The Black Box

In life there are often a few defining moments that result in our courses being forever altered. We tend to follow a very structured path, even if we think our lives are chaotic when compared to those around us. We still have a plan and a path in front of us about where we at least think is pointing us in a good direction that we can make sense of. Then there are moments that are sometimes tragic and sometimes magic that flip us right off our path and into the abyss of uncertainty. We feel unraveled in these moments, these are moments when one path is gone and no others are apparent. We feel lost, scared, and just generally anxious and confused . It’s only when we grab back on to a new path and climb aboard that we start to feel more stable, when all the intangible components of our personality and our desires find hope in a new direction, even if it’s just a sliver of such. I feel like it’s like a black box. Like we are all just chugging along and then we hit a black box, we go inside, a bunch of stuff happens, and we come out on the other side in a new direction. Sort of like the kidney, we don’t really get it, but our blood somehow turns to piss, and all is well.

You can read a million quotes about how when “one door closes, another opens”, yada yada. But, the real challenge in life is to go through these black boxes and actually embrace that philosophy deeply enough that we can go through transitions without suffering. The problem we have is that we can tell ourselves that, and still be up all night worrying about shit because we can no longer see more than a few feet in front of us. I recently had a conversation with one of my good friends about a quote I like on Obama’s desk that reads “Hard things are hard”. And it’s really that simple. If you want to do hard things in life, they will be hard, and you know what? That’s ok, because they are supposed to be hard. Walking away from something that felt stable into instability to find something better is hard, and it should feel hard, it shouldn’t feel easy, because it’s freak’n hard, and hard things are hard. Thanks Obama! So why do we stress out about life being hard when we do hard things? I think it’s because in some lala fantasy world deep down we want hard things to be easy….Dumb!

You’re probably catching a theme of an introduction here. I recently went through one of these black boxes of life and my course is likely forever jarred, and yes, it’s been hard, and stressful. The fine points of this black box will be left for a later post. But, here are the salient points of what my “other side” now looks like, and really that’s all that matters.

-I left Family Medicine, the reasons being multifactorial, so I now wander the earth as a military honed general practitioner.
-I still wear the flight surgeon badge, I’m now in the National Guard and have the awesome opportunity to work with some amazing people and fly in the back of F-15s
-My new day job is kind of incredible. I landed a gig as a general physician in federal corrections.

The above three points essentially took six months of some of the worst and probably best anxiety I’ve ever experienced. I say best, because surly life has more black boxes in store for me, and I feel more prepared for the next one having dealt with this one. Mainly this has been a large part of the reason for my blogging absence as I struggled to rearrange the pieces of my life.

So without further delay, onto the next chapter… Correctional medicine!

The place I work at is a fairly sensitive environment, so for the sake of my own quasi metadata protection I will simply say a couple of vague things. The location is in the middle of nowhere, and I work at both a high security penitentiary as well as the most secure federal facility in the country where they lock up guys that are either so violent or notorious that they can’t be in a high security penn. If you’ve read the news in the last 20-30 years about the capture of a major terrorist, spy, or serial killer I am likely managing their blood pressure, teaching them stretches for their knee pain, or chatting about sleep hygiene.

As a general intro with more blogs to hopefully follow I’ll say a few things. The Uber Maximum as I will call it is a different universe. Inmates are kept is very strict isolation in their own cells for 23 hours a day with one hour a day of recreation, where they walk around a bigger area alone. I once counted, from the time I go from entering the building to the time I get to an Inmates cell I go through about 15 security check points. Everything is very high tech, very clean and organized. It’s like being inside some sterile space station where the house killer aliens. Large corridors connect housing units, and there is a small clinic room in each housing unit to conduct clinical encounters. When I see patients/inmates they always have at least two officers escorting them and they are always in full cuffs with a belly chain. Which has of course made doing shoulder exams a very creative process.

The penitentiary in contrast is a wild jungle. Inmates are generally free to roam around their housing units, and the yard while fully interacting with each other. Drugs, fights, stabbings, and gang violence are a constant theme. The HBO show “Oz” comes to mind a lot. Most of the guys are doing between 30-50 years, plenty are lifers, and some are getting out in a few months. The medical unit is a closed unit in the middle of the penn. I stay in my office most of the day and Inmates typically come to me, similar in many ways to a normal clinic. There is also a trauma room in the clinic where inmates are stabilized and then quickly shipped out to a local ED if needed. In the few months I’ve been there the level of action is starting to parallel my time spent in Afghanistan.

I imagine you might think this sounds horrible, but it’s actually an amazingly fulfilling job. I feel like more of a doctor in the pen and Uber-max than I’ve ever felt. On the outside or the “streets” as it’s called, we typically don’t think twice about multiple referrals to a variety of different specialists that will then typically happen with expedition and ease. Things are a little different inside a prison. Although inmates can still get speciality care if they need it and go outside it becomes a security risk and a large logistical challenge to do such so efforts are made to get them the care they need on the inside visa vie your friendly penitentiary physician first. As someone that likes to do a little of everything, it’s a great opportunity. There is as we know an opioid epidemic on the streets as well, there is not one in prison, at least if there is it’s not because of medical. Drug diversion is a giant problem so rationing narcotics and sedatives becomes imperative. What this generally means is that alternative pain modalities have to be explored, mind body medicine, yoga, and other rehabilitation modalities are heavily utilized. Granted they are a challenging population to work with, they are willing to work if they can be influenced correctly. To me, it’s already been rewarding.

A couple of other major selling points have been that although we are supposed to see the inmates in a timely fashion from when they place a request to be seen, or their chronic care clinics come due it’s not a matter of clinic bankruptcy from decreased RVU production if the doctor isn’t seeing 25 patients a day. So I’m afforded a very leisurely pace. If I take an hour to see someone and go over their history that is just fine. I’m not holding up jimmy from getting picked up from soccer practice because of the angry mom in the waiting room. The days of 20 minute encounters are over and I can practice medicine as slow or fast as I generally want or need. Another point is that a lot of these guys have never had decent medical care. They’ve either bounced around in and out of jails or they’ve just never seen a doctor before. So the pathology has been fairly impressive as well. I’m finding myself managing everything from newly diagnosed Hep C, HIV to common colds and icky feet. There is always icky feet though, every clinic, everywhere, icky, funky, sticky, yellow feet, alas.