Sunday, January 29, 2012

Out of Heart


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The Smith Islanders use the expression “out of heart” to describe a state of discouragement, disappointment, or depression. Looking back on the last week, it’s a reasonable description of where I’ve been since my last chemotherapy treatment. I described my miserable weekend where I was unable to appreciate the NFL Conference Championships. For the past week, I felt overwhelmed by an odd, faint, noxious smell. The thought of writing in the blog was a turn-off.  I have been too weak and short of breath to climb the stairs and have relied upon the elevator that the home builder installed for his wheelchair-bound wife.
At the time of my 4th round of chemotherapy on Dec 30, the drug “Alimta” was substituted for Taxol. The reasoning was that the combination of Carboplatin, Taxol, and Avastin had not arrested the disease.  Therefore, I no long met criteria for the study which continues to be open to those who get some remission of illness and then go on to test a maintenance treatment. So, the 4th round was changed to Carboplatin, Alimta, and Avastin.
The 4th round seemed to be the easiest with respect to chemotherapy side-effects. However, my pain level shot up particularly in my left chest and mid-back. On my 5th round, my last visit on Jan 20, Dr. Neal told me that I had gotten the four doses of Carboplatin and had likely reached maximum benefit.  He believed that Avastin was not likely to be offering much and we decided on Alimta alone for the 5th and 6th rounds.  After the 6th round, I would be offered another clinical trial.
I’m currently rethinking this strategy. Chemotherapy for this stage of the disease is more about “quality of life.” Chemo is minimally effective for extending life. Its major purpose is the reduction in symptoms that arise from the tumor and it’s byproducts—most recently that has been back and chest pain. But I’ve just gone through more than a week where the side-effects from the chemo took the joy out of every day. And, as far as pain control was concerned, I seem to have stopped receiving any benefits from chemo a few weeks ago. In order to achieve pain control, I am using large doses of opiates via fentanyl patch and I’m receiving local irradiation to the spots in my lumbar spine and left chest. These local treatments appear to be working.  I’m not sure of the likelihood that the treatments are contributing to my symptoms.
So, why continue chemotherapy? If the purpose is not life-prolonging but symptom sparing, and if the therapy is not sparing symptoms, and if the therapy appears to be causing symptoms and reducing my number of quality time, what is the rationale for continuation? How likely am I to catch a break that will increase time or quality without an exorbitant penalty in side-effects?
This is the issue that I will be focused on for the next few weeks. Stopping chemotherapy might make me eligible for enrollment in hospice. I’ll discuss this with Dr. Ward who manages my pain medication and is a medical director for a local Hospice. I’m particularly anxious to speak to Dr. Palchak about this. He is in his early 50s and  he has a wealth of experience with this cancer. I’m hoping that we can sort through the facts together and incorporate my preferences into another treatment plan.
Sunday January 29... It is early afternoon. It's a beautiful day on the Central Coast. I wanted to let people know why there hasn't been a recent post. If I'm feeling well enough, I'll get back to the blog tomorrow.



Monday, January 23, 2012

Career Change at 50

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As I'm beginning this on Wed Jan 18, I have to report that I've needed short-acting pain medication--one dose each day-- on Monday and Tuesday. The chest pain remains well controlled but I am having low back pain and weakness in my left leg to the point that I cannot lift my leg into the auto when I want to drive. So I'm scheduled for an MRI of the lumbar spine today to see if there is nerve compression.

Thu Jan 19. Yesterday was one of those mixed bags that makes it impossible to predict either short term or long-term future. I got the report from the Chest CT scan from last week and it showed shrinkage of the chest tumor and the lymph nodes in the chest. However, there was a significant increase in the amount of bone destruction in the spine. Yesterday afternoon, I had an MRI of Lumbar spine which demonstrated the increase in destruction and growth of the tumor into the psoas muscle, a large, powerful muscle that attaches inside the body cavity from the spine to the thighs. So, today, Dr. Stella, the radiation oncologist will go to work to develop a treatment plan for attacking the tumor around the spine and around the painful rib. He warned me to be sure that I took analgesics before coming to see him today. I'm very curious about this process and I'll do my best to relate it to you.

Fri Jan 20. I visited Dr. Stella yesterday. They use a very high voltage x-ray machine to deliver energy to the area of tumor. Because high energy beams are not particularly good for providing images, the high-voltage machine is attached in tandem to an imaging machine. I was positioned on the table and several pictures were taken with the imaging machine to obtain the exact area to deliver the radiation. In my case, there are two areas, one to my Lumbar spine where the tumor is destroying the vertebrae and pushing aside the muscle. The other area is to my left 5th rib which has been eaten away by tumor at the place where it hooks into the spine.

Dale is the technician at Dr. Stella's office that does the positioning and pulls the trigger for the high beam radiation. Once I had been positioned, another test picture was taken "just to be sure." Then I was zapped for about a minute in each of the windows. An India ink tattoo was placed on a few spots on my belly and chest so that I can be more easily repositioned on my next visit which will be Monday.

The reason that radiation works is because of the differences in growth rate between normal tissue and tumor. Tumor is reproducing much faster than normal tissue. In order to reproduce, the tumor cell has to go through "mitosis" where the chromosomes line up next to each other and copy themselves. While in mitosis, the cells are particularly vulnerable to radiation that causes mutations in the cells. One hopes that the mutation will prevent the cell from surviving.

In addition to a direct beam of radiation through my abdominal wall to hit the Lumbar Spine, the high beam machine can rotate through a full circle and attack the same area from the back. So the Lumbar treatment is split into front and back blasts of energy. The rib is only a centimeter or so away from the skin in my back. The treatment to the rib is from the back.

I was told that I might notice improvement in as little as 2 weeks. A normal course of treatment may be from 4-8 weeks. I was glad to get started yesterday. I'm hoping to be able to reduce the amount of pain medication. I think that will make me less tired.

Today, Jan 20,  is my chemotherapy day at Stanford. A CT of the chest was done locally on January 13. The radiologist in San Luis Obispo thought that there was some overall improvement in things inside the chest with continued progression outside, in the spine and in the ribs. However, the radiologists at Stanford did not share that optimism and continue to call the disease "progressive." Dr. Neal, the oncologist, decided to stop the carboplatin and the Avastin and to continue the Alimta for two more cycles...today Jan 20 and again on Feb 10. I'll then get another CT to assess progress. He mentioned something about being offered another clinical trial of chemotherapy after Feb 20.

Mon Jan 23 The lost weekend. I had no symptoms from chemotherapy other than a change in sense of taste on Friday night. I awoke early on Saturday feeling well and started to work on taxes. Late in the morning I felt overwhelmingly tired. We had visitors coming at 2 P.M. and I wanted to get a nap, but I couldn't manage to get out of bed. I would awaken for a few minutes then doze off to sleep. Company came and went but I still couldn't get up. Over the next 12 hours or so, I was up and down with prostate symptoms as well and I  ran a fever of around 100.6 with sweats.
Early Sunday morning I noticed that I was having low back pain that had escaped control of the Fentanyl patches and I began to take short-acting oxycodone and I've been using it off and on up until now. Since I am scheduled for a radiation treatment, I want to make sure that my pain medication is adequate to allow me to move around on the flat, hard surface of the x-ray table this morning. Yesterday afternoon I could not pay attention to the NFL games and I napped through most of them except the last half of the 4th quarter of the Giants game.
Believe it or not, the most annoying symptom is a strange smell that is faint and metallic. It makes me feel nauseous and like a crybaby. If I can sit outside in the sea breeze, the ocean smells block it out. I decided to see if pot were any help. Instead of using a vaporizer, I took a small pipe and took 1 hit. About 30 minutes later, I found myself eating. I was able to sit down with Jasmine for an hour or so afterwards and then I went and took another hit. It seems to let me tune out the smell.
This morning I am weak and shaky, but I am able to eat and the odd smell is much less prominent.

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Career Change at 50
In 1992 I had been working as a prison medical director for five years. It was probably the most challenging and interesting work that I had done in medical practice. It required hands-on medical practice, oversight of medical services, supervision of physician assistants and nurse practitioners, responding to complaints from a variety of sources, and resource management. It also gave me the opportunity to do a fun project by developing a computer-based inmate locator and reminder system for routine sick call and chronic disease clinics. I was also writing a small handbook for dealing with "Difficult Patients."
I had become very much interested in "relationships" in medical practice--particularly between doctors and patients. Of course the driving force for the relationship was "the patient's disease," a process that begins when the patient recognizes some change in his body. Most of the literature in this area came from psychiatry and I was increasingly drawn to fantasies about retraining in psychiatry. I was in a mood to return to an academic environment and to have an opportunity to learn new skills and to read extensively in the field.
With my two boys, there were two college education responsibilities heading in my direction, but Molly and I had agreed upon our separation that we would share these costs. I had made a decision many years before that it would be reasonable to bear the full costs for a state university and that any desire for something more expensive would be on the child who wanted to go that direction. My thinking at the time was that expensive undergraduate degrees were no better than state diplomas (I'm not as sure of that now) and that the child could find a way through academic achievement, work, and borrowing if something more was desired. I assumed that a choice of professional or graduate school was the most significant decision, far overshadowing the actual selection of 4 year university study.
Finally, the health care agreement between Maryland and our prison contractor, Correctional Medical Services (CMS), was in the final year. There were several companies that intended to bid for the new contract. All of this came to a head in 1992 and I began to look seriously at a career change. I have given my reasoning previously, but I'll repeat some of it here.

1993: I'm 50 and wondering if I can do this anymore
I have reached the age of 50 and realized that I had been a much better family doctor at age 40, when I moved to Smith Island. At the age of 40, I was still delivering a few babies each month, taking care of newborns and children, doing routine GYN work, particularly pap smears, assisting in surgeries, etc. I was still reading a lot of general medicine. By age 50 I had moved out of family practice to prison work, all adult males and administrative duties. As the medical director of a prison for 6 years, I had seen our wonderful psychiatrist, 70 year-old Charlie Bagley, in action . He came to work a few hours after I did and went home a few hours before I did and took no call which I did for me and for him. He was making twice my hourly rate. It was time to think about retraining for the home stretch of my career.

Psychiatry had great appeal. I had always been interested in it, particularly so when working in a prison and discovering that most of sick call was about something other than being physically sick. Not many physicians were curious about this, but I was.

Consider the difference between medical and psychiatry emergencies in sheer volume of the number different types of medical and surgical problems that come racing through emergency room doors. Chest pain can be heart attacks, pulmonary emboli, pneumonia, a cracked rib, shingles, peptic ulcer, dissecting aortic aneurysm, etc. What about abdominal pain? Appendicitis, cholecystitis, liver abscess, peptic ulcer, celiac or superior mesenteric thrombosis, Crohn's disease, ruptured spleen, kidney stone, inguinal hernia, etc, etc. There are severe time restrictions on making the diagnosis since survival with some of these conditions is predicated upon very early recognition and intervention.

Compare these medical emergencies with the treatments that must be provided the psychiatric patient? The primary tools that are useful in psychiatry are threefold...
  1. talk to the patient, see if you can de-escalate the situation
  2. if the patient is threatening self or others, you may grab the patient and try to control the situation with overwhelming physical force humanely supplied and applied
  3. medicate the patient with one of about 4 or 5 various cocktails of proven effectiveness
Voila! My goal at 50 was to practice medicine as long as possible. Psychiatry was the most attractive. It is also a discipline where experience gradually increases personal effectiveness. The wisdom of interaction with other humans is collective. I could be a better psychiatrist at 70 or 80 than at 55. I was sure that this was not possible for me in family practice.

Retraining meant that I would have to move. I had hoped to wait until Keith completed high school because he was active in basketball in a small school where he was guaranteed some playing time in his junior and senior years. He had a good group of friends--he was just a great kid with a wonderful temperament (it sure balanced out mine).  He was very smart and funny.
In the last year of the health care contract at the prison, CMS decided that they could not afford to give raises to staff. Instead of raises, the company decided that they would do other things for employees, like sponsor picnics and group outings. The big bonus for the year was to take us Eastern Shore yokels to a Baltimore Oriole baseball game in Baltimore, 150 miles up the road to the gentrified part of Maryland.

Keith's Wisdom and Humor
Love Those Os
On a late spring day in 1992 there was a company-sponsored outing for our prison health workers. At about 8:00 we boarded a large bus in Princess Anne Maryland and made the trip to Baltimore Camden Yards, the home of the Orioles. It was a part of Baltimore that I knew well, a few blocks away from my medical school. We had made good time and we were told that we about 90 minutes to kill before entering the stadium. I took the boys for a quick trip to Burke's bar, an old hangout from time in Baltimore. It was a lot cheaper feeding and filling up two teen-age boys at a restaurant than trying to accomplish the same feat at a ball park.


We made it back to the bus in plenty of time and we were met by the CMS regional manager who was to escort us to our block of seats where the president of the company would greet us. As I recall we were parked near far left field while our seats were in far right field.  So we started walking--a rather long walk through the crowds--down from left field, around the home plate area, and then another hundred plus yards down the right field line. When we reached the general area of our seats, we started to climb. And we climbed and we climbed to the top tier. Near the top of the stairs, we were greeted by the CMS president. 


It was at this time that I could hear my son, Keith call out to me. He was a couple of rows down. He has a booming voice. "Hey, Dad. Your company spared no expense!"


I got a laugh out of watching the major leaguers do their pre-game calisthenics and stretches. I thought about Babe Ruth whose row house at birth was just a few blocks west. It had been turned into a bar and grill, named Ruth's, and was two blocks from University Hospital. It was a favorite watering hole with medical students, at least for my class. It had a pinball machine and good roast beef sandwiches. It was also a hang-out for people coming off call and frequently filled with resident physicians wearing various colored scrub suits and drinking draft beer at 8 A.M. Rather than being out there stretching before the game, the Babe would have been at a place like Ruth's bar, knocking back a couple of beers with hot dogs. Then he would look at his watch and say to his pals, "Let's go play some ball."


Finally, the game came. In the second inning I saw a line drive pass above the second baseman's outstretched glove at the same time that I heard the sound of the ball coming off the bat. The ball had traveled 127 feet before the sound had reached me. Keith was right.


On Being Fortunate
Selfish knave that I am, I had a significant self-interest in my boys making it to the age of 21 without being a participant in an unwanted pregnancy. I wanted no part of more child responsibility. So, I was the parent who would give the lectures about condoms on a yearly basis. To the disclaimer, "Dad, we know all that" my response was "If you know all that then show me right now how you will remove a condom." 
The usual response to this query was "YUK."
The last time I asked Keith about his condom use was his first year of college. "Keith, are you practicing safe sex?" His response: "When I get lucky."


On Bereavement
A middle aged woman is sitting with her husband at my kitchen table. I'm serving cake and coffee. The lady is complaining about her 82 year old father who buried his wife of more than 50 years only 6 months prior and has just taken up with an old flame with plans of marriage. "I can't believe it is only 6 months," she said.  Keith piped up in a consoling voice, "Maybe he mourns quickly."

Keith plays things close to the vest. He is wonderfully good natured and met the girl of his dreams midway through college. I've never seen them bicker. As far as I can determine, they are still in love after after more than 10 years. He works as an economist and he is able to balance his work with his family life.  He loves to cook and has followed his wife's path into the veggie world. I admire this kind of ethical decision, but I suspect I will prefer warmed over bleeding beef until the day I day. I can't imagine the thought of life without a hamburger in my future. Should bovines go suddenly extinct, I'm likely to pull the plug.

BRIAN
Brian is very deep. As a child he was hard to soothe. In addition, his parents were engaged in their own struggles and he was in leg casts for much of his first year. He needed little sleep and didn't want to nap. His care could be very wearing. He also had recurrent, painful ear infections that added another dimension to the mix--really messy diapers from the antibiotics in addition to his pain.

He is mathematically gifted. I'm pretty good at doing mathematical estimates in my head. He is several times faster. While on Smith Island, he won the Math prize for the region that included several counties on the Eastern Shore. He received a similar award and scholarship in high school. He loved playing basketball and I think that he worked hard getting the most out of his physical attributes. (After all, we know that "White Men Can't Jump"--aren't you tired of all the bullshit that fails to recognize African-American superiority in many areas of Athletics? What is that denial all about? The Soviet Union was great at ignoring science that contradicted the various versions of Marxism that were fashionable in different eras. Don't we do the same thing with ignoring what we see in the NBA and NFL every day?)

In a much earlier post, I mentioned Racism and fessed up to some of mine. There is no way I can look into my childrens' heart of hearts and claim that there is no vestige of racism. However, I have good knowledge of how they spent their time and treated friends and acquaintances for the past 25 years. In 1987 they were very concerned about moving from a "lily white" insular culture and going to a larger school that was about 50% African American. However, they were basketball players and this was a sport that in Pocomoke was dominated by blacks with a sprinkling of whites. We had a color-blind basketball court in our back yard that was located close to the geometric center of town. I think that my boys are close to color-blind today but remain aware of what their black friends must still deal with in our society.

Brian married a Lorena, a woman from Guadalajara who is intelligent, has great people skills, and exerts  a calming influence on this smart, restless guy. I didn't meet her until going to Guadalajara a few days before their wedding. I liked her from the start. She was very direct. "How do you explain having been married five times?" was perhaps the second question after "How was your trip?" That made me like her even more. I don't remember exactly what I said but I do know that it was equally direct. I may have pointed out that she owed me some gratitude for my first divorce and marriage to Molly thereafter.

Brian has been enveloped by his wife's large extended family. He is fluent enough to pass for a native speaker. A day after his wedding, there was a party with a mariachi band outside of the city. I remember looking at him sitting with his friends in light hearted conversation. He appeared to be so relaxed and to be in such a good place emotionally that I had one of those "Peak Moments," a place that is so good that it can't really be described very well in words. Seeing your children in a good place is hard to beat.

Their first child, Oliver, is "almost perfect" according to Brian. He is big, curious, bilingual, and stubborn. Two years ago, Brian and Lorena found out that she was carrying a "Down's Baby." This was confirmed by chromosomal analysis showing Trisomy 21 after birth. This was quite a blow to their sense of the future. Lorena is very close to her mother and I suspect that she had hopes for a similar intimacy with her daughter.

The baby, Ana Paola, was very sick. She had congestive failure to the point that she did not cry because of the additional exertion required by the heart. Surgical intervention was required but the heart was too small for several months. Surgery was finally done on October 2010. She was in the intensive care unit for a week. She required doubly synchronized electronic heart pacing--both atrium and ventricle. There were concerns that she may have had a stroke on the fifth or sixth day but the symptoms passed.

It has been eye-opening to see Lorena's and Brian's response to all of this--the blossoming of love for the child, the acceptance of the limitations. It was so gratifying  to see my child demonstrate a level of love and concern that exceeds anything that I have been able to find within myself--and to see it done with such pleasure and grace is remarkable.

Privatized Medicine in Prisons
States have found that it is very difficult to use state employees to run a 24/7 medical operation--it becomes particularly expensive to staff nights and weekends because of overtime costs. With seniority considerations, the cost of labor increases yearly. The specter of rising pension entitlements is also as a negative.
California uses state employees to run prisons. The prison closest to my house in California is typical. There is a "chief of mental health" who supervises psychologist and psychiatrist supervisors, who then  supervise psychologists and supervisors.
Above the "chief of mental health" is a "health care administrator at the prison," a set of regional administrators above that, a chief psychiatrist in Sacramento above that, and an assistant director of medical services above that.
So there are at least 4 layers of supervision above the chief of mental health. Of course no service work, i.e. face to face care, occurs except at the lowest levels--psychologists and psychiatrists, 2 levels below the chief of mental health. Lot's of layers on top of the folks who actually provide the services.
The Maryland system was much tighter. In Maryland, there was a headquarters staff that was headed by an Assistant Director of the Department of Corrections for the state. Below this there was a management team--experts in Medicine, Psychiatry, Nursing, Social Work, Pharmacy, Accounting, and Contract Monitoring. They were not there to supervise. They were there for planning, oversight, program direction, and quality evaluations. There were several nursing field workers who were capable of going to an institution and doing investigations of various complaints. So there was an essentially bare bones organization at the top. All of the supervision of medical line staff was pushed down onto the contractor who was given quite a bit of latitude provided that the medical care was considered acceptable.

The Maryland contract included staffing numbers of specific health care personnel during certain shifts for the various institutions. The contract was expected to staff at that level and to provide an adequate level of care. Accounting was done using reports from time cards with spot audits as well. Maryland imposed stiff penalties on the contractor for failing to provide any mandated coverage. I don't remember the exact rates. Nursing was the largest staff of employees. The penalty for failure to provide a contracted hour of nurse care might have been as much as twice the going rate from the standpoint of salary. This imposed a significant financial incentive on the part of the contractor to fill the positions or to fill shifts from contract or "registry" staff.

Musical Contractor Chairs.
In 1993 I saw how a changeover from one contractor to another comes about. It was not pretty. Nurses who had come when the prison opened had now worked five years for CMS. They had started at the entry level and had acquired raises along the way. In addition to increases in pay with seniority, there often comes some other benefits like more sick time or annual leave.
The new contractor was not bound by any arrangements made under the former contract. While the new company was anxious to keep good staff and to make sure that they would be able to deliver services from day 1, there was no obligation on their part to do it with the same personnel. This was a time of high anxiety for the healthcare staff as they were interviewed individually by the management team for the new contractor which in this case was Prison Health Services (PHS). The first concern was keeping their current job, the second being the reimbursement.
As it turned out, anyone hired by PHS was a "new employee" with benefits fixed to the company's policies. Everyone started over. It didn't matter that a number of employees were on the verge of celebrating a work anniversary with the prior company, Correctional Medical Services (CMS). All were back to square 1.
I came to believe that it might be beneficial to "lose" a contract from time to timed since it destroyed long-term seniority for any employee and prevented "benefits creep."

Looking at Residency Programs
My personal finances remained solid even with the new company. They tried to play hardball and would have if they could. I trusted my instinct that very few physicians would want the job. I negotiated a very good contract for myself but I immediately began searching actively for psychiatry residency programs. Normally, these are four year programs with the first year spent in general medicine with emphasis in neurology.
I was hoping to find an institution that would give me credit for my internship of 1969-1970.  At the time Brian was beginning college at William and Mary in Virginia and Keith was entering 10th grade. Molly was a resident of Virginia which has an excellent state school system that included William and Mary (where Jefferson studied law), the University of Virginia, Virginia Tech, and others. Anyway, these state schools seemed to match up well with the more expensive private Universities.
My first choice of programs was Virginia Commonwealth University. It is located in Richmond within about an hour of William and Mary. I went for an interview. They would accept me if I chose to enter as a first year resident--meaning I would need to spend four years there to complete the program. There were no openings for me in the second year. It wasn't negotiable and this closed the door to the possibility of remaining within 90 minutes from the boys while I was retraining. Keith was not pleased at the idea of moving but he was stoic. I did want to know from him whether there was some geographic location that would be appealing to him for a couple of years, but he was non-committal. It was more likely that he would go to live with Molly.
At this point, everything seemed open. Without day to day parenting responsibilities, I could live anywhere and retrain anywhere. "Anywhere" was very attractive. After almost 10 years of East Coast weather, the thought of a dry Western U.S. environment was most appealing. I was particularly interested in New Mexico, Nevada, Texas, and Arizona. I looked at programs in Texas and Arizona as a visitor and I was encouraged to apply. However, I liked the atmosphere better in New Mexico and Nevada and I applied to those two institutions.
I liked both programs. Each had different strengths and weaknesses. The weakness in Reno was the small size of the department and the fact that the program was in its infancy--just a year old. There was an existing class of 1st year residents that I could join in the second year. This would be the first "graduating" class from the psychiatry residency program. Residency programs often supply "cheap" doctor manpower to the hospitals and clinics served by the program. If a typical psychiatrist was making $120K in 1993, a resident might be making $30K. It is cost efficient to use the resident whenever practical. New Mexico was excellent at squeezing residents in this way. The advantage of Reno was that the psychiatrists there were used to doing all the work themselves--I judged them to be less likely to be effective exploiters.
I was accepted by both programs. I chose New Mexico primarily because of the culture and history. It was a well-established department and the living conditions in Albuquerque and Santa Fe had attracted retired academic psychiatrists who enjoyed doing part-time teaching. If you check out the authors of various standard textbooks in psychiatry, it is surprising to see the number of contributors from the University of New Mexico.



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Monday, January 16, 2012

Some Notes for Prison Physicians

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Here are some observations and suggestions for physicians engaged in Correctional Medicine based upon experiences in prisons and psychiatric hospitals for the criminally insane in Maryland, Nevada, and California.

Some General Observations:


1.  It is very expensive to attempt to control the activities of human beings, especially antisocial human beings with energy enough to throw themselves into a battle with health care providers and other authority figures.

2. Inmates have an excellent communication system within the prison and they possess a large fund of knowledge about employees. If prisoners care to know they can easily find out what car you drive, where you live, and how much money you make. They will know who your friends are among other staff.

3. Some of your co-workers in prison have a great need to feel loved and respected and will establish relationships to fulfill those needs with inmates who are wonderful at providing compliments and flattery. Mental health staff are just as vulnerable as other staff and correctional officers. Inmate-staff relationships  include the passing of information about staff.  Last year I was angry at having a prisoner ask me about my upcoming vacation. He wanted to know if I was going any place or just staying home. It meant that some staff member had been blabbing this information and gave an inmate an "opening line" in an attempt to become "familiar" and to break out of something other than a formal relationship.

4. Inmates sometimes work in teams to "set-up" prison staff. Once a staff member violates a regulation,  that if known to the warden would result in dismissal, the inmates can bring pressure upon the worker. Typically the blackmail will take the form of bringing contraband, like money, drugs, and cellphones into the facility.

5. A very good and interesting book on the subject of staff-inmate relationships is Games Criminals Play: How You Can Profit by Knowing Them by Allen and Bosta. I think it is a must read for anyone working in a prison. It was very helpful in orienting me.

6. A prison is a part of the criminal justice system. However, the Criminal Justice System is less about justice and more about convincing.  Given the adversarial system, the inmate quickly separates himself from "his case." It is no longer about responsibility for the murder, but about the ability to "convince," and "plead the case." This is a perfect situation for antisocial persons who refuse to take responsibility for actions. However, something approaching the "truth" is pretty important for making medical decisions.


7. I've mentioned previously that there is often friction between correctional officers and health care staff who may be looked down upon as do-gooders. Many correctional officers have come to their profession after failing to find jobs in other police forces. In California I believe that the only requirement is a high school education. The occupation can be high stress, particularly when working around young, violent offenders in lock-up units. It is easy for health care workers to consider their own roles to trump security concerns and to make decisions that infringe upon the discretion of the correctional officers. Correctional officers are taught from day 1 that the primary purpose of the prison is the maintenance of security. This difference in perspective is a source of irritation for both groups.
Training can go a long way toward smoothing over such differences by allowing each group to grasp the point of view of the other. For example, it frequently occurs that an inmate refuses to leave the cell for a physician to do an evaluation. If a newly hired physician merely tells the correctional officers to remove the patient from the cell and put him in an examination room, things are likely to heat up. Extracting an inmate from a cell is not a trivial exercise. It will require a "use of force." A situation involving such force will result in a number of correctional officers participating in the exercise who will then be spending hours writing a report detailing their activities and observations during the "use of force." 
Rather than merely demanding that the patient be removed, a physician will do better by approaching custody and stating the problem: "I need to see inmate so and so in the examination room. He doesn't want to come, but I really need to see him. How can we accomplish this?" Correctional officers will often have a solution. "Inmate x has a good relationship with C.O. John. Let me see if John can come down here and help us." If John is able to easily persuade the inmate, then a lot of time has been saved. If the inmate continues to refuse, correctional staff have at least had a shot at the problem. The supervisor might discuss the use of gases like pepper spray as opposed to the use of battle gear and shields to enter the cell. Cell extraction is frequently associated with injuries. In many institutions, all cell extractions are recorded both for training and as evidence in the event that claims of injury are made by the inmate. I worked in a prison at the time that cameras were first introduced for this purpose--it makes an incredible difference. Everyone is on their best behavior.

Some General Rules for Physicians:

1. It's best to maintain your distance from inmates when you are not in a professional setting. When hailed by inmates as you pass through the yard, you can say "hello" and even mutter something about the Jets-Dolphin score when asked, but I try not to allow an inmate to fall in beside me and begin a conversation about his medical condition or anything else. Rather than walk across the yard with the inmate, I stop and tell him that I can't discuss anyone's medical information in a public place but that I would be happy to continue the discussion at a sick call visit. I wish him a good day and leave him.  When you are passing through a place where there are inmates, you are part of the public theater. Giving an inmate (particularly a healthy one) attention other than a greeting may be seen as reflecting a special relationship with the inmate in question. When you say goodbye to an inmate after stopping his attempts at conversation, don't fall for the hang dog "I'm being disrespected" bullshit. The inmate knows very well what is going on--that others are watching a performance. And he'll also know that you're aware of the game and that you won't give the appearance of having any special relationship. But say hello in reply to every greeting and give respectful nods to all. There is nothing more that is required. With severely mentally ill, this rule can be modified as necessary.

2. Make sure that your medical department is running a clean operation. One needs to be practicing good medicine. If not, the rest is just a scam, isn't it? Is this medical care that you would feel comfortable with for you and your family? If not, you need to look at your ethical compass. 
Sometimes inmates will attempt to prove that your medical department has denied them care by neglecting them or not honoring their request for sick call. Most of the time when an inmate says that he "already put in a sick call slip" for some problem, he will be lying and blaming someone in the system. However, you need to make sure that sick call slips are getting to the medical department in a prompt fashion and that they are being acted upon. 
The inmate is basically powerless when it comes to accessing medical services and needs the assistance of custody or a sick call slip. After several months or a year or two, inmates will have created a report card on you. If you practice as a caring physician, they will know that. If they see what appears to be poor or uncaring medical services, they will develop a poor opinion of your dedication to your profession. If they see you as bowing to every inmate pressure, they will see you as a fool and a soft touch and wonder about your medical abilities to see through what all the inmates know to be a scam.

3. Don't grease the squeaky wheel, but do gather information. The physician must also be a "cross examiner." When an inmate claims a prior medical condition and states that he had a prior schedule for a medical service that was interrupted by prison, those records must be gathered. Inmates claims about medical conditions and other medical problems that will affect conditions of his incarceration must be corroborated. Should the inmate refuse to comply with that reasonable request to obtain the prior medical records, the inmate must be informed that without that information, a decision will have to be made based on the data currently in front of you. By the way, never trust written information provided directly by the inmate. Data about the prior medical history must come from an original source.

4. Practice medicine up to the limits of your capacities, particularly in urgent situations. If there is any way that a medical problem can be managed in the institution, it should be done there. Physicians on call, whenever possible, should be expected to come to the facility to see any patient where transfer is being considered unless it is a life or death emergency. One wants to avoid involving a naive, free-world physician in the care of the correctional patient whenever possible. 
Physicians are trained to take their patient at face value at all times. As prison physicians we know that is a mistake in our special population--a little more evidence is required. Antisocial individuals are less likely to be as concerned with the notion of truth and are more likely than others to exaggerate or lie in order to seek an edge or a special accommodation.

5. Don't Avoid the Difficult Patients. There will be a set of patients who appear weekly on the sick call list. Some of these patients are attempting to "establish a case," creating a paper trail that "proves" that they have a serious medical condition (as indicated by the multiple visits for the same complaints that were not successfully addressed.)  In Maryland, this was much easier to manage than in California. In Maryland, we could admit a patient to the infirmary for a few days to better observe the behaviors. A lot of medical problems seemed to disappear after 24-48 hours never to reappear. Do not put off the frequent attender based only upon your observation that "he's just been seen." He needs to be seen in order to satisfy Estelle v. Gamble. You must demonstrate an ongoing attention to his complaints. Here is a medical suit brought against me and everybody else while in Maryland.
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 989 F.2d 491
NOTICE: Fourth Circuit I.O.P. 36.6 states that citation of unpublished dispositions is disfavored except for establishing res judicata, estoppel, or the law of the case and requires service of copies of cited unpublished dispositions of the Fourth Circuit.
Robert Leon BUCKNER, Plaintiff-Appellant,
v.
WARDEN, EASTERN CORRECTIONAL INSTITUTION; Commissioner of
Correction; William Donald Schaeffer Governor; Lloyd
Gatherum, Medical Department Supervisor; Correctional
Medical Systems, Incorporated, Defendants-Appellees.
No. 92-6228.
United States Court of Appeals,
Fourth Circuit.
Argued: December 4, 1992
Decided: March 9, 1993
Appeal from the United States District Court for the District of Maryland, at Baltimore. Norman P. Ramsey, District Judge. (CA-91-2362-R)
Julie Uebler, Student Counsel, Appellate Litigation Clinical Program, GEORGETOWN UNIVERSITY LAW CENTER, Washington, D.C., for Appellant.
Aron Uri Raskas, KRAMON & GRAHAM, P.A., Baltimore, Maryland, for Medical Appellees.
Audrey J.S. Carrion, Assistant Attorney General, OFFICE OF THE ATTORNEY GENERAL, Baltimore, Maryland, for State Appellees.
Steven H. Goldblatt, Director, David B. Goodhand, Supervising Attorney, Heidi A. Sorensen, Student Counsel, Appellate Litigation Clinical Program, GEORGETOWN UNIVERSITY LAW CENTER, Washington, D.C., for Appellant.
Philip M. Andrews, KRAMON & GRAHAM, P.A., Baltimore, Maryland, for Medical Appellees.
J. Joseph Curran, Jr., Attorney General of Maryland, OFFICE OF THE ATTORNEY GENERAL, Baltimore, Maryland, for State Appellees.
D.Md.
AFFIRMED.
Before WIDENER, HALL, and NIEMEYER, Circuit Judges.
PER CURIAM:
OPINION
Robert Leon Buckner, an inmate at Eastern Correctional Institution (ECI) in Somerset County, Maryland, sued various state officials under 42 U.S.C. § 1983, alleging they had been deliberately indifferent to his medical needs, denying him medical care in violation of the Eighth Amendment. See Estelle v. Gamble, 429 U.S. 97 (1976). In particular he alleged, "I need corrective surgery on my lower lip very bad. The M.D. (Dr. Sohr) here at ECI has said that this [is] 'elective' surgery and that I only want it for cosmetic reasons. On the contrary, the greater portion of my lower lip is missing because of an [automobile] accident in July 1991 and when I eat food falls back out of my mouth and it is hard for me to speak and/or articulate." He seeks injunctive relief to require reconstructive surgery and damages.
On the defendants' motion for summary judgment, the district court entered judgment for them, concluding that Buckner failed to show deliberate indifference to his medical needs. The court pointed out that the record establishes a "high level of involvement" by health care providers and that the action taken by the health care providers was "neither grossly incompetent [n]or inadequate, nor was the treatment provided shocking to the conscience or intolerable to fundamental fairness."

Having reviewed the record carefully, de novo, we conclude that, while Buckner has established satisfactorily a continued need for treatment of a medical condition that existed before he entered prison, he has not demonstrated that the defendants' response was in any sense deliberately indifferent. The record establishes quite the contrary.

As the result of an automobile accident on July 11, 1990, Buckner sustained extensive facial injuries for which he was admitted to Prince George's Hospital Center. When he was discharged two weeks later, he had undergone plastic surgery to repair substantial facial lacerations, including lacerations extending into his lip. No evidence was presented that he sought any further medical treatment, however, until late December after he had been convicted of theft and committed to ECI-a period of some five months.

After he entered into the custody of the Maryland Division of Corrections on December 7, Buckner submitted a sick-call request, on December 11, complaining of back problems and a bad tooth. On sick-call requests of December 13 and December 17, he continued to complain of his back problems. On the December 17 request, however, he also indicated he was having trouble with solid foods because of his facial surgery in July. On each of these sick-call requests, as well as all of the 30 or more that followed in connection with a diversity of complaints, the response by medical authorities was immediate, and in each case they provided some form of treatment.

Buckner complained about pain in connection with his facial injuries for the first time on December 19, 1990. He was provided with pain medication and advised to engage in facial exercises. A few days later Buckner was examined, in connection with his facial injury, by Dr. Eric Sohr, who referred him to an oral surgeon, Dr. D. B. Rae. Dr. Rae suggested a mandible labial frenectomy to give Buckner better flexibility with his lower lip. The operation was actually performed on March 13, 1991, and a week later, when Buckner was seen during his post-operative examination, Dr. Rae noted that the surgery "looked great." Buckner apparently agreed, reporting having been "very pleased with the result." Thereafter, on numerous occasions Buckner complained about facial pain and on each occasion was provided with a prescription for pain medicine. To assist Buckner in eating at a slower pace, he was offered a "feed in option," which he refused.

Approximately two months later Buckner insisted that he needed a further operation, leading to an administrative complaint and the complaint filed in the district court. In response to his request for further surgery, both Dr. Sohr and Dr. Rae, who are not shown to have had any bias or ill will toward Buckner, gave their opinion that Buckner's facial condition "should not interfere with eating and speaking" and that further "surgery for this problem [was] unnecessary and purely for cosmetic reasons." They nevertheless continued to treat Buckner's pain with medicine and to see him on a regular basis. Buckner's administrative appeal was denied by the Maryland Commissioner of Correction based on the opinion that no"corrective lip surgery is required."

Buckner makes no assertion that he was not given prompt treatment, but only that he was denied a further operation on his lip. He disagrees with the opinion of two doctors that further corrective surgery would be only for cosmetic reasons. Regardless of whether there might be another doctor who might agree with Buckner on this point, this is not a record on which a claim for deliberate indifference by the state officials is shown to any degree. While it is indeed unfortunate that Buckner continues to suffer pain and defacement from his automobile accident injuries, under the circumstances presented, we believe that the defendants met their constitutionally-established obligations to Buckner. See Russell v. Sheffer, 528 F.2d 318, 319 (4th Cir. 1975). We therefore affirm the judgment of the district court.
AFFIRMED

This is reasonably standard type of inmate suit. There was no evidence of any medical care for this problem in the five months prior to his incarceration. Once incarcerated he becomes focused on getting plastic surgery to his mouth, although his first sick call slips are for back and dental pain. (In fairness to the inmate, he may have experienced increased scarring and skin contractures during the first few months after surgery. So the appearance of complaints at 5 months would not be particularly unusual.) He was seen by the Physician Assistant in sick call and by me a few days later. Our prison was fortunate in having a contract with an oral surgeon who was able to see Buckner within the facility and to perform a frenulectomy. Even more importantly, the surgeon's experience and comfort with his findings allowed him to stand up to the inmates' continued complaints and lawsuits.

Notice also that Georgetown University has used the inmate's lawsuit as an opportunity to give their students experience suing the neighboring government officials in Maryland.

Although he claimed he couldn't eat in the short amount of time provided at the dining hall, he refused an opportunity to take meals at a slower pace and there was no evidence that he lost weight. In the free world, the inmate would be warmly received by a plastic surgeon provided the patient was willing to accept the need to pay. I'm not sure whether Medical Assistance (Medicaid) would have paid for this surgery had the patient qualified. Facial scars are relatively common in prison. This patient was the squeaky wheel. His complaints were never ignored. He was seen promptly. However, we could not have provided this inmate with his surgery without, in all fairness, being willing to provide cosmetic surgery to any other inmate who desired it.

From the above, case we can determine what the judge needed to see in order for us to have met our constitutional mandate. 
  • he has not demonstrated that the defendants' response was in any sense deliberately indifferent. The record establishes quite the contrary.
  • On each of these sick-call requests, as well as all of the 30 or more that followed in connection with a diversity of complaints, the response by medical authorities was immediate, and in each case they provided some form of treatment.
  • Thereafter, on numerous occasions Buckner complained about facial pain and on each occasion was provided with a prescription for pain medicine. To assist Buckner in eating at a slower pace, he was offered a "feed in option," which he refused.
  • While it is indeed unfortunate that Buckner continues to suffer pain and defacement from his automobile accident injuries, under the circumstances presented, we believe that the defendants met their constitutionally-established obligations to Buckner
6. Establish Formal Clinics for Frequent Attenders and Difficult Patients
Some of the more difficult patients are those who manage to "split staff" into the good guys and the bad guys. The more needy the staff, the more likely you will find staff who enjoy being the good guy. They are likely to go easier on the patient, to provide more medication, more likely to give lay-ins, and to petition other staff for special accommodations for the patient in question.
The "splitting" inmate can identify those fault lines that exist between staff members and wiggle into them and increase the distance in the split. The more extreme examples of such patients are likely to be so-called "borderline personality disorders." It is hard to imagine more miserable people. They do not have a firmly founded sense of self. Their emotions can bounce around wildly and they often show self-destructive behaviors including cutting on themselves and head-banging. They may attach tightly to a staff member and will hurt themselves if they perceive the care-giver as abandoning him.
Borderline patients thrive on cracks between staff--divide and conquer I think it is. While staff is divided it will be hard to establish boundaries for the patient because the staff is unable to bring themselves to a place as a group where the boundaries can be defined. When viewing a staff that has recently become more dysfunctional, look for a borderline personality disorder patient. In the most severe cases,  the pathology cannot be readily "contained" or "held" by a single person. It will definitely take a village. In order to defeat treatment, the borderline patient will be working to destroy the cohesion necessary for the group to enforce the "no fly zone."
When you identify a difficult patient in the medical department, you are likely to find that the same individual is having problems dealing with custody staff and with his boss at work or his teacher at school. When such a patient is complaining about the inadequacy of care, it is often useful to assemble everyone involved in care, including mental health and custody when appropriate, physicians, nurses, and administration for medical. With all the disciplines there, the inmate is asked to explain the nature of his complaint and his proposal for solving the problem. Following that presentation, a free ranging discussion can follow. The medical department can provide information that has been culled from the previous visits and explain the current status quo and treatment plan.
A group approach provides multiple witnesses who can refute the borderline patient's own perception of the sequence of events and the boundaries of the treatment plan. Everyone is on the same page. It is less possible for the patient to make unchallenged claims about the treatment plan.

7. If you do your job correctly you will be sued. While it is hard for inmates to get much traction in malpractice suits, it is very easy for them to file lawsuits complaining about a violation of their constitutional rights against cruel and unusual punishment. In seven years in Maryland, I believe that I was sued more than 10 times. In four years in Nevada I was sued twice, both times by patients with severe mental illnesses. If you have practiced reasonable medical care, you will win your lawsuits if you can demonstrate consistent and reasonable responses to the inmate's complaints. One of the problems with being sued, is that you will be carrying this history around for the rest of your life. You will be notifying every state board and hospital where you apply for licensing or privileges in the future. This is one of the down sides of prison medicine.

8. Be quick to admit mistakes.  Inmates are probably better at detecting deception than any other population. The medical department will make mistakes. Look at the high medication error rates in free world hospitals and nursing homes. There will be frequent errors in prison as well. Most of them will be Medication Errors. Few will be of serious consequence--but they must be admitted and documented. As a part of the documentation, there should be a chronology that indicates that the information about the error has been passed back up the chain of command. 


As a medical director in Maryland, I took it upon myself to have a visit with inmates who had experienced a medication error. I handled it in a formal manner. "Mr. Smith I called you up here today to let you know that we are aware that an error occurred in your medical care. (dialog with patient about the nature of the error and the possible effect and what you are doing to try to make sure that it doesn't happen again.) "
Then I would continue. "Mr. Smith, I wish to apologize on behalf of the medical department. Would you like me to put it in writing and send it to you, or can I just give it to you directly? "
Mostly they would accept an immediate verbal apology.
"Mr. Smith, on behalf of the entire medical department, I want to apologize for the error that we made. We will do everything in our power to make sure that it does not happen again."


------------------------


Friday, January 13, 2012

Life in Pocomoke City

**********
medical     *
**********
Tues Jan 10  A very encouraging day.
I'm essentially pain-free this morning. Yesterday I had an MRI of the brain. There were no metastases noted. I have experienced a large increase in the number of "floaters" in the right eye. A few years ago I had a "vitreous detachment" in the left eye that seemed very similar to this current episode. I'll go back to the optometrist sometime this week and let Tiffany Smart, O.D. give it a look. She does a thorough examination and she will send me on to an ophthalmologist if needed.

Today I have an appointment with Dr. Stella for radiation oncology to see if there is some pain relief that he can give me with radiation of the diseased rib and perhaps even the tumor in the spine.

The fact that the brain appears to remain clean encourages me to do what I can to use that brain as long as I can.

Wed Jan 11 Midnight
I saw Dr. Stella today. He examined me and reviewed my chest scans. My left 5th rib has deteriorated at the point where it attaches to the spine. It is an area that is "busy" anatomically, with a lot of nerve traffic. Since things are much better, he has recommended that I keep taking the Fentanyl and wait to see what transpires in the future. I have an appointment to see him again in 6 weeks.

Thur Jan 12
I saw Dr. Palchak yesterday. He detected some weakness in my ability to lift my left leg--for example, it is  hard to put on my underpants and to lift my leg over the bathtub wall.  He ordered yet another scan for me, an MRI of the Lumbar spine. He suggested that any tumor compressing a major nerve might benefit from spot radiation.

My bottom line in all of this has to do with my brain. I believe that the purpose of my body is to carry around my brain. As long as my brain continues to work reasonably well, I'm willing to do "tumor nips and tucks" that help me maintain a reasonable level of functioning. Should invasion of the brain occur, I'll be less inclined to seek aggressive treatments.

My Medical Team
I think I'm in very good shape going forward. Dr. Neal at Stanford is doing my Chemo and essentially calling my treatments shots. Dr. Palchak  has graciously agreed to take over my care here in San Luis County if the trips to Stanford become too much. My Pain Management doctor is Mark Ward. He is also medical director of one of the local hospices. The odds say that I'll be needing those hospice services before I am done with this. Finally, Dr. Garry Kolb is my local primary care physician--a wonderful human being and doctor. And then--I'm married to Jasmine--I have my own psychiatrist who made soup for me this evening.
------------------------
Life in Pocomoke City
The boys had mixed feelings about moving off of Smith Island in 1987. They were leaving 4 years of accumulated friendships to a new home and school. On the island they had lived in an all-Caucasian cocoon. Exposure to other ethnicities and cultures had only really occurred while they were with their mom, Molly, in Northern Virginia. They expressed some anxiety at attending a large school (compared to a one-room school house) with a racially mixed population.
http://en.wikipedia.org/wiki/Pocomoke_City,_Maryland

Pocomoke is a very rural, Eastern Shore of Maryland town, with almost equal numbers of blacks and whites (simpler language here). It is a community that is very much involved in youth sports and the practice fields are heavily used on Saturday mornings with soccer and field hockey for ages 5 and up. The basketball program is excellent and little Pocomoke high school is frequently in contention for the State basketball championship. Among the boys, the soccer teams were mostly white while the basketball teams were mostly black. My kids and I had played basketball for recreation for several years. After purchasing a house, one of the first things that I did was to add a basketball court in the backyard. I only wish I had spent a little more money and upgraded the backboard and hoops.

The boys were growing like weeds. Brian was taller than me by seventh grade and didn't stop until he was 6'4"-- he is more slender and wiry...like his mother. Keith is 6'2" and strong as a bull. He is more thickly built like me. Both of them are smart and quick on their feet. Keith is particularly witty when he take jibes at himself.

In 1990 I was invited to meet with the school board about some issue that slips my mind. I said something about segregation and a couple of members interrupted me and wanted to know what I was talking about.
"Well, a very obvious example is the use of the movie theater. On Friday nights, the white children go to the movies, while on Saturday, the black children go."
"But that's because they like to do it that way."
I pointed out that this was called de facto segregation--a carry over from an older era. Although there was no law or ordinance that required that the two groups behave in this manner, there was a tradition and an expectation on the part of parents that their children conform in this behavior.
However, in my seven years in Pocomoke, I never felt any racial tension or animosity. The high school sports scene was a major bonding experience for the community where most folks were within a five or ten minute drive to the high school gymnasium. It was so much easier to attend a game when compared to difficulties one is likely to incur in suburbia.
Our home was on the main street and had been well-built in 1912. It was spacious with high ceilings, a roomy entry hall way with a large staircase to the right. The downstairs had full-size living room, dining room, full bath, pantry and country kitchen. There was a back staircase leading from the kitchen to the second floor. When the extended family came to visit, the children loved running a circular route over the two stairways.
As soon as I had accumulated a little money, I renovated the attic and put in some skylight and a comfortable shower. The boys took over the second floor.
It was like living in a fraternity house much of the time. I had pushed my work schedule back into the early morning. For much of the time there, I was able to get up around 4 A.M., get in a quick run, shower, and be working by 5:30 A.M. I seldom left the institution for lunch and was generally home from work by about 5 P.M. So, I was putting in 10-11 hour days as a matter of course. I was also on call most weekends. That meant that I would go to the facility on Saturday or Sunday with my hours flexed around the boys' schedules. Even though I spent about 60 hours most weeks in the facility, there was a negligible commuting time and and more than 15 hours of work spent during times when the boys were getting up and getting off to school. So, I was able to eat evening meals with the boys. Sometimes these weren't much. I know that we gave Pizza Hut a ton of business, but our evenings were generally together. One Christmas I bought them each a "Lazy Boy" and the living room became our "man cave."

Women
I was very busy in Pocomoke and there was loneliness as well. I had not reached a point of emotional security such that I was able to feel fulfilled living on my own. I missed sex, but I missed physical closeness and companionship even more. I did have a live-in girl friend for several months. We had a great companionship but it wasn't love. We both moved on.
I dated M, an African-American schoolteacher for several months. She had a young son of 3 and she occasionally spent an overnight with me in Pocomoke. It was almost always when the boys were in D.C. with their mother, but every once in a while, we were all in the house at the same time. Given the size of the house, there were no privacy issues to speak of and my boys got a kick out of her child. But I felt no need on my part to lie to my children.
It was very interesting to experience first-hand the discrimination against African-Americans and "mixed" couples that occurred in Salisbury. When M and I went out to eat, it commonly occurred that we had long waits for service and/or errors in our food orders.
I dated  Carmen, who was from St Bart's in the French Virgin Islands. She was one of 17 children. She had her own business as a hairdresser in Salisbury and she was an incredibly hard-working person. We had good companionship cooking and dancing together. This woman had spent half a lifetime cooking regularly for twenty people a meal. I liked smoking Turkeys outdoors and throwing together ratatouille with Eastern Shore vegetables. She liked plantains and fried bread, spicy meats with Caribbean zip, and seafood. Many Sundays would find us working in the kitchen together, while the boys were out playing basketball with their friends in the yard. These remain special memories.

Making Money
Prior to working in prison, I had never been in a position where I was paid for every hour of medical work. I would estimate that 10-20% of my time as a family physician ended up being "pro bono" or noncollectable. However, by 1990 I was working more than 2500 hours a year. I had started out with a contract that pain $40 an hour in 1987 and by 1992, I was at about $60 an hour. My small, fixed salary and on-call pay brought my earnings up over the $150K mark and I had begun saving for retirement. Financially, things were much brighter for me. I had also become very interested in some of the medical and psychological aspects of prison medicine and I had begun work on a small book about the management of "Difficult Patients." This was a labor intensive project but it overlapped with the work that I was doing at the prison.

The Return of the Past
As my children began to pass through adolescence, I began to spend more time reflecting on my own childhood. When my father died in 1988 I was in the process of remodeling the attic of my house into a large Master suite. I let the contractor go, and I began to do the dry wall work myself. While I did it, I pretended that I was working on the project with my father. (You might recall my father's adventure digging out the basement and his use of male offspring to push the shovel and wheelbarrow. In the Pocomoke attic it was just me and Army Bill for a few months.)
It was during my own adolescence that I had begun engaging in self-destructive kinds of behaviors, partly as a rebellion against my father's control of my life and partly as a means of proving to the little hoods in our neighborhood that I was not an ass-kissing nerd. I was tired of being mocked for being smart.
The self-destructive behaviors were cigarette smoking, beginning to drink alcohol while attending high school, taking myself out of the high school honors class, and refusing to do more than about 60% of my homework.
Well, by 1988 I was the father of a very bright 13 year-old boy who was working out his own adolescence issues. I was also 45 years old and looking back at some of the wreckage that my wide wake had left behind.  I could see the relationship between Bill and Kathy Henderson as something very special, a free-flowing love with natural give and take. The administrator at our prison and his wife both worked on site and they managed a wonderful work and couple relationship. Relationships had failed me, or to be accurate, I had failed my relationships.
Later on in life, while practicing psychiatry, I came to believe that it was fairly common for parents to revisit their own past prompted by the growth and development of their children. In Las Vegas, there was a severe shortage of child psychiatrists. Most of them would not accept insurance for office visits. I did general psychiatry and I was happy to see most children. It frequently occurred that the parent could recall experiencing a rough psychological patch at an age generally corresponding to the current age of the child brought for treatment.

The Volvo Mystery
When my older son, Brian, reached driving age I sold off my little turbo charged Ford Probe and found a used Volvo 740 to add to my 1984 Oldsmobile station wagon. I figured that these were perfect automobiles for a 16 year old driver. I had no illusions about the need for any self-respecting teen male to test the maximum speed of all fleet vehicles. I looked upon that as inevitable.
Until Brian was 16, either Molly or I made the trip with the boys back and forth to D.C. for visitation. With Brian driving, it would be possible for the boys to make the trip on their own.
At last the day came for the boys to make the 150 mile journey together. It was a Friday afternoon and they left after school. I was at work. I received the first phone call about an hour later. Brian told me that the windshield had been cracked by flying stones from a car pulling off of the shoulder. This was followed by another phone call 45 minutes later, again from Brian. He had become concerned about a "hitch" in the steering and he had pulled into a Volvo dealer in Easton, Md. where they told him that the steering should be fixed immediately for several hundred dollars. I was already aware of this situation and had checked it out with my local mechanic who told me that it was not an urgent matter. I told Brian to keep on driving.
The boys were scheduled to return on Monday. I was at work on Monday and received the next call. The secretary told me that it was my son who was calling to inform me that there had been a little accident. Thinking that Brian was telling me about the windshield again, I told the secretary that I already knew about it and I continued working.
When I got home that evening, I found that the poor Volvo had taken another hit. The right front fender had been pushed in with the loss of the headlight. I looked at Brian. He looked at me and suggested that "A bra will cover that right up." Of course, this wasn't what I wanted to hear. "What in the hell happened?"
Brian's story is that he was waiting patiently at a stop sign about to turn left onto a one way street when a speeding car nicked the right front fender and sped off. It seemed like a weak story to me. I told him that he needed to take the car to the body shop the next day to repair the headlight immediately and to get an estimate on the fender. 
The following day, I called home to check the status of the car. Keith was there alone and informed me that Brian had taken the Volvo to a local park to play basketball. At this point I was very angry. I hadn't given permission for the use of the car. I told my co-workers I would be gone for an hour or two and I headed home. I realized I was too angry to be effective at that moment, so I called my brother, Dana, and told him that I was having murderous thoughts about my older son. He calmed me down.
It's twenty years later. I still don't know what happened to that damn car. I've pleaded with my son on several occasions, most recently in October, to tell me the whole story. I've pointed out the cruelty involved in forcing me to go to my grave in ignorance. He says that he is sticking to his story at the current time.


The boys were generally respectful and kind. From the age of 12 they did their own laundry (of course some of the loads were single shirts or pants). Pocomoke City was about 1.5 miles in length which made it possible to walk to any location and eliminated concerns about chauffeuring them. Both became very involved in high school basketball and I could be home in time to pick them up from practice when necessary. It was a very laid-back life if one were willing to accept a rural lifestyle. I couldn't think of a better place for raising children.

When I think back to those years, I often recall a trip taken in 1992.

Disney World
Roller Coasters
In order to maintain my Maryland license I needed to attend 25 hours of medical education or instruction every year. Mostly I had used mail order sources--they are much cheaper than flying somewhere and staying in a hotel while attending a conference.
However, in 1992 I considered mixing a conference for me with a vacation for the boys. There was an infectious disease conference in Orlando FL at Disney World. As a part of the conference "package" it was possible to purchase discounted passes to several parks in Orlando. The whole intent was to balance the professional's need to get credit and to have the family vacation during the day the physician was in the classroom. The family could be together in the evenings.
Keith and Brian were interested in roller coasters and it was easy to talk them into going with me on the trip where they could ride several. There was also shuttle service from the hotels to each of the parks. It would be possible for me to provide the boys with a pass to a different park each day. These are not inexpensive passes. I recall them being on the order of $50 each. 
We flew to Orlando and checked into a hotel that was about 2 blocks from the conference hotel. Each morning I gave the boys a pass to a park and then I went to the conference. Normally I would eat lunch with a friend or a colleague. However, on the third day I went back to the hotel at lunch time to retrieve something. The boys were sitting around watching the NCAA March Madness. 
"When are you guys taking off for the park?"
"We've been."
"The park's only been open for an hour and a half."
"Yeah. Well we just wanted to ride the roller coaster."
"Did you ride it more than once?"
"No, it wasn't that great."


Space Shuttle
While we were in Orlando, NASA was trying to launch a Space Shuttle flight. I told the boys that we were going to make the two hour drive to the coast in the morning to see if we could get a look at it.
"So, we are going to have to get up early."
"What time?"
"Well, they say they are trying to launch at 5:30, so we will need to leave here right after 3 A.M."
Neither wanted to go. Neither could imagine getting up that early. I was really surprised at the lack of adventure. (Maybe it was the strong teen drive to avoid being seen with an adult who might be construed as a parent.)
"We'd rather watch it on TV."
Of course with enough nagging at 3 AM they did get up and were good sports about it after we had left Orlando an hour behind. There was a delay in the launch of about an hour, so we did not see a launch in the dark. But my--what a sight and sound. It was like the sun ascending.
Recently I received a pat on the back--sweet appreciation.
I miss teen-age boys.





Monday, January 9, 2012

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.