work remotely...in Israel. I've also spend a lot of time shadowing the providers, medical assistants, front desk workers, and case managers at my clinic in addition to meeting with various people in the administrative office. Today I met with the finance department, HR, and the development director. Apparently, it takes 14 full time people in billing to collect our revenue!

Last week the CEO, who has worked in his position for over 20 years, took me to lunch at a local sandwich shop. (I don't think a CEO of anywhere else I've worked has ever said boo to me, much less bought me an artisan sandwich.) The clinic is all about teamwork, and they've done a good job to assure I have a good understanding of how the team functions.

I've been impressed by the many innovative problems that the clinic has been pursuing for the last 10+ years such as group visits, an integrated behavioral health program, and patient registries for diabetes, depression, hypertension, and pregnancy that generate quite a bit of data to support our quality outcomes.

And best of all, the clinic is about 20 minutes from my apartment!

To quote Annie, I think I'm gonna like it here!

Getting Paroled

It's the eve of my last day in prison and my emotions are mixed. I am happy that I will be "free" of the long Monday morning commute and being away from home all week, but I am also sad to leave the friends I've made (nurses, not inmates) and leave the patients without a doctor. Someone will come to fill my worn out Dansko clogs before too long I hope. And sooner or later, I know I will run into an inmate on the street or in my next office.

Overall, I feel really grateful to have been employed for the last 7 months and to have had this experience in prison. The correctional population has definitely experienced the health effects of poverty and being uninsured and I have enjoyed getting to take care of people who have no one else looking out for their medical needs (and often haven't been getting any primary care on the streets for years before they came to prison). I am constantly surprised and saddened by the number of women who attribute their long term health problems to physical abuse and drugs. I saw a 27 yr old today who had all of her teeth pulled and didn't qualify to get dentures in prison. I started talking to her about nutrition and eating fruits and vegetables, and she told me the kitchen doesn't given her any because she can't chew them. She broke my heart. It also seems like 90% of the women in prison are mothers, which I also find to be very disheartening. What choices and circumstances led the middle school school English teacher I saw today to end up in prison?

I had to laugh to myself yesterday when I walked through the prison yard and a diabetic inmate said to me "Bye, Doc!" and then, to her friends, "That's my doctor!" (Like there is any other doctor in our prison...) There have definitely been some satisfying moments, heart breaking stories, a few good laughs, and many patient tears, plus a few of my own. I leave with gratitude for my time in the slammer and excitement for my next adventure.

Hasta la vista, La Quinta!

The Mother Load

If you are unsatisfied with the medical attention you have received in prison, should you:
A) send excessive kites, each with more capital letters spelling URGENT and exclamation points that the last
B) write a "grievance" stating your complaint, which must be answered in a meeting with the nurse supervisor
C) have your mother call the warden and threaten that if the warden doesn't call back in 30 minutes, your mother will go to the media

All of the above have happened, and choice C (+/- media or lawyer contact) occurs to a surprising degree. I mean what business does the mother of a 38 year old former methamphetamine user with chronic leg pain have calling the prison medical clinic? I am totally appalled by the number of parent phone calls my boss fields for FULL GROWN INCARCERATED ADULTS. (It's not like the teenagers' parents are calling.) I mean, I know my mom has my back, but if I went to prison, I think I'd have to make my prison bed and lie in it.

Welcome to Prison!

Recently I attended a provider training meeting at a department of corrections facility called the Denver Reception Diagnostic Center. While it may sound like a place where pepperidge farm cookies and lemonade greet you while you wait for a mammogram, the DRDC is actually the prison where all of the inmates get a physical exam before being sent to other prisons around the state. It is surrounded by a double fence with many, many rows of razor wire. Not so friendly. Initially, I was hoping to be placed at that prison since it's a short commute from my apartment, but it wasn't in the cards.

The provider meetings are a nice opportunity to chat with the other prison docs, NPs, and PAs and to compare experiences. The prisoners seem to get very good healthcare in prison, even for all the bureaucracy required for specialist visits and non-formulary medications. I do feel like I've won when a patient I've referred to a specialist has surgery (and I receive a legible consult note!), even though that's not supposed to be the most gratifying part of primary care. Seeing improvements in hemoglobin A1cs has also made me feel like I'm "doing something," which is also satisfying.

The guest speaker at the meeting was a retired infectious disease specialist who now works for a drug company. One might think that a drug company doesn't stand to benefit much from having a relationship with the department of corrections and its limited drug formulary. However, with oral Hepatitis C drugs on the market, there is a lot of money to be made, especially if a large organization like DOC starts incorporating oral anti-virals into its Hep C protocol.

Another interesting stat I learned at the meeting:
1/4 of HIV positive patients interact with the justice system in a given year. This represents an exceedingly high burden of disease for the corrections population. All prisoners get testing for HIV, syphilis, Hep C, and Hep B on arrival to the reception diagnostic center. I did get to tell a very relieved patient last week that her HIV test was a false positive (after an indeterminate Western Blot and an undetectable viral load x 2 over 6 agonizing months of not knowing for sure). My HIV patients are actually super stable and will be more like to die with HIV than from HIV. It's amazing how well HIV can be managed, especially when detected early. Hard to believe 20% of people in the U.S who are living with HIV don't know it. (Shout out to Aurelie and our grand rounds!)

Know the Code

Hello from National Correctional Employee Appreciation Week!

This week, to thank us for our hard work, the prison is providing daily treats. Today was rootbeer float day...tomorrow nachos....Friday BBQ. Some of the other prison workers will be enjoying a steak dinner...others, a shoeshine. I think I would prefer the shoeshine to yesterday's "pop and popcorn," but the breakfast burritos on Monday were tasty!

And now, a fashion lesson from a recent prison email:
"With the warmer weather upon us it is a good time to revisit 4469-01, Appearance and Dress Code, particularly with respect to non-uniformed staff. The regulation does allow for wearing of "dress gauchos or capris" and provides the following definitions:

Capris/Crop Pants: A style of pants that is loose fitting and designed to end mid-calf or just below the calf with slightly flared legs.

Gauchos: A style of pants that is loose fitting and designed to end mid-calf or just below the calf with legs that are flared to resemble a skirt.

With both definitions, the key points to remember the fit (LOOSE), the length (MID-CALF) and that they are to be "dress" versions of these garments. To be allowed, the article of clothing must meet these definitions, regardless of how they are marketed."

For my remaining two weeks, I'm sticking to slacks.

Work Holiday Proscription

Prisoners of many faiths can continue to celebrate their religious beliefs while doing their time. I receive many emails with lists of offenders who will be allowed a day off from work for religious Holidays; thus, a work Holiday proscription! These informative emails provide the prison staff with some information about the traditional Holiday practices. Occasionally, there is a special meal... or a fast. Some of these Holidays have included Native American Sweat Lodge, Wiccan Samhain, and Passover.

One can also purchase various religious items from the prison canteen to aid in her practices. Perusing this list is like taking a mini-lesson in comparative religion. A Buddhist meditation cushion and Sacred Path cards are the most expensive items on the list, setting you back about $58 and $40 respectively. Religious texts cost about $20. Other interesting items include Thor's Hammer, 2 oz. of Earth (68 cents), a prayer shawl, numerous herbs, and cedar shavings.

I frequently check my patients' canteen lists when they request that I prescribe medications that are available on canteen (mainly prilosec). I can't say I've seen a lot of religious items on their lists, but they do buy a lot of cup of noodles and something called "hot crunchy cheese," which can't be good for the old GERD.

So in case you were wondering, there is some shopping in prison! Looking forward to the horticulture hanging basket sale in a few weeks.

A Gravy Train with Biscuit Wheels...

Our new nurse manager is a capable, compassionate, and sassy Southerner with a lot of energy to whip our clinic into a well oiled machine. When I told her that it seemed like the prison nurses had a tough job, she told me that compared to other jobs she had, this one was "a gravy train with biscuit wheels" (except that with a Southern accent it sounds like "wils," which is even funnier. In fact, I have been laughing about this all weekend and every time I see her.) I started thinking that maybe my prison gig is also a gravy train with biscuit wheels and perhaps, in my four weeks left, I should adopt a better attitude. Sure, all my patients are not as pleasant as homemade mashed potatoes, but it's time for a new coping strategy....humor!

There are many funny moments in the prison clinic amidst the drama behind bars. One patient started our visit the other day by recounting a dream she had the night before about bags and bags of chocolate candy. Another patient told me the color red triggered her asthma. I replied, "Good thing I didn't wear red today." She then responded "um, I mean red dye..." (She now reminds me of this every time I see her.) There is a lot of construction on our campus right now withe a few pieces of heavy machinery strewn about. I heard during one lock down, some ladies were holed up in their cell houses looking out the window for the "bobcat," which they believed was loose on the prison campus. While I have seen various wildlife including rabbits and cats running through the yard, the only bobcats I've spotted are made of steel.

18 days and counting

As they say in prison, I'm going to "kill my number," which means serve my time until my maximum release date, May 19th. (Well, this is a self selected release date.) I will be starting a new job closer to Denver at a community health center where I can enjoy such benefits as sleeping in my own bed! And not getting up at 4:30 on Monday morning! My cell phone can even come to work with me. (Maybe I should go wild and get a smart phone...the flip phone was a big upgrade for me 4 yrs ago...)

I feel a bit ambivalent about leaving the prisoners without a doctor, but it's time to say adios to La Quinta and work closer to home. A primary care nurse practitioner is also departing the prison for a new job, leaving only the affable nurse practitioner gynecology specialist to deal with the medical needs of the ladies. Hopefully they can recruit (and retain) a provider soon. This was always a temporary position for me, which I let the inmates know, but I still always feel guilty leaving patients. With our residency transitions, I already have "broken up" with patients 3 times in my short career so far.

The demands of the inmates and this job are wearing on me. On my way out last week, two ladies brazenly stopped me in the yard with various demands. One stuck her tongue out and wanted a diagnosis for the coating on her tongue. The other woman irritably asked why she hadn't been scheduled for an appointment yet. Many of the prisoners lack boundaries, and I was not too happy about being asked to perform a tongue exam in the middle of the prison yard. (Although I could also imagine this happening on the outside in a grocery store or the gym...) Today I hopped aboard the "ambulance" golf cart and caught a ride out of prison, skillfully avoiding probing questions. Just 18 more walks out of the prison, and 4 more early morning commutes!

Another day, another trichomonad...

A few things have changed since I started working in prison. My signature has become abbreviated from its full 19 letters to a squiggly line. I've also gotten better at telling people No. (No, you can't have a note to get out of work/a bottom bunk bed/neurontin/medical snacks...) Unfortunately, I may also be becoming more callous. Too many patients with "excruciating, shooting pain down the bag of their legs" last week almost put me over the edge.

One good thing that has changed is my skill in microscopy. I always found looking at slides of vaginal discharge to be rather time consuming and fairly low yield for diagnostic purposes. I mean, is there really clue cell in there or not? How come yeast never looks as obvious as it does in books? Somehow, I've gotten by. However, the number one prison kite is for "discharge, odor, help!" so I've had to make many a slide over the past few months. This slightly laborious process has occasionally been rewarding, like a month ago when I peered through the scope and saw the flicker of a tiny protozoan moving independently in the slide. Trichomonas!!! Finally! They always teach you to look for something moving on the slide, but usually the whole process is a big let down. Today I was very suspicious for trichomonas based on this patient's exam. I searched all over the tiny slide until I saw it, a trichomonad, ticking repeatedly under the cover slip with its flagella.

After I broke the news to the patient and handed her 2000 mg of flagyl, I called in a nurse to check out the slide. One of the nurses is studying to be a nurse practitioner so I thought this would be a good teaching moment. Then all the nurses came in to look and were fascinated, making comments like "look at it's little whip tail!" and "is that a phagocyte?" Even a prison guard wandered in to see what all the fuss was about. She started rattling off things she had seen under a microscope, which included an amoeba and a worm. She was happy to add protozoa to her list. I was happy to actually see something I could recognize and treat.

Check out this narrator's sweet Northern Ohio accent:

Spring PrisonBreak II

Just so you know, this isn't turning into a travel blog (although that would be a more fun read than my recent posts...) I wanted to share some pics from my recent trip to CA and will bring you back behind bars at the end.

Zion National Park

Angel's Landing


Kolob Entrance

From Utah, to Anaheim...


We didn't get to go to Bahrain, but we did take a happy cruise around the world.
It's a small world, after all...........



This lively Huntington Beach street performer hammered a 4 inch nail up his nose, reminding me of the importance of regular tetanus shots.




As we made our way from the O.C. to San Diego, we stopped in San Clemente for a picnic with some goods from Trader Joe's. (How I have missed TJ since moving to Denver!) Walking toward the beach, we noticed some conspicuous orange jumpsuits the words "California Department of Corrections Prisoner" on them. Just a hard working prison work crew digging a hole on the beach. There was 1 guard for about 12 prisoners, who each took turns digging in the sand for unclear purposes. I'm sure you have to be a well-behaved inmate to get assigned to a beach work crew.


A few prisoners can't rain on my picnic.



In San Diego, the correctional system good times continued. Here I am in front of a jail cell in Old Town. There's no escaping this rusty steel box. Later that night, I watched my first episode of Prisonbreak. We also met some self proclaimed "bad guys" at a bar in San Diego while watching the San Diego State v. UConn basketball game. I overheard them talking about their brother who was doing time. A few pitchers of beer later, we nearly witnessed a brawl between one of the ex-cons and an old guy in sandals regarding whether or not the older guy was really from San Diego. (He bet against the Aztecs.) Later, he was kicked out of the Ye Old Plank Inn Bar and was told to "come back tomorrow." We, and the Aztec basketball team, were out.

Back through AZ and NM on the way home...


Vistas from Petrified Forest National Park. Warning: Don't take any petrified rocks or you'll be thrown in the slammer!



All good vacations must come to an end...

Two pieces of chocolate cake, yes please

Since returning from my roadtrip, I've had a rough few weeks. Perhaps there was an influx of demanding inmates (or a release of some of the nice ones). Maybe it was the high drama of many people crying in the office due to pain, or the many people I have sent to the emergency room for evaluation. Regardless, I am feeling burned out and haven't been much up for blogging. So I couldn't pass up chocolate cake today when two pieces came my way. One of the nurses brought a chocolate cake made with sauerkraut, which was actually quite good. Then another nurse had me over for dinner and served a double layer chocolate cake. It was a nice treat.

Today I went searching for the results of a few studies I ordered. Unfortunately for me, but fortunately for the inmates, two of the ladies had been released to the community corrections program, where people are living in a half way house type setting. The medical file goes back to storage in Denver upon release so I may never see labs or studies I've ordered if the patient leaves before it can be reviewed. One particular patient had a complaint of a breast lump about a month before she left. I sent her for a mammogram and ultrasound, and she left prison two days later unbeknown to me. I requested the result today and it turns out she had a suspicious nodule that should be biopsied. I had to call her at her halfway house to break the news, and then send a certified letter with the results. They often have no insurance and very limited access to medical care once they are out of prison, so I have no idea how she will follow-up. It also frightens me to think what might have happened had I not remembered to check up on that result. I order a lot of studies here and can't be sure I always review the results before the patients disappear into the abyss of community corrections and the charts go back in to the ether. Sounds like a good way to get sued, which I am desperately trying to avoid. Yesterday a patient casually mentioned her ACLU medical malpractice lawyer during our visit. Not a good way to win over medical staff and impress others.

Spring PrisonBreak I

The Saudi Arabian military may have foiled my spring trip to Bahrain, but they didn't stop me from taking a epic roadtrip to my birth land in place of the Middle Eastern excursion. Matt and I stocked my car with camping gear, beach towels, and a cooler of diet coke, and set off west on a 10 day roadtrip. We spent two days at Zion National Park enjoying the dramatic canyons and awesome hiking. Instead of camping in the windy 30-50 degree weather, we opted for an extra night at the Zion Lodge. Matt, typically a hardy soul, even snubbed the Lodge's rustic "western cabin," opting for the "motel" room with a flat screen TV so he could watch the NCAA tournament. I was just happy to be warm. Save the camping for the summer!

We also ventured in the nearby town of Springdale, Utah for some bumbleberry pie at a sprawling complex containing a hotel, gift shop, bar, and theater. When forced to choose between a raucous St. Patrick's Day party and a slice of bumbleberry pie in the coffee shop with old people, I chose the pie. Future patrons, choose your a la mode flavor wisely.
Matt: "We'll take the 'giggle bush' ice cream with the pie."
Bumbleberry Sales Clerk: [firmly] "That's not ice cream. It's sherbert. And it doesn't complement the pie."
Me: "Uh...I guess we'll take the bumbleberry ice cream?"
BSC: "Good choice....I guess I shouldn't be so controlling..."

Anyone can read on a 5 ft sign in the store that a bumbleberry is a cross between a burpel and a binkel, grown on a giggle bush. http://www.bumbleberry.com/

American's Most Histrionic

There are times in prison when I feel like I'm on a new reality show called America's Most Histrionic. I have to remind myself to be patient with the dramatic wincing during gentle exam maneuvers and with the high volume of tears shed in my office. My first patient yesterday has been challenging to care for during our many visits. Aptly named, her last name is a synonym for "hit," and her chief complaint at our first visit was "punched the wall 20 times." This visit went fairly well; at least I didn't feel like punching a wall 20 times.

The drama continued out in the "yard" during the afternoon. Perhaps its the beautiful 75 degree weather or the fact that the entire campus is under construction to make it more disability friendly, but the ladies are a little testy. I was walking through the rubble to get back to the sidewalk when I witnessed and out and out brawl between two offenders in the grass during the evening medication line. It seemed like I was watching it in slow motion and thinking "hmmm...that's odd...are they fighting?!!!" I motioned to the guards, and another inmate broke up the fight. The ladies were then hand cuffed and likely taken to "the hole." Not a typical sight during my stroll across the yard. As they always say in prison emails, "be vigilant and stay safe."

I had my first prison nightmare last night. I was involved in some kind of theft and had to go to prison for 1 day. When I got there, they told me I had to stay for 5 days, and I was devastated. I woke up in a panic, thankful to be safe in La Quinta without a rap sheet.

Morse Watchman Keywatcher III

For those who can't keep track of their keys, consider installing the Morse Watchman Keywatcher III. A personal electronic code allows access to the box, which guards thousands of prison keys. I have not yet figured out what the massive 4 inch key above my set opens.

Elite Status

Exciting news in the land of hotel living....I got an email saying I am two stays away from reaching Elite Status at La Quinta. This includes such fabulous perks as bottles of water and craisins in my room, free upgrades to my king suite, and a 30% point bonus. Tara at the front desk said she knew I was getting close to upgrade my status from Gold to Elite. With my rewards programs and roller bag, I feel like George Clooney in "Up in the Air." (Although I definitely don't operate by his "let go of the baggage weighing you down, unload the backpack" motivational strategy. Never known for my light packing, I come in every week dragging at least 5-7 bags of weekly supplies. A girl's gotta eat, knit, and blog...)

Reason for Visit, Part I

A patient in prison or on the outside has to state a reason for the visit when making a doctor's appointment. This statement then gets transferred to the doctor's schedule to explain why the patient is being seen. Somehow this seemingly simple bit of information can be lost in translation and transformed into a bit of medical hilarity.

My favorite reason for visit in residency was "Patient says the emeralds you made her don't fit and she needs new ones." No, I actually wasn't carving gemstones or making jewelry in the exam room (although that sounds fun!) The emeralds were actually ear molds that my patient requested I help her make so she could send away for hearing aids. (She lived alone and her overweight and beloved service beagle, who came to nearly all of her visits over 3 years, couldn't help her with that task of daily living.)

My prison schedule has some equally amusing reasons for medical appointments including:

"I am really not trying to be a pain in the behind, but the pain in my knees overide it all."

"States 'insides' coming out. Was in reference to her vagina."

18 year old male:
"Complains of pain in his vulva."
(Apparently, he was told by some other teenage offenders that the proper term for pain in his left upper quadrant was his 'vulva.' Poor guy.)

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.