Ely State Prison 2

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March 10. It's 1 A.M. Yesterday started at 3 A.M. when I awoke having to urinate badly, had some trouble pulling myself out of bed, began huffing and puffing as I moved to the bathroom, was afraid that I would dribble all over, too breathless to stand and search for my urine stick that seems able to hide easily these days and about whose orientation in space I have little knowledge--It's About Schmidt for me at this point in my life. I have not taken enough hytrin and the bladder remains full without any flow and I'm still huffing and puffing and hoping that something will begin to dribble out and relieve the pressure and finally it comes and a I'm able to slow down my breathing and relax and let things flow. Urination? has achieved a place in the pantheon of major concerns. Urination?Yes! has achieved great standing. At 5 A.M. and 6:30 A.M. there were minor replays despite my use of some extra hytrin.

Ely State Prison 2
Thinking back on my time there, I am struck by the organizational efficiencies demonstrated in the privatized system of medical care at Ely when compared to what I have seen in the past three or four years in a State-run system in California. The Nevada prison was small enough to match an expected general practice for a family physician. This means that a relationship was possible and much more likely. In a bigger prison with multiple physicians, there will be temptations to manipulate by physician shopping. Even when caseloads are assigned, inmates realize that they can receive emergency treatments by the strength of their complaints and by their knowledge of symptoms which can be woven into the story of illness.
In California there is a lot of micromanaging of medical and psychiatric care. Some of that has to do with improving standards of care, but a good bit of it is plain "Cover Your Ass" beforehand. An example is the family Tricyclic Antidepressants (TCAs). There are no more effective antidepressants and they have been around since the 1950s and 1960s. However, they can be used to overdose and this can be done with a 2 to 4 week supply if hoarded and taken at once. In California, these drugs were taken off of the Psychiatrist's formulary some years ago and could no longer be prescribed for depression.
In Nevada, Tricyclic Antidepressants are just as lethal but were continued safely by crushing each dose, mixing it with liquid, and requiring the inmate/patient to drink medication while the nurse observed. I found the class of TCAs sometimes useful for treatment of Attention Deficit Disorder without resort to amphetamine-like drugs that are likely to be abused in prisons. In 4 years at Ely I never saw a TCA overdose.
Eric Stokmanis M.D., an internist was the Medical Director. He was excellent. In addition to Internal Medicine, Eric had an overall curiosity about all of medical practice, particularly minor surgery and orthopedics. He was able to handle the full range of outpatient department complaints from the prisoners. He also knew when patients needed to be shipped out for local surgical or tertiary care.
The medical observation rooms and the infirmary at Ely State Prison did not distinguish between psychiatric and medical cases. The same staff of nurses and mental health technicians cared for both. I think this is a huge strength. It makes it harder for a medical department to look at bizarre behavior and automatically attribute it to a psychiatric condition rather than a delirium. There were seldom more than 2 psychiatric patients behaving badly at the same time and our overall incidence of physical restraints declined while I was there. In Nevada the process for using psychiatric medications over the objection of patients was based upon a Supreme Court Decision.
http://en.wikipedia.org/wiki/Washington_v._Harper
The Supreme Court ruled that the patient was entitled to a full institutional review and not to a court hearing. This is a much more efficient mechanism than is currently used in California. In California, three lawyers will be paid for each hearing--a judge, an attorney for the inmate, and a California attorney who will prepare and file the papers for the State.
The Death Row
Death row housing is done at Ely although executions are carried out in Nevada State Prison in Carson City.

http://en.wikipedia.org/wiki/Capital_punishment_in_Nevada

I generally visited the death row once or twice a week. There were several patients who received antidepressant medications and some suffered from anxiety attacks. These patients were seen on a regular basis for medication evaluations and changes. Any of the inmates could request a mental health visit and generally these were screened by 1 of 3 mental health professionals, after which the therapist would discuss the case with me before I followed up.
The atmosphere on death row was very calm. Nevada is a state that is in no hurry to execute anyone. You are more likely to die of natural causes than executions unless you decide to forego your appeals. The warden designed the schedule on the Death Row with an eye toward maintaining a low-key atmosphere. There were live weights on Death Row but not elsewhere. The men were allowed out of their cells for considerable periods of time during the day. There was no evidence of racial animosity. Many of the inmates continued to work on their "cases."
One of the first of the inmates I got to know was Lawrence Colwell, Jr.
http://en.wikipedia.org/wiki/Lawrence_Colwell,_Jr.

My first impression of Mr. Colwell was an empty cell that was so neat and tidy that one would expect that a monk was living there (at least Sohr's interpretation of how such a monk's room would appear). He was initially receiving some medication. When asking him about the future, he told me that he expected to be executed--that he had committed a horrible crime for which he had no real explanation. He believed that justice demanded his own execution. As you can see from the Wikipedia article, he appears to have represented himself in such a way to guarantee his execution. Although Colwell had committed a heinous crime there remained for him a need to face and own his own behavior, rather than to deny or mitigate his actions. He saw no alternative but a life for a life.

In contrast to Mr. Colwell was another death row inmate who had come to Ely State Prison with depressed mood, failure to maintain hygiene, difficulty sleeping, difficulty thinking, weight loss, etc--the classic signs of a major depressive episode. He was maintained on antidepressants for about 6 months until he adjusted to the death row and stopped medications. There was definitive video evidence of his crimes. However, when I interviewed him a year after arrival, he was no longer depressed. He was angry and complaining of the way his "case had been handled." He expressed outrage that he had been "in the marines to protect his fellow countrymen" and they had the nerve to give him a tainted trial for his multiple murders. He was able to separate himself from his actions using the vehicle of his "case." This is one of the weaknesses of our adversarial legal system--the case takes precedence over the admission of responsibility and the possibility of rehabilitation.

Here is some recent activity with respect to the Nevada Death Row:
http://ccadp.org/nevada.htm

What do you think? Penpals anyone?

http://nevadaprisonwatch.blogspot.com/2011/09/costs-of-nevadas-death-row.html

Guilty But Insane
Nevada was one of a few states that eliminated a plea of "Not Guilty by Reason of Insanity," (NGRI) and instead permitted a plea of "Guilty But Insane." In most states, a patient found NGRI would be committed to a state hospital for treatment. However, in Nevada, patients found Guilty but Insane were very likely to come to Ely State Prison and be included in available mental health programming. This meant that a Schizophrenic man who had killed his parents and offered passages from the bible as justification would likely be one of our prison patients during the first few years subsequent to the crime.
Uncertainty in Medicine
The Guilty but Insane plea is at the heart of one of the most bizarre experiences I have had as a physician. Sometime around 2000 we received a patient from the prison mental health center near Las Vegas. He had pled guilty but insane to a murder charge. As I recall, he was in his early 30's and arrived with a diagnosis of schizophrenia. A part of the narrative that came with the patient was that the transfer to a prison had been "pushed" by the family of the victim who demanded that the patient be treated like everyone else and spend the first year of incarceration at the maximum security center at Ely. It was also curious that there were some newspaper articles that quoted the judge in the case as believing that the murderer/patient was malingering his mental illness.
When the patient (I'm going to call him Mr. C) arrived in Ely he was already on an antipsychotic medication, called Clozaril, that is frequently the medication of last resort because of a side-effect profile that can lead to the loss of key parts of the immune system and death from infections.
When evaluated at Ely, Mr. C was able to communicate reasonably well. He endorsed previous membership in the CIA. He expressed sorrow and remorse about having killed a young woman and an antidepressant was added to his medications. Mr. C remained at Ely for several months. He was seldom any trouble and he continued his Clozaril without incident. He spent several weeks in the infirmary over the years and I saw him frequently. There was no doubt in my mind that he suffered from Schizoprenia, but probably of the paranoid, higher functioning type.
Shortly before I left Ely, Mr. C asked to talk to me. He related that the Courts had overturned all pleas of Guilty but Insane and that the District Attorney had stated that Mr. C would be retried. If C pleaded guilty he would be given Life in Prison without the possibility of parole. The District Attorney said if Mr. C pleaded Not Guilty or Not Guilty by Reason of Insanity then the state would seek the death penalty. Mr. C asked me if I knew of any psychiatrists who might be willing to look at his case. At the time, Jasmine was board certified in Forensic Psychiatry. I gave Jasmine's work number and thought no more about it until about 2 years later.
In 2003 Jasmine received a phone call from a lawyer for Mr. C. He asked if Jasmine would meet with him to discuss a case. Jasmine was in Las Vegas every other weekend and so an appointment was set up using the office for my private practice. Two attorneys appeared. They summarized the case against Mr. C and then asked if either Jasmine or I were interested in participating in the case. Either Jasmine or I asked for the most damning information from the case and our jaws dropped open.
As a part of the plea of Guilty But Insane, Mr. C was required to identify the location of the body so that it could be autopsied and returned to the family. Mr. C provided a location and a forensic team retrieved the body. The problem was that it was a body other than the victim's.
Jasmine and I looked at the lawyers. "You've got to be kidding! How could anyone willingly provide testimony that might lead to Mr. C's release. Life without Parole seems like a rather light sentence for a person who appears to be a serial killer."

Uncertainty--the Goddess of the Universe