Ethnicity of Patients, Through Week Two Behind Bars

Top 5 Prescriptions, Through Week Two Behind Bars

1. NSAIDS
2. Anti-virals
3. Topical Steroids
4. Cryotherapy (Done in clinic)
5. Intranasal Steroids

Top 10 Complaints/Illnesses, Through Week Two Behind Bars

1. VIRAL HEPATITIS
2. HEMORRHOIDS (Making a big push, so to speak. Jumped from #8 last week)
3. OTHER DISEASE VIRUS/CHLAMIDIAE
4. DIABETES MELLITUS
5. OTHER/UNSPEC DISORDER OF BACK
6. DISORDERS OF LIPOID METABOLISM
7. ALLERGIC RHINITIS (They all want an "allergy shot")
8. OTHER LOCAL SKIN INFECTIONS
9. OTHER HYPERTROPHIC CONDIT SKIN
10.PERIPHERAL ENTHESOPATHIES (Mostly knee pain)

What Do You Do for the Man Who Has Everything?

I mean every symptom.

"My chest and throat feel like there are hot needles stabbing them, and my left side feels heavier than my right. I think something is seriously wrong with my body. And nobody will tell me what's wrong."

The guy sitting in front of me is wired. He's anxious and seems scared. It's obvious he's been through some hard times. Many years ill-spent, many drugs taken, and no doubt many bridges burned, torched, scorched. The crimes he's committed have finally caught up with him, and he's landed in prison for who knows how long. Now he's found this not-yet-cynical PA student who's listening attentively, and he unloads.

"I had this car accident when I was 24, and they gave me a shot in my spine. Do you think they might have messed me up? I mean that was like 20 years ago." He looks at me, and I realize I can no longer just nod my head in respectful listener mode. He expects an answer.

"Your symptoms don't sound like that's the case," I say. "You'd likely have some lower extremity problems, versus left arm problems." He's OK with that answer. Whew.

"I don't want to be around anyone," he explains. "I just stay in my cell as much as possible, because I don't know what I might do to somebody." Uh oh. I wonder if I should be worried for my safety, and I start to regret shutting the door for privacy at the beginning of this encounter.

"I can't stand the people here. I hate the fake gangsters. They ain't shit. I was in Oakland where they had real gangsters. This one white dude bought a pack of cigarettes off a black guy, and the skinheads told him he had to go back and make it right, meaning he had to do something to that black guy. When he didn't do it, they stabbed him 11 times. Right in front of me."

I think to myself maybe fake gangsters aren't so bad, and I say something along those lines to him. He actually agrees, and then continues with a litany of complaints that has my head spinning. Sometimes he's short of breath. It can happen when he's walking or just sitting. Sometimes it happens late at night. Sometimes he feels like he's "checked out" and he feels apart from himself. At those times he can't move or speak. He's also tired all the time. His face feels flushed. He gets dizzy and light-headed. His brother died of cancer in his forties. He's 44 and thinks he's next.

I decide to examine him. All pretty normal, despite the fact that he looks much older than he actually is.

Physical Exam...
Vital Signs: BP 126/84, HR 75, 97% on RA.
General: Well-developed/Well-nourished. Visibly anxious.
HEENT: Normal shaped head, no signs of trauma. No pallor to conjunctiva.
Lungs: Clear to auscultation bilaterally. No ronchi, rales, wheezes
Cardio: Regular rate and rhythm, no Murmurs/Rubs/Gallops
MS/Ext: No weakness in upper or lower extremities.
Neuro: Extra-ocular muscles intact. No focal neurological symptoms.
Lymph: No lymphadenopathy.

I've glanced at his medical history and he's been through every test there is. EKG, Cardiac Angiogram, EEG, lab test after lab test. With the exception of Hep C with a very low viral load, they're all normal.

I also see that he's bipolar and antisocial, with a Global Assessment of Functioning (GAF) of 51 to 60. This means "Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) and/or Moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with co-workers)."

I ask him about medications. In the past he's taken Gabapentin, Topiramate, Meclizine, and a few others, but nothing currently. His religious views make him reluctant to take any medicines. We talk a little about seizures, which he had as a child, and I explain that some of his symptoms may be connected to that. He's very glad to hear that, and seems grateful that I'm listening and thinking about what might be going on with him. Then I cautiously ask him if he's visited with the facility's psychologist, who I have heard is doing some sort of biofeedback therapy with inmates and getting good results. I wait for an angry response, for him to say I think he's just crazy.

Instead he says, "I'm not into self-hypnosis, I'm a Christian." Hmmm. In another time and place, that comment would be met by a smart-aleck remark. Today, I don't dare.

Instead, I re-frame it to him. "Have you ever had a time where you talked to yourself, and helped yourself get through a tough moment?" He likes that analogy, and says he's talked himself down from many bad moments.

We finish up by going through each of his recent lab tests, line-by-line. I tell him where I would look if I was worried about specific problems, and he starts to feel better as we progress through the litany of normal results. I don't think anyone has ever done this for him before. He doesn't say it, but I can feel he no longer thinks he's going to drop dead.

I suggest he make an appointment to see the psychologist and give the relaxation/biofeedback thing a try. I also say that if he thinks he's having seizures or any other serious problem, he should come back to the clinic right away. He says he will do that. He also promises to see the psychologist. He shakes my hand and we walk out to the front door together.

Did I help this guy? I think so. Did I miss some huge medical emergency that is going to kill him. Could be, but probably not. He's had these symptoms forever, and smarter folks than me have had their shot at diagnosing him. All I did was listen to him, lay my hands on him a little, and decipher some lab tests for him. Whatever I did, it worked, and he walked out better than he came in.

I'd say that's pretty good medicine.

Awkward Moment of the Day

The patient is a young black man who seems pleasant, but a little "off." He has a few complaints regarding this or that, and then states that he can't see out of his left eye. Without asking any further history, I immediately grab the ophthalmoscope and dive right in, checking the good eye first, and then moving over to the problem eye. I can't see anything going on in there. No bleeding. No signs of infection. No reflex of light coming back at me. Hmmm.

"Is this a glass eye," I ask.

"Yeah." I got shot through the eye a while back," he answers.

Oooh snap! I feel dumb.

My Other Jump Rope.

Double dutch in the Irish Channel. New Orleans, LA 1991, by Bryce Lankard

Yesterday after work I was feeling grumpy, so I went looking for a game at the court next to the workout facility here. I shot around a little, trying to make eye contact with the few guys who were entering the building to workout. Said hi to one guy and he frowned. He actually frowned at me.

Luck not turning around, I see the Associate Warden drive up. He’s kind of a big shot around here, but I go ahead and challenge him to a game. He looks just like Howie Long and sounds exactly like Bill Clinton. He shot right back with a challenge of golf--of course.

Finally, this one guy drives up. I size him up. He’s short. Good for me. He’s older than me. That’s also good. He’s carrying a jump rope and goes in, then comes back out in shorts. Alright. I ask him if he’s up for a game. “No, I came out to look for my other jump rope.”

Who has two jump ropes?

I think I actually helped someone yesterday.

Saw this guy at the clinic last Friday, who was having trouble with his asthma. Kind of a funny looking guy. He bucks the trend in prison by looking much younger than he actually is. I wanted to take a look at his meds and consider prescribing something in addition to an albuterol inhaler, which is all he had. He’d been using it multiple times a day, every day, and as my fellow PA students will all tell you, that’s inappropriate. It means his asthma is poorly controlled.

But in a twist on the Hippocratic Oath, the first rule of prison medicine is “Do No Thing.” Or, do as little as possible. Accordingly, one of the clinicians decided just to have him come back in a few days and see how he was doing.

He came back yesterday, lungs sounding like a squeaky gate hinge, and I decided to see him even though he wasn’t on the schedule. I got a good look at his medications. He had two inhalers. One he said was a short-acting rescue inhaler and the other was supposed to be a longer-acting medicine. He had been using them both several times a day. They were both plain old albuterol, and the “long-acting” one was expired since June of ’08. Damn. Now that’s expired.

Expired medicine in the garbage, he got two nebulizer treatments and a prescription for an inhaled steroid. I also checked him with a peak flow meter before, during and after treatments. He went from 190, to 285, to 320 mL/min. Not perfect, but improved. He also didn't do the test quite right, which is OK. I'm not sure where he’s normally at because even though he’s had asthma since he was a teen, he’d never done a peak flow check. Never? He’d also never had a nebulizer breathing treatment.

He walked out with open airways, breathing deeply and no longer sweating from the work of pushing air out and in.

My Raisin Is In The Sun.

LANGSTON HUGHES

It only took me six days to officially be sick of government medicine. The exact moment is a little harder to come by.

Maybe when I called one preceptor over to have a look at a draining pustule and he prescribed 7 days worth of band-aids without even looking at it. Maybe when the PA on assignment here said he thought about quitting every day of his life for fifteen years, and then decided he would stick it out 5 more until retirement--And he's giving me career advice as he says this!
It could have been when the guy who can barely walk and who obviously needs an MRI for his swollen knee gets two ACE bandages and NSAIDs. If he's stubborn enough to come back he'll get an x-ray. And then he'll stand (sorry--he can't stand) in line for an MRI. And then? I dunno. He might get a knee brace, or something along those lines. He might get referred out to ortho. He also has a badly swollen right middle finger, post dislocation and reduction, with some sensory changes along certain aspects of the finger. But it wasn't really discussed. One thing at a time.

As I walk out the door to freedom, I can hear the guards blasting away on the shooting range next to the facility.

I'm reminded why we're all here.

Top 10 Complaints/Illnesses, Week One Behind Bars

1. VIRAL HEPATITIS

2. DIABETES MELLITUS

3. DISORDERS OF LIPOID METABOLISM

4. HERPES ZOSTER

5. OTHER DISEASE VIRUS/CHLAMIDIAE

6. MIGRAINE

7. ESSENTIAL HYPERTENSION

8. HEMORRHOIDS

9. OTHER AND UNSPECIFIED ARTHROPATHIES

10. PERIPHERAL ENTHESOPATHIES

How to Get Hepatitis C

Get yourself a jailhouse tattoo, using a piece of guitar string as a needle. Don't ask where that guitar string needle was used previously.

Rule #1

If a prisoner enters your exam room in handcuffs, he should leave your exam room in handcuffs.

Meaning that if you can somehow convince the guards (correction officers) to un-cuff him for the duration of your exam, do not, and I mean DO NOT, walk him out of the room and down the hall without his cuffs on to return him to the custody of his captors. They will yell at you.

If you ever end up in prison, just tell everyone you are Canadian.

This I learned from an actual Canadian who's in prison for smuggling pot. He's super-chiseled like a lot of prisoners, and he's tall, with flowing blond hair that makes me say "Tarzan!" inside my head. He's unique, though, in one very special way. No tattoos. Not a one. No baby's faces trying to look innocent as they stretch over some dude's pecs (a common tribute to a child on the outside,waiting for dad who's on the inside). No slogans like "Outrage" inked across the hand, no elaborate patchwork blanketing the arms, no "Thug Life" arching over the umbilicus.

"Not my style, eh" he says when I comment on it. "I stay away from all that."

He punctuates every other sentence with "eh" so I ever-so-astutely ask him if he's from Canada. Duh.

Apparently it's great to be in prison if you are Canadian. Everybody loves you. "The Mexican guys tell me they got my back," he says. "The black guys tell me they'll watch out for me. Even the skinheads say they'll protect me. I could get elected mayor of this place," he says with a big grin.

He's in the clinic today because he can barely walk from osteoarthritis of both hips, but it's his right one that is just bone-on-bone. He says he's put in for a hip replacement, and I immediately calculate the odds of that ever happening. I also immediately panic over what to do for this guy. I haven't been cleared for surgery just yet. He bails me out and says he just wants a cane. Whew, I think I can do that! But wait. Can prisoners have canes? Can't they beat each other to a pulp with canes? Would they make an exception for the Mayor of Prison?

It turns out prisoners can have canes, if they promise not to beat each other with them. I guess that's the same rule that would apply for you and me. He gives me a terrifically charming smile and says "Thanks, eh. I feel better already!"

I would vote for this man.

Remember that movie where the inmates played the prison guards?

I am shooting baskets out next to the guest house where I'm staying here at the prison. From where I stand I can see all the various buildings that house the inmates. Each one is for a different kind of prisoner, based on behavior and risk of escape. To my immediate left is "Camp Cupcake" where the minimum security prisoners are--and minimum means no fences, no locked doors. When I walk to and from the clinic in the morning and the afternoon I walk right by these guys. Every facility, even the more secure ones, are filled with exercising inmates. At Camp Cupcake it's mostly joggers and walkers in the morning. Then handball, racquetball, more jogging, basketball, baseball, and weight-lifting in the afternoons. One guy throws a huge, heavy medicine ball as far as he can, sprints to it, does ten push ups, and then throws it again with the opposite arm and sprints to it, repeating the routine over a hundred-yard stretch of open field. Some of these guys are big, strong, and in excellent shape. One of my patients is a former MMA fighter who works out 5 hours a day.

This brings me to the guards--sorry, "Correction Officers." They see these ultimate workout routines and they take notice. The prison staff actually have a state-of-the-art workout facility that gets used a lot. This isn't the buy-a-gym-membership-for-the-New-Year-and-then-never-go crowd. One guard, I mean officer, says they have to stay strong to fight the prisoners if needed. Me, I couldn't work out enough in a million years to fight MMA guy. But I don't have to. I'm Androcles, who pulls the thorn out of the lion's paw, so I'm safe. I think.

So I'm shooting baskets, and starting to get used to the glint of the sun off the razor wire, and a big, hulking guy walks up and says hi. He's wearing a plastic garbage bag-shirt under his tank top to make him sweat more. Okay, whatever.

I figure out pretty quickly that he's a C.O. (correction officer, not a guard, remember). He wants to play some ball: Make 'em, take 'em, to 7 points, gotta win by two. Regular baskets count one point. Three-pointers count as two. He isn't tall, but he has arms way bigger than mine. Waaaaay bigger. And he has a chest like a horse. He's from the Midwest, and like many a farm boy he can shoot the three. I find that out on the first possession. Then I overcompensate and guard him close and he goes right by me. It's 3-0 and I feel lame. I finally get the ball on a missed shot and I actually begin to contemplate a strategy of making him run around and sweat excessively under that garbage bag to make him tire out. But then I think how tired that would make me, and I just take a shot. It goes in and so does my next; a turn-around jump hook off the glass. 3-2 and I start to think I can take this dude. Then I dribble the ball off my leg, and curse under my breath. He's super nice and never makes me feel bad, even as I continue to make blunder after blunder. But he cools off from outside and I make a few shots to keep it close. Eventually he takes the game 7-5, and we shake hands and re-introduce ourselves so that we can remember each other's names.

Current Record: 0 wins, 1 loss.

But it's a long season, and I am blessed with dumb optimism and high hopes.

There but for the grace of god, goes Lebron James

I love basketball.

I love the athleticism and the grace. I love the player, really. I'm talking about the guy that can flat out play. The guy that can move so quickly that he leaves you standing, or breaks your ankles, or just makes you clumsily reach and grab in a futile effort to stop him. He dares you to stop him, and you can't. I wish I was that guy every time I bounce a ball or clang a miss off the rim, every time I jump as hard as I can and go nowhere.

You know the guy I'm talking about. He's strong, but thin. He's black, usually. He's cool. He's bad ass.

I saw that guy yesterday in the clinic. I know he could do all that I just described and more. Except for two things. One: he's behind bars, locked up. Two: He was shot in the head. Twice. Now he walks slowly, the pace dictated by short-circuited nerve endings. His right leg doesn't cooperate. His head still jukes and feints quickly, but not because he wants it to. He has a scar running the width of his forehead where someone opened him up.

I'm standing in front of him. Close. I'm looking at the scars from the bullets that passed into his right forehead, and he grabs my hand more quickly than I care for him to. It surprises me, not just because he's fast, but because he's gentle. He takes my hand and rubs it across his forehead so I can feel the once-shattered skull and the unnatural contour of what should be smooth bone. I'm slightly embarrassed as I nod my head in clinical appreciation.

He has a book with him, Menace to Society. I ask him if it's the same as the movie, and he says no, it's just stories. We don't say much more. I can't really do anything for him. He says he's getting out soon and not sure where he's heading. Maybe California where he has some family. I renew one of his prescriptions and get him some padded insoles for his feet, which are hurting more than usual since he gave up his cane. He says he's giving up the cane and trying to get stronger. He's even started exercising. I wish him well, and he's gone.