Prison Medicine 2

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medical         *
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Mon  Jan 2  4 AM:  Nothing new to report. Miserable pain in left chest and back.

Tue  Jan 3   4 AM: The past 24 hours turned out to be my worst pain wise. I was waiting for the long-acting opiate patch to "kick in" and afraid of overdosing using the combination of patch and short-acting opiate. The side-effect from overdose is a loss of respiratory drive and respiratory arrest. Dr. Ward called me at about 4PM yesterday and said to add another patch which I did and which helped. Things have become more manageable at this point.

Sat Jan 7. Yesterday morning I awoke and something was wrong. I wasn't sure if I had died or had become another person because there was no pain. I could twist around and produce a little bit of hurt, but something fundamental had occurred. It has been almost 48 hours since I have had to take any short acting opiate. I am using the fentanyl patches, a 50 mcg per day and getting a good result.

In the meanwhile, I obtained an MRI yesterday that shows damage to the left 5th rib, probably where the tumor attaches to my chest wall. I will follow this up next week to see if there is some local radiation to the painful areas that will allow me to back off on the opiates.

Anyway, it feels like I got some quality part of my life back, or at least the possibility of that.

Sun Jan 8:  I am still painfree at most times, other than when I am trying to lift my legs and get up from a chair. However, there was another headache this morning and a rapid increase in the amount of saliva production together with nausea. I took Decadron and suspect that this is increased pressure in the skull. I have an MRI of the brain scheduled for tomorrow and will have more information later in the week.

The almost certain failure of chemo has put me back in touch with the initial sense of loss first experienced when discovering that your life expectancy has been severely diminished--but the loss does not feel as acute. I think I've managed to work my way into a better state of acceptance. My recent experience with pain has clearly demonstrated to me that there are moments where continued life looks less appealing than the end of everything--for me these value judgments are closely related to the sense of suffering.

It is curious that I ran into a Hopkins trained psychiatrist at the Avenal Prison last summer, Will K. We had the opportunity to eat dinner once a week for several weeks and I found myself a little jealous about the kind of training that I believe he received in his psychiatric residency. As a result of my time with him, I had made a decision to work again with sicker mental patients in a forensic facility and had been planning to begin doing so in November. I felt rejuvenated and better able to look at psychiatry in a different fashion and to re-evaluate some long-held beliefs and prejudices.

Because of my time with Will, I read a book by Paul McHugh The Mind Has Mountains. McHugh was the long-term chair of psychiatry at Hopkins whose influence still permeates the department. The book is a series of essays. I recognized the point of view as tending toward right-wing Catholic thinking with rigid right-to-life arguments such as condemnation of removing life-support from Terry Schiavo.  The book is remarkably well-written. The material on false memories and multiple personality disorders is so right-on that I wanted to kiss Dr. McHugh's ring. However, he was particularly hard on poor Jack Kervorkian.

I think Dr. McHugh assassinated the messenger rather than deal with the message. I believe that it is reasonable for human beings to make decisions about continuing their lives, and I am chilled at the idea that other individuals or institutions or organizations should remove that "right" from us. I agree that a benevolent society "should" make adequate pain relief and treatment of depression available to all patients experiencing a terminal illness. However, when an appropriate political time arrived for our society to look dispassionately at this issue, only Jack Kervorkian stood at the door willing to put his life on the line "to make that case."

Should my disease progress, I will be wrestling with decisions about extending life versus quality of life.

Time Warp
There has been a significant change in my perception of time. Each day seems almost like an eternity and I'm talking about pain free days as well.


I frequently awaken shortly after 2 or 3 A.M. Like most old men, my first stop is for urination and then I generally try to go back to sleep. Sometimes it seems like several hours later when I look at the clock and it is 5:30 or 6:00 A.M. At that time, it is time to get up. I go upstairs and make fresh coffee, catch up with email and try to write something. Then the sun enters my day and I catch my first glimpse of the ocean. There is no deadline. No responsibilities other than to take care of myself and let Archie out every once in a while.


By the time 9 AM rolls around, it is inconceivable to me that time is passing so slowly.


I compare this to my practice in Las Vegas in 2007. I would be up around 6 A.M. and sometimes see patients in the office at 7:30 A.M. and then the day would take off and it would seem only an hour later that it was 7:00 P.M. and that Robert Granieri, the office manager, and I would have seen 25-30 patients. The busier the faster.
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Prison Medicine 2
I found working in prison in 1987 to be rewarding. The culture of the prison is even farther from mainstream than the culture of Smith Island and the culture of ranchers and cowboys.
One of the biggest adjustments for me in prison was the loss of control of doorways. On the way into work, one passes through a number of secure doorways, sometimes called "sally ports," where your passage depends on displaying documentation (such as a badge) or where a correctional officer can get a good look at your face and clothing. By the time I left several years later, I had become institutionalized. At times I found myself waiting for doors to open that were unguarded.
Sometimes access to a portion of a prison depends upon a correctional officer who is working alone in a tower. Humans have needs for bathroom breaks on occasion. It can happen that the pedestrian you are stuck in a sally port for a few minutes. This can be frustrating even for the best-adjusted human beings, like Dr. Bagley, our psychiatrist at Eastern Correctional Institute (ECI) in 1988.
One evening I was on my way out of the prison and walking toward a sally port that was about 150 feet away. I could see that Dr. Bagley was already at the 16 foot high razor wired gate. He was pushing the button to alert the tower guard that he was waiting but nothing was budging. All of sudden, Charley Bagley, M.D.,  70 year old ex-wrestler and ex-marine, started to kick the shit out of the chain link gate. By the time I reached the gate, he had calmed down but he was still muttering under his breath.

For me, a big positive  in that job was the opportunity for daily contact with many other professionals. Solo practice of medicine doesn't offer those same benefits. However, in the five years where Dr. Bagley and I worked together, I know that we had forty or fifty lunches together and several conversations each week. It was an enriching experience in my life. He was my first psychiatrist mentor.

Prison Security
Sometime during the first few weeks of working in prison, I had an extended conversation about security with one of the older captains. He had worked his way up through the correctional system over more than twenty years. We were discussing the risks that occur when inmates are referred to outside medical providers, such as seeing them in their offices or in an emergency room.

Captain C
Captain C described a trip that he made  to University Hospital Emergency Room in Baltimore with an inmate. While waiting for the physician, the inmate needed to use the toilet. Captain C and his partner cleared the bathroom. Captain C stood outside the door and waited and waited and waited. After a few minutes he entered the bathroom and was met by the inmate who now had a gun, perhaps acquired in the same fashion as Al Pacino got the gun in the Italian restaurant assassination scene in Godfather. The inmate stuck the gun in Captain C's face and demanded his wallet, opened it to the driver's license and said that he was going to that address to kill his family if...at which point Captain C reached for the gun as an instinct and the trigger was pulled...but the gun misfired.
The point is that two correctional officers can be overcome by sufficient force at medical offices, emergency rooms, surgical centers, etc. Transportation in and out of the institution and receipt of outside medical services are times of risk. In order to foil any attempts to communicate outside movements of inmates, it is important that inmate patients not be aware of time specifics of future medical appointments.  A number of people in the medical department are likely to be aware of this information and it does happen that inmates do obtain, usually by accident, specific information about upcoming medical appointments.
Nowadays, many inmates have cell-phones. When the correctional officers come to take Inmate A out for an appointment, room mate B could make a call to outside agents of inmate A notifying them that the transport process has begun. This may be enough information to firm up an escape plan.


****   There is a problem with inmates not having more specific information about upcoming medical appointments. -- Things happen! Sometimes medical appointments fall through cracks. In the free world, the consumer has enough information to participate in care and would have knowledge that an appointment has been missed. Screw-ups are more likely to be identified earlier on the process. In prisons we lose this important backup since the consumer remains in the dark. This puts increasing pressure on the prison's data system to more accurately track appointment visits. In California, failures of tracking led to missed appointments for critical interventions. A great deal of effort has been expended in addressing this. As an outside observer with experiences in Maryland and Nevada prisons, I shared some thoughts with folks that were beginning to look at various computer information systems in 2008 when I first began working in prison. 
After receiving outside medical attention, an inmate patient should return to his institution with several pieces of information. 

• There should be a written report that updates the prison physician with the current status of the medical problem. 
• There should be a plan of treatment for the patient for the interval until the next scheduled appointment.
• There should be a information about the timing of the next expected visit

 In Maryland all returns from outside appointments went to the regional infirmary. It was fully staffed 24/7. If there was something that needed immediate medical attention after the trip it could be provided quickly. It could be insured that all of this new data was matched up with the patient's medical record and available to all providers. If there were questions, an immediate call to the outside medical office could be generated when memories were fresh. The bottom line was that the inmate's downstream medical plan was put in place as soon as possible after the outside appointment. This part of the system was very tight.
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Suffering In Prison
At the Maryland prison, the physician assistants had the primary responsibility for managing sick call--a difficult assignment because "saying no" to special requests is an important component of the job. If inmate patients were not satisfied with their sick call visit with the physician assistant, they were scheduled for me to evaluate. As a part of that medical evaluation, I gathered the family medical history, including causes of death of parents. Over the course of seven years at the Maryland prison, I interviewed hundreds of patients. There wasn't a week when I didn't hear that a parent's death was due to a murder.

The social history for many inmates was replete with neglect and failed attempts to establish a useful, supportive network. In many cases there was no consistent work history. Where such a history did exist, it was more likely to have been disrupted by drug and alcohol abuse and dependence.

John J
He was known heroin addict who suffered from chronic pancreatitis. His medical record from other institutions described him as "drug seeking." It seemed that way at first, but as we continued to gather more information, he turned out to have a tumor of the pancreas. He did need pain medications and we placed him in the infirmary. He knew he was dying and the social worker helped him to reach out to his teen age son to arrange a visit. He kept a small sheaf of papers in the bedside stand and he appeared to make entries from time to time.
He was with us for several weeks. He continued to lose weight. He appeared to be comfortable with his medications, seldom complaining of any breakthrough. One morning when I came to work, the infirmary nurse asked me to come back. It was a little before 6 A.M. John had died. The sheaf of papers had been torn up and were in a small pile on the bed stand. The scraps seemed a metaphor for his life. Is this all that it was? It was overwhelmingly oppressive to imagine what had happened to John during the previous day.


Documentation is the Truth
There are a lot of possible reasons for inmates wanting to lie or stretch the truth. On the first or second day of work in prison, I was present to observe "pill call," a process whereby the inmate comes to the pill window and receives ordered medications. The nurse has a Medication Administration Record for each person scheduled to come to the line. Here is an example of such a record. Each drug is listed on the MAR. When the nurse gives the medication, the appropriate grid box is initialed. MARs are standard fare in institutional nursing, such as hospitals, nursing homes, and prisons.

Sample Medication Administration Record: MAR

On that particular day, I tried to help the nurses and I took the next patient in the queue who told me that "the old nurse" had made a mistake--that he had never actually received the medication. He indicated with a slight nod of the head at Tess, a staff member in her sixties or early seventies. It was very easy for me to take my age bias and run with it and assume the truth of his statement.

I went to talk to Phil Nichols, the CMS regional manager who had hired me. He was also overseeing this process. He said, "Look at the MAR." The MAR had Tess's initials for the previous dose has having been given.

"Eric, the documentation is always the standard. Sure, there will be mistakes. When it comes to a conflict between the MAR and the patient's statement, you'll have to take the MAR."

Not Everyone Is Guilty
Over the past few decades, there has been an accumulation of information about the mistakes made by the criminal justice system. There has been perversion of the process in some police departments. There has been forensic evidence fraud. We have very good information that eyewitness testimony is very unreliable when sorting out strangers, particularly individuals of another race.

However, I'd guess that many more inmates deny their guilt than admit it. When it comes up for discussion in a medical encounter, I would simply explain to an inmate that this wasn't for me to decide. It was my job to make sure that everyone incarcerated at our prison was getting good medical care.

Visit Overload
At ECI we had the luxury of filling the prison gradually, beginning with about 20-30 patients a week. They had been screened and were believed to be healthy. The State understood that it would take some time to begin to put together a referral network to handle more severe medical and surgical problems.

What I first noticed was the skewing of the demand for services. From my interest in preventive medicine and primary care research, I knew that the healthy population we were serving would average fewer than 2 visits to doctors a year while in the free world. However, our guys were requiring closer to 10 - 12 visits a year.

The kinds of complaints were expanded. There was a big demand for cosmetic products for dry skin, oily skin, and itching. Special shampoos and soaps were requested. There are commissary hours in prisons so that inmates can purchase basic cosmetics, aspirin, tylenol, etc. We attempted to make a variety of simple medications available as inexpensively as possible. However, what appeared inexpensive to me had a different impact on inmates who might be earning a dollar a day in a prison job.

I don't have all the facts in front of me at this moment, but I believe that I estimated that one sick call visit a month per inmate was a reasonable ball park estimate for the demand for sick call services. In a prison of 2000 men, this would be 2000 visits per month, or 60-70 visits a day to handle the outpatient part of things.

The Correctional Medical Services (CMS) contract utilized physician assistants (PAs) for basic sick call work. For each visit, the PA would construct a SOAP note and, where appropriate, provide a treatment such as a medication. However, each SOAP note had to be reviewed, signed, and dated by the responsible physician within 48 hours.

Medical Director Work Day
I generally left my home at around 5 A.M. and started work at the prison around 5:15. I'd go to the East Side Medical Office where I could review and sign off on the previous day's sick calls. I pulled aside cases that appeared interesting or more complicated for further review during the day.

I called home a little before 7 A.M. and made sure the boys were up and getting ready for school. (I would double check about 20 minutes later). I proceeded back to the infirmary and made rounds on the inpatients until the morning staff meeting which was led by the CMS administrator and included nursing staff, PAs, pharmacy, psychology, and social work. This was the major working meeting for the day and participants left here with a pretty good idea of what the focus of their day was likely to be.

After the morning meeting, I did rounds in mental health, checked in with the administrator, and proceeded to ECI West where I reviewed all of the sick call progress notes from the previous day in the same fashion as I had handled them on ECI East.

This routine was generally finished before about 10 A.M. leaving me to attend to a variety of other problems including attention to inmates currently hospitalized outside of the facility, evaluation of medication usage in the facility, response to inmate and family complaints about medical care, and hands-on provision of medical services for inmates whose problems could not be managed in sick call situations.

The Most Common Form of Pneumonia Encountered in 1988
The most common pneumonia found in our society is "community acquired pneumonia," where symptoms are caused by a few different pathogens. However, the population in prison was different.

In 1988 HIV/AIDS was the big medical story. One of the first useful antiviral medication was just coming on line in the form of AZT. The HIV virus destroys immune CD4 cells in a few ways. When the level of these CD4 cells falls below a certain number, certain "opportunistic" infections occur. Normally the immune system handles these organisms effortlessly. In all of my training and 20 years of practice, I had never seen a case of pneumocystosis, although I had heard about a case in a child with an immune system disorder.

The organism, pneumocystis, is everywhere but only causes problems for folks with immune deficiencies. In HIV/AIDS the pneumonia develops so insidiously, that the patient does not appear to have the level of distress that would be indicated by the low blood oxygen levels. The patient does not necessarily appear sick until you begin to look very closely, at which time you will likely be amazed at the extent of abnormalities in the Chest X-Ray and the arterial oxygen concentrations.

When the patient did appear for treatment it was often a terminal event with death occurring in a few hours or days. Given the large number of IV drug users in the Maryland prison population and the propensity for needle-sharing among IV drug users, there were a significant number of HIV positive patients within our prison but state law at the time did not permit identification through individual screening unless it was requested by the inmate.


The Most Common Surgery in 1991
At ECI our most common surgery was bowel repair with re-anastomosis of the colon. Young men came to our facility having survived gunshot wounds to the abdomen that perforated the colon. One of the reasons they survived was because the R.A. Cowley Shock and Trauma (named after my first medical mentor) existed in Baltimore and was able to provide life-saving assistance to victims of multiple gunshot wounds. When the colon was perforated, it was externalized in surgery with a colostomy. As the colon healed and demonstrated good function, it became possible to put the colon back together. A goodly number of gunshot victims were engaged in criminal activities and would find themselves in the care of the prison system within short period of time after the shooting.  Although someone can live for extended periods of time with a colostomy, one has to be very careful about hygiene in a prison. There is a built-in loss of privacy and exposure to the habits and smells of others.  We considered this to be a reasonable priority and certainly trumped the need to do anything about the PIP joint described below.


The Fifth Proximal Interphalangeal (PIP) Joint
In 1989 an inmate's left fifth finger was caught between two body-building weights and he sustained a fracture that included the PIP joint. The PIP joint is the one closest to the knuckle. The alignment of the finger had not been affected and there was no obvious deformity. However, the fracture did extend through the joint space itself. Fractures through joint spaces often heal with loss of normal motion and eventually develop arthritis.

This accident had occurred on a week-end and the doctor on call opted to send the patient to a local emergency room where the diagnosis was established. While the inmate was in the emergency room, the physician there decided to refer the patient to a hand surgeon the following week.

When I came to work on Monday, I found the information from the hospital and saw the referral to a surgeon. So, I called the surgeon. He informed me that his preferred treatment for such an injury was a replacement of the entire joint.

This turned out to be an instructive case for me. Had the inmate been injured on the job and lost his entire 5th finger, the average monetary award would have been about $5000 in compensation at that time. My brother is a right-handed dentist. He suffered a similar injury in his teen years to his right hand but managed to make a good living for many years.

The cost of a joint replacement would be more than $20,000 for the surgery alone and would have required extensive physical therapy for months subsequent to surgery. Each physical therapy session would have required travel outside of the institution accompanied by correctional staff. Even with the surgery, the patient was more likely than not to be left with an arthritic outcome at some time in the future.

In other words, there was no literature that clearly supported a better outcome with the more aggressive care. The obvious benefit was to the hand surgeon who would have been reimbursed handsomely for his services. However, as a result of the trip to the E.R. the patient had a current medical order for a referral to the hand surgeon. If you recall from Estelle v. Gamble, medical orders need to be respected and require full medical evaluation before cancellation.  I called the patient up to the clinic and examined the hand and the x-ray and continued the "buddy splinting" that had been applied in the hospital emergency room.

There was no "emergency." One could reasonably await healing to see if loss of mobility in fact occurred and to take additional steps at that time. He was scheduled for the routine orthopedic clinic that was held monthly inside the prison.

One can imagine other cases where the full function of the left fifth finger would be required, such as in a musician dependent upon income from performances.

Wanting to Appear Intelligent
One of the most egregious cases of bilking the state occurred with an eyeglass contractor. Eyeglasses are among the many medical services that are provided to inmates. At ECI, there was an eyeglass vendor who came to the facility once a month and performed refraction services. On his next visit, he would bring eyeglasses and distribute them. One day I was leaning against a wall in the break room and I looked at a couple of pairs of eyeglasses. It appeared that they were only window glass. When I examined them more closely, I was at a loss to see where there was any refractive error at all.

I called the vendor's attention to this. His explanation was that we had "a large number of African Americans in our population, many of whom wanted to appear to be more intelligent." The vendor claimed one of the perceived associations with intelligence was the use of eyeglasses. And so, the eyeglasses were  provided and intended to create the illusion of studiousness and intelligence. Actually, even if his prejudicial stereotype had been accurate,  he was wrong as we subsequently discovered. It so happened that the eyeglass case was particularly attractive and was made with several colored, leather-like layers that were useful in arts and crafts projects. The inmates were not wearing the glasses, they were using the covers. We put the vendor on notice that he was expected to use Medicaid standards for the provision of any eyeglasses.

Lawsuits and Entitlement
In public debates, we often hear politicians decrying the notion of "rationing" medical services. The truth is that such rationing has always occurred. The rich have always been able to purchase more and presumably better quality services than the poor.

We have seen that inmates have a right to medical care as a result of their status of incarceration. The armed robber has to get in line with everyone on the street for medical services until he is incarcerated when his status changes and he is essentially guaranteed a place at the head of the line. That is at least one take on the current situation.

Most inmate patients do not abuse their right to medical care in any significant way. However, a significant percentage of folks in prison exhibit antisocial behaviors and believe themselves more worthy than others. Many are clever and see that incarceration presents an opportunity to obtain medical and dental work that they put off while pursuing the pleasures of the free world. As incarcerated felons, they work to collect on their new status. There are even manuals that circulate with information for inmates to press their case for more benefits by applying more effective pressure on prison officials

However, there is a State interest in providing a constitutional level of health care to inmates at the least possible cost to taxpayers. In Maryland a decision had been made to have private contractors provide medical care rather than attempt to do so with state employees.

As a medical director working for a private company, I was permitted to make decisions about the "constitutional standard of care" for the institution. The company expected me to keep costs low. Although I was never given any kind of "bonus" for financial performance, I knew that the company (CMS) was certainly looking at costs and would look at costs again very carefully the following year when we discussed a contract.

On the other hand, the State of Maryland had already handed the available money to CMS and would want the company to provide as much service as possible. Having already paid, the state would want all inmates to be happy and stop complaining.

This is a fine line for the medical director. I had to be the conscience of the company but a cost-effective conscience. I developed a set guidelines to try to help me walk this fine line. I'll outline these in another post, but one of the basic principal was that:

     Every inmate must be treated equally. Greasing the squeaky wheel was out. 

This stance means that you will be saying no to a number of antisocial individuals who are very determined to have the medical care that they choose. They will have accumulated data from their past medical evaluations and the prison records themselves to bolster their "case." (In prison a lot of things boil down to cases. We'll see more when we get to psychiatry at the Maximum Prison in Nevada.) The masters of intimidation will be putting in sick call slips on a daily basis, writing to the warden and the governor's office, involving their family to make phone calls, etc. They will try to inundate you with paperwork and you will reach the point where you wonder if it was all worth it--to stand between a determined inmate with 24 hours a day on his hands and the medical care of his choice.

Well, if you don't stand up against it and you give one person the green light, how can you justify not doing the same for everyone else who is requesting the same thing.

Dr. R and the Munchies
Dr. R was the psychiatrist who covered the facility when Dr. Bagley was away. In 1988, the ECI dietician came to me and said "Dr. Sohr, I just can't keep up with the night time snacks being ordered by the medical department." d She caught me totally unaware. 
"What do you mean?"
"I'm making almost 200 bed time snacks. I called around to other prisons and they laughed and said I better let you know."


I knew that I wasn't ordering these and I had not permitted Physician Assistants to order special diets for other than diabetes and heart disease. I thought that any additional special orders had to come from me. However, physicians are allowed to order special diets and Dr. R was a physician. Dr. R had ordered the 200 special diets. I needed to see him.


Now in most prisons, there is a standing policy that discourages the use of "sleeping" medication. Most of the effective "sleepers" are habit-forming and they tend to be cross-tolerant with alcohol and downers. They are often used in large doses to produce a "high." (If you don't think that there is an exceptional pressure for many inmates to get "high" a month in a prison will convince you otherwise.)
One of the ways that psychiatrists get around this prohibition against sleepers is by using low dose of older antidepressants, the tricyclic antidepressants. Even in relatively low doses, they can cause drowsiness. However, they also increase hunger.


When I spoke with Dr. R he told me that he was, in fact, treating complaints of insomnia with antidepressants and then adding a bedtime snack for the "munchies."


I explained to Dr. R that I had to justify his diet decisions to the institution and that I couldn't tell the warden that we were treating the "munchies." Special diets from the medical department were supposedly restricted to medical issues for which a special diet was a recommended part of the treatment plan. We also talked about the use of low dose tricyclic antidepressants. These are drugs that are among the chief agents for overdose suicides. I asked Dr. R to try to get his patients off of the subtherapeutic doses for depression as soon as possible if that were consistent with good care. He agreed. 


Prison Health Care Professionals
At the time I began practice in a prison, I had been doing solo medical work for most of my career. In the prison I was interacting with other physicians and professionals for most of my entire working day. Many of the health care staff that gravitate to that field for work are looking for "adventure" or something different than the day to day activities of routine medical practices, hospitals, and nursing homes. The pay in prisons tends to be a little better and is an exposure to a new culture, something that I have always enjoyed in moving from one position to another.

Bill and Kathy Henderson
The longest lasting, continuous relationship from my time at ECI has been with William Henderson, D.D.S., who was hired as the dentist about the same time as I came aboard. Bill was about 38 when we first meet. 


The first prison dental operatory had not been installed and yet there were patients scheduled for the next week. As I entered his office, I noticed that he was unpacking some strange looking equipment. He said that it was his emergency kit and would let him do the most basic dental procedures things without an expensive, formal working operatory. He said that he had put it together so that he could provide dental care to his family at sea.


Approximately 5 years prior, Bill owned a successful, high-end dental practice in Half Moon Bay, California. He and wife, Kathy, had a young daughter, Megan, who must have been about 8. Bill's dream in life was to have a sailboat and to cruise. As Megan aged, the window for an extended cruise with the family was closing and, so, Bill and Kathy decided to go for it...to make it happen.


They sold the dental practice and bought an old moving van. They packed the house into the moving van and drove it to Nebraska and parked it on the old family homestead. Then they continued on to Florida, where Bill bought a 42 foot steel sailboat hull and spent the next year building their sailboat--everything by hand.  


They set sail and cruised the Caribbean for two or three years. Kathy did home-schooling with Megan and supper was often a reflection of the day's luck with the spear gun.


As the adventure ran its course, the family decided to have a look at the East Coast and sailed up into the Chesapeake Bay and finally up the Pocomoke River where they were surprised to see river front lots at affordable prices, particularly when thinking about the cost of similar properties in California. They bought a good size lot and built a floating dock where they could moor their sailboat and began looking for work. Bill found the dentist job at the prison and we have been friends every since.


After purchasing his land, Bill and Kathy set about building a house which fronted on the Pocomoke River and which overlooked a bird sanctuary. You could sit on their front deck and look out across the river and watch the bald eagles a few hundred yards away.


Bill is an artist. After completion of the house, came the built for library and entertainment systems. I was most impressed with the chandelier that he fashioned out of copper tubing.


Having the house built, he built a dark-room for Megan's photography and a workshop for himself. He then began to make guitars. 


He began to feel burned out at the prison and took a job working with developmentally challenged patients. A few years ago I was surprised to receive a request from Johns Hopkins for a letter of reference for Bill. He and Kathy had decided that a job at Hopkins was a good career move. I wrote Hopkins and told them that they were not only getting a great dentist, but an artist as well.


http://www.hopkinsmedicine.org/dome/0706/feature2.cfm


What I love most about the Hendersons is "true love." They have been married more than 40 years and the genuine love and respect in the relationship just shines through. They met in college when Bill was at Humboldt State. When they decided to get married, Bill had already committed to a summer job with the Forest Service counting the salmon at some gate on a fast flowing river. There was a small cabin erected on a hill above the salmon gate. Bill asked permission to do the job and to bring his new wife with him.


Kathy packed for the honeymoon trip, including a box of electric hair curlers. They needed to fly into the work site, at which point Kathy was informed that there was no electricity there. There was no running water. The accomodation was an 8' x 10' cabin with a stove and kitchen work counter at one end and a bed at the other end. Kathy said it was pretty convenient, to be able to cook and eat and then just lay back in bed.


All of their provisions came by air as well, but Kathy said it didn't matter what she ordered, the food that was shipped out was always the same. The couple tended the gates several times a day in between visits by bears to the outside Sushi Bar.

Kathy and Bill on flanks. Daughter Megan and her Golden Retriever in Middle.

On one occasion  family came to visit them unexpectedly (I never figured out how you would "drop in" on someone by air, but it happened. Some of the family had to sleep on the floor but needed to share that space with the mice that were frequent visitors as they scurried across the floor. Kathy noted that it was a very short family visit.


Wrap Up
My work in prison in Maryland for seven years was so varied with such a diverse set of problems that time sped by. It has been difficult to present that time in a coherent fashion. While in prison, I became very interested in "difficult patients" and in the problems they presented for physician decision making, particularly in prisons. I began writing a monograph. However, the subject matter fit between the borders of family practice and psychiatry. As age 50 approached, I realized that I was more and more interested in psychiatry. I saw myself as becoming more removed from "the whole of medicine." I had become "specialized" into adult male medicine and administration. I began to explore other options.