Of the four facilities I currently work at the high security penitentiary is my favorite, and where I spend most of my week. I find the higher security Uber maximum prison to be draining. The inmates are constantly locked down, they have nothing to do most of the day but fester on their problems which often makes their quasi-medical issues become immediately life threatening in their own minds. The inmates at the low security and medium security facilities sometimes don’t realize they are in prison. I often get of mirage of complaints about the wait time for medical, or why they can’t have their turmeric ginger tea shipped in. At the pen the inmates know they are in prison, most are convicts that have been in for the greater part of their life and still have several years to go. The Penn is what you imagine prison to be like. Gangs, fights, drugs, it’s all there. What follows is an average day in my life.
If prison is anything it is a passage of rituals. The first ritual begins at the front door walking through security. This is basically the same as going through airport security, bag scanner and all. I’ve learned some daily tricks however, wearing a velcro belt and rubber watch help with the constant undressing and annoyance that we all love. After security there is a walk down a set of stairs to the central command station (bubble) where I check out my radio and keys with “chits” that I’ve been issued. At the end of the day I return these in exchange for my chits. My keys and radio go on what I call my “Batman belt” which is essentially a police issue duty belt. In addition to my keys and radio I also have two small medical bags that have everything from Band-Aids and thermometer probes to tourniquets and needles to decompress a punctured lung. After leaving “the bubble” there is a long hallway that goes underground and under the fence into the main compound. From here there are a series of sally ports and gates that the main bubble opens by watching cameras placed above them. This maze ends for me at the outer door of the medical clinic. The outer door leads to the waiting room. Normally when I come in around 7:30am this room is filled with inmates, and walking through the lobby to the inner section of medical is always the scariest part of my day. The room is usually full of rather unsavory looking characters, most of whom I now know, several of which I know are not very fond of me for my relative ease to dismiss their drug seeking antics. If there was ever a “hit” put out on me I imagine this is where it would go down. There was a story about one of our medical assistants being taken hostage by an inmate in this very room months before I arrived.
The inner sanctum of the medical clinic is a large windowless fluorescently lit corridor lined with a variety of clinic rooms and administrative offices. In the middle is a large treatment room that doubles as a trauma room. I got lucky with my office, it’s one of the bigger rooms and it even has a window, although the window just looks out into the windowless hallway, it’s still a window! I’ve tried over the last couple of months to make my office into my own little safe space by strategically placing some fake plants and one of those pink salt lamps. It’s far from a med spa, but it brings me a sliver of peace in a sea of toxicity.
The day we are going to walk through starts like any other day, and for the most part continues in that way. I get to my desk around 7:45 with my printed schedule for the day waiting for me patiently next to my keyboard. At the pen we have “call outs”, these are specific times that inmates can move to medical from their housing range. There are three callouts with the last being at 12:30. Inmates are notified a day earlier that they are scheduled for a medical appointment during one of these three spots and hence “called out”. The first call-out is at 7:30 and I typically have two or three inmates scheduled before the 9:00am call out. Logging onto the computer I access the EMR to start looking inmate information up. The EMR in the prison is actually outstanding. I was obviously worried about the prospects of learning yet another clunky overly complicated EMR when I started, however the Bureau’s EMR is simple to use and has all the information on every inmate going back 20 plus years, not to mention all the records from every institution they have been at. It is a real nationwide working system, and it’s kind of awesome.
My first patient of the day is a new inmate to the pen that needs an intake appointment. By policy when an inmate arrives at a new facility they have to be seen by a physician within fourteen days of arrival if they are taking any medications or having any ongoing chronic issues. All of their medications are generally only written for a couple of weeks until they can be seen. This inmate was being seen as he had a “diagnosis” of schizophrenia and was on Risperdal a fairly powerful antipsychotic. I sat down with him for quite a while and we went over his chart and entire mental health history. He was never psychotic or schizophrenic in anyway. He had been started on antipsychotics many years ago when he was in an out of jails. Unfortunately, this is a common story I see fairly often. Inmates that are generally disruptive, overly aggressive and severely antisocial are given medications to “calm them down”, these medications often have to have incorrect justifying diagnoses. After chatting with him some more and reassuring him that he is not and never was a crazy person I decided to treat his underlying anxiety with some Zoloft and attempted to convince him to follow up with psychology for some therapy. As a General Practitioner simple psychiatry is within my scope of practice, and I’ve generally been willing to help out as much as I can with psychiatric care. The great part about this is that I have at least two psychiatrists that I can reach out to at anytime with questions and guidance. I have little doubt that I’ve learned more in the last six months about general psychiatry than I ever would have in any practice setting in the “free world” as a primary care doctor.
The next guy had a sprained finger, but was adamant that I check his worsening hemorrhoids. So he got a free rectal exam. There is a taboo uncomfortable feeling asking a prisoner to drop their pants and so that I may insert a gloved finger into their rectum.
My first inmate at the 9:00 callout was probably one of the more interesting cases of the week. The PA asked me to take a look at him, and we scheduled him in. Normally there is a PA in the morning that does sick call, if they have questions or things they are not comfortable with they will come and get me. The inmate was a tall white gentleman with a swastika tattooed on his neck. Normally when I see a white inmate I play a game similar to playing “Where’s Waldo”, It’s called where’s the swastika. Prison if heavily racially divided. Inmates fall into one of four categories; white, black, native American, or Latino. In the common areas on the housing ranges there are four TVs, one for each race, just to give you an idea. The vast network of prison gangs also directly corresponds with race. I’m often told that most new prisoners will quickly affiliate with a gang just to survive. White guys unfortunately don’t have many options outside of various white supremacists factions. I’ve heard one of the oldest and most notorious prison gangs the “Arian Brotherhood” was founded by a Jewish inmate, go figure.
So, this fellow is seeing me today because he has a very large and concerning abscess on his neck. I took one look at him and asked “IV drugs”? He reluctantly answered, “Ya” and admitted to attempting to inject Suboxone into his neck two days ago. He also admitted that everyone on his range shared one needle. How they got Suboxone a type of narcotic into the prison is beyond me, but they have some very creative ways. I expressed to him my concern about this growing infection and suggested or rather demanded that we send him to the ED for immediate IV antibiotics and possible imaging. He refused, when we told him he could die, he didn’t seem to care. One of the more seasoned nurses came in and pulled the inmate aside to ask him some more questions. He put him out in the hall and then approached and told me the whole story. The inmate wanted to go to the hospital, but if he were gone from the yard for too long his skinhead counterparts would think he was ratting on them, and would likely be in jeopardy of being killed when he came back. If I deemed it medically necessary we could ignore this, which would result in him being placed in solitary for protection upon his return, and likely he would have to be eventually transferred to another prison. We came up with a compromise and allowed him to return to the yard for a few hours to explain to his gang that he had to go to the hospital in order to avoid any conflict upon his return.
While I was figuring out how to write a note that attempted to document this treatment plan my phone rang. The nurse from the Special Housing Unit or “SHU” was asking if I would come down to see an inmate. If your not up to speed on popular TV prison dramas the SHU is basically the segregation unit where inmates go when the get in trouble. We don’t really have “solitary” per se, the inmates in the SHU are stuck in their cell 23 hours per day with a cellmate. From a medical perspective the SHU is especially challenging. There is a small clinic in the SHU that has basic medical supplies. Two officers escort the inmates out of their cells handcuffed. They are then brought to the clinic and remain in cuffs for the duration of their encounter. The challenging part about the SHU is that it is an assault on all the senses. The smell is a confusion of paint, urine, and stale musty air. The inmates are constantly yelling, either to communicate, or just protest. Trying to conduct an interview over screaming inmates and loud radios can be quite draining.
I was being asked to see an HIV positive inmate that was on hunger strike refusing to take any medications. I don’t remember the exact reason for the hunger strike, but it was something minor, like not getting the food he wanted. Hunger strike is a whole different topic, but there is a very well defined protocol we follow. The inmates have every right to protest and go on hunger strike, but we have every right to keep them alive, so if certain lab values start to fall off the cliff they get forced nutrition via a tube down their throat. This inmate had just started his hunger strike so he wasn’t in jeopardy of such measures. I chatted with him for quite a while. He had very low understanding of his disease; actually, you could just say he had low understanding of basically everything. After describing to him in the most terrifying detail possible how all the infections associated with AIDS will rampage his body he agreed to eat and take his meds again.
The next guy I saw back in the clinic was a newly diagnosed Hepatitis C patient. Hep C is rampant in prison. It is estimated that the risk of contraction from sharing needles is upwards of 80%, and a lot of guys share needles either from drugs or tattoos. Since the new treatment is so expensive we assign priority levels to all inmates with Hep C based on certain laboratory scoring guidelines. If they start to get sick, or they are more medically complicated they get treated.
My final two patients were both for chronic pain. As you can imagine this is one of the most challenging topics in all correctional medicine. Many of the inmates are generally in terrible physical health. If they haven’t been shot, stabbed, or beaten at least once in their life of crime it would be surprising. The other challenge is the constant risk of drug diversion. This comes in several forms, but collecting pills to sell is typically the favorite. The interesting thing is that we don’t really have an opioid problem like the outside world, because we simply don’t give opioids, hardly ever. The risk of diversion is just too great. There are rare exceptions of course, but they are quite few and far between. Motrin, Tylenol and other NSAIDs are the mainstay of treating pain. Gabapentin is frequently used as well, but this is also highly abused and the prison medical culture is steering away from this. We use a liquid form, but I’ve heard stories or inmates spitting in back up to sell. There are other agents like some of the anti epileptic drugs that can be used for neuropathic pain similar to Gabapentin. The problem I have with this is that if the pain isn’t neuropathic in nature it simply isn’t going to work very well. We don’t have physical therapy onsite, and sending them outside for physical therapy is costly and potentially dangerous. All this to say options are pretty limited for pain management. Early on I established a relationship with on of the Bureau’s physical therapists. I now can at least do a good physical exam, email it off, and get recommendations for physical therapy. We are working on getting resistance bands that will be carefully monitored. You can imagine the issues a prison would have with resistance bands. They could be a weapon, tourniquet for drugs or even used to catapult dead birds filled with drugs to a neighboring yard (no joke).
Since this prison complex is far away from any sizeable city I have a nice hour-long drive home at the end of the day. This decompression with the cool mountain air and a good audiobook seems to be critical to my mental health as I’m sure you can see the average day can be quite challenging, but usually quite fulfilling.