Final Tally: Top 10 Complaints/Illnesses through Week 6 Behind Bars

1. ALLERGIC RHINITIS
2. VIRAL HEPATITIS
3. GENERAL MEDICAL EXAMINATION
4. DIABETES MELLITUS
5. OTHER/UNSPECIFIED DISORDER OF BACK
6. DISORDERS OF LIPOID METABOLISM
7. ESSENTIAL HYPERTENSION
8. OTHER LOCAL SKIN INFECTIONS
9. URTICARIA
10. ABDOMINAL/PELVIC SYMPTOMS

Oh Come ON ...

I hope this doesn't mean I'm getting cynical...

... but if you claim you need a wheelchair because of "excruciating" sciatica, and you have an appointment to evaluate whether you still need that wheelchair assigned to you, you should probably show up to your appointment IN that wheelchair, instead of walking over from your unit as if out for a Sunday stroll.

Interesting Case of the Day

Today's candidates for Interesting Case of the Day are:

1. Pus-draining armpit.
2. HIV+ patient not getting better, not getting worse.
3. Bad-smelling urine after eating the turkey in the cafeteria.
4. Drug-seeker.
5. Hepatitis C patient seeing "flashes of light."
6. I know my blood sugars are high, but I'm working on it.
7. Imperforate Anus.

And the winner is ...

Drug seeker!

No, just kidding. The winner is of course the young man with a history of imperforate anus. He's a new arrival to the prison here. He's in for "getting real angry" and "shooting up a house while some people were in it." No one got hurt, and he got 48 months. Anyway, he was actually born without an asshole, as he says. Thus he disproves the oft-quoted maxim that "opinions are like assholes; everybody's got one."

After living with a colostomy bag for a while, surgeons created an artificial anus for him. Unfortunately, it doesn't work as well as yours and mine. For one, it has no anal tone (I know because I had my finger in it a couple of hours ago) and it looks a little different from the standard anus. It's basically just an opening in the anal cleft ('butt crack' to you non-medical types).

Having no sphincter means he can't really control what comes out, and he's in clinic today requesting medical approval for a private cell because he soils himself daily. Unfortunately this often happens while he sleeps. He wants a private cell so he can use the toilet right away, when he needs it, without worrying about his cellie needing it or being in his way. And also so he can clean himself and his clothes without being embarrassed and having to deal with a roommate. And he has "really, really bad gas," too, he told me. Yep. I found that out during the interview.

Will he get a private cell?

Highly doubtful, regardless of what we recommend. And we are willing.

UPDATE 6/24/2009:
There is a private cell currently available, and other inmates have been complaining about this patient, so the hope is that staff will accommodate him with a cell of his own.

I just hope it's not in solitary.

Top 10 Complaints/Illnesses through Week 5 Behind Bars

1. ALLERGIC RHINITIS, takes a commanding lead.
2. VIRAL HEPATITIS, just won't go away
3. GENERAL MEDICAL EXAMINATION
4. OT/UNSPEC DISORDER OF BACK
5. ABDOMINAL/PELVIC SYMPTOMS
6. OTHER DISEASE VIRUS/CHLAMIDIAE
7. DISORDERS OF LIPOID METABOLISM
8. URTICARIA
9. DIABETES MELLITUS
10. OTHER LOCAL SKIN INFECTIONS

Seen in Clinic This Week

1. An inmate reading the book "What Color Is Your Parachute?" by Richard Nelson Bolles. It's the best-selling job-hunting and career-changing book of all time. Hope it works for this guy.

2. An inmate who accidentally sprayed Muslim prayer oil up his nose. He'd been keeping it in an old spray bottle and got it confused with his prescription for flunisolide, an inhaled nasal steroid used for allergies. Comment with your best dumb joke.

3. An inmate with an acute ankle injury sustained in the rec yard, in much pain. After being discouraged from ordering an x-ray, I went ahead anyway because I dutifully followed the "Ottawa Ankle Rules" in making this decision. Two days later I noticed it hadn't been processed and asked the x-ray tech if he would get to it.

"Maybe by next Friday," he said.

... And that's why I'll be glad to be done with prison medicine.

Time, Warped

The guy who cleans the clinic each day is a Mexican-American close to my age--maybe a little younger than me. He's been in prison for a while, and still has a few more years to go. I know he likes music, and since there are a few Mexican bands that I like, I asked him one day about his favorites.

"You like Café Tacuba?," I ask.

"Who?"

I explain who they are and that they're from Mexico.

"Do you know Molotov?," I say.

"Nah, I don't think so," he answers.

"How about Maná?," I try. This band is a little more mainstream and has been around since the late '80s.

"Yeah, I seen them on TV," he says. Finally, a hit.

I quickly figure out that musically he lives in the early 1990s, probably about the time he entered the prison system. Anything later is largely unknown to him.

He tells me he likes Los Tigres del Norte. This is one of the oldest and best-known groups from Mexico, singing in the Norteño style. He also really likes a guy named Chalino Sánchez, a singer of narcocorridos; ballads about drug smugglers. Sánchez is the O.G. of Mexican music, the Latino Biggie and Tupac. Like them he died young and violently, and is now idolized by many.

Sánchez was an illegal migrant worker/coyote/drug dealer who turned singer while in a Tijuana prison. He was hugely popular in the late 1980s among California's underground Mexican music scene. But not so popular that he wasn't shot while on stage in early 1992. Chalino, who always performed with a gun tucked prominently in his belt, fired back. Sánchez survived, but was kidnapped later that year in Mexico and found murdered with two bullet holes to the back of his head. The murder remains unsolved, but has been attributed to the Federales, to drug dealers, and even to an elaborate hoax, with Chalino alive and in hiding somewhere.

Sánchez is my guy's favorite. A singer who romanticized drug dealers with lyrics referencing torture and death. Am I surprised? A little. My guy is soft-spoken and extremely polite. He works hard and has told me that when he does finally get out, he will never end up in prison again. He says he's too smart for prison and is wasting his life inside. He loves history, and religion, and can quote obscure references and texts.

But then again, much of prison life is a contradiction:
The beauty of the landscape surrounding the razor wire. The order and structure imposed on the violent and unstable. The often mean spirits of the caretakers, and the men in clinic who are always inmates first, and patients last.

My guy has seven years left before he's out. As for me, I'm not sure where I'll be in seven years, but I do know that in seven days I'll be done with this rotation.

I won't miss it.

Memo To Health Services

INMATE COMPLAINT: My hand is fucked up.

HOW LONG HAVE YOU HAD THIS PROBLEM: Since 6-9-09

RATE YOUR PAIN (10 = WORST IMAGINABLE): 10


MEDICAL PROBLEMS YOU HAVE? CIRCLE ALL THAT APPLY:
Mental Health Problems.

This is written on one of the call-out slips we get in clinic from patients who can't come to see us in person. It's in pencil (more on that later), and scrawled in messy, but still legible, child-like writing.

One of the guards handed it to me, saying "I have a present for you."

The patient is in solitary confinement. We go over to see him, passing deeper into the facility through another layer of secure doors. We're in SHU, or Special Housing Unit, where inmates are kept to either protect them from other inmates or protect other inmates from them. In this case, to protect one from himself.

Back on June 9th, he stabbed himself in the hand multiple times with a pencil, and as I peek through the tiny window in his cell door, I see a pencil laying on his bunk.

"Is he supposed to have that?," I ask.

"We haven't been able to get all of them yet. It's the last one," says a female officer.

The PA opens the "trap." That's the small hatch in the door for passing meals, meds, and pencils, I guess. We're going to examine him through the trap.

"Let him take your temperature," says the PA.

A scruffy-looking Native American kid, 25-years-old, sticks his mouth up to the trap and opens.

"Under your tongue," I say automatically. I bend down to make sure I place it where I need it.

"Get your head up," the PA tells me. I raise my head a little.

"More. Keep your head higher. And step back a little," he tells me, not OK with my proximity to the patient.

His temp is 99.2. Not bad. He puts his hand through the trap and I'm warned again not to get too close as I bend down to look. It's red, swollen, and has two puncture wounds, one on each side of the back of the hand.

"We're going to give you some antibiotics. Are you allergic to anything?," says the PA.

The exam is over. The entire encounter is over. We walk away and are let back through the two locked doors that form sort of an air-lock between us and the main part of the facility.

I write up the note, prescribe Bactrim for 10 days, and imagine the meds passing through the trap on their way to my patient.

Is That Right?

Patient of mine yesterday mentioned that he had moved to Mexico a while ago and lived there for a couple of years before moving back to the States.

“Did you like living there?” I asked.

“Nah. Too much crime.”

"Do you know there's a guy in the lobby who's bleeding?"

Oops. That would be my patient. That was the pharmacist talking, and I walk over to the door and sheepishly let in the patient.

"¿Está sangrando?," I ask him.

He's a dark-skinned Cuban about 50 years old, and he was in earlier complaining of a "larva" crawling under his skin. He had a wee bump on his back, up near his scapula, with some fluid inside. He said it itched pretty bad and that he felt something moving underneath.

I told him it was probably nothing, certainly not a worm, but that we could sample the fluid inside and send it off for culture if he really wanted. He said sure. I did also say (I swear), that we could do nothing and just wait and see what happened. Or we could put some kind of cream or ointment on it, and see how that turned out. Nope, he really thought there was something IN there, and he just had to know what. O-kay...

So I prepped him, cut a teeny tiny incision (I swear), and swabbed it for culture. I patched him up with some antibiotic ointment, some gauze and tape, and told him to check back in a week for los resultados, the results.

Out in the waiting room, he noticed blood on his shirt and decided to say something, apparently because he didn't want to be accused later on of being stabbed by someone, I guess.

I took a look under the bandage and sure enough there was a trickle of blood. Damn. The patient assured me it was nothing, and that I didn't need to do anything. The guard just over-reacted, he told me. But I'm pretty sure you're not supposed to let your patients slowly bleed to death.

It was at this point that I regretted ever cutting into him, and I really regretted not using lidocaine with epinephrine when I initially numbed him up. Stupid. Dumb. That would have vasoconstricted the blood vessels and probably would have prevented this whole mess.

I tried direct pressure, like the scouts taught us. Still bleeding. I tried steri-strips to close the wound edges. Still bleeding. The preceptor (who is not our usual preceptor and is really more of an administrator) said "let's cauterize it." I gulped nervously and he proceeded to burn this guy's flesh, OH MY FREAKIN" GOD, without numbing him up first. The patient didn't appreciate that, and I started thinking about alternative careers. I could shock chickens to death, my mind flashed.

The patient was the best sport ever, and waited patiently while I injected lidocaine with epinephrine this time, and finally the trickle slowed to whatever is slower than a trickle. I did also hit him with the cautery wand a couple of times just to be sure, then steri-stripped him and built a big pressure bandage over the wound. I taped him up as we chatted in Spanish about Cuba. He was working on a fishing boat, and jumped ship to Mexico one year, gaining his freedom.

I nervously sent the poor guy out the door, wondering how long it would take before I received a phone call letting me know what a complete dumb-ass I really am. But my patient? He was happy as a clam, because he finally found out there was no worm living under his skin.

God Bless America?

Top 10 Complaints/Illnesses, Through Week Four Behind Bars

We have a tie! ...
1. ALLERGIC RHINITIS (It's Allergy Season)
1. VIRAL HEPATITIS (It's always Hepatitis season)
3. GENERAL MEDICAL EXAMINATION
4. OTHER/UNSPECIFIED DISORDER OF BACK
5. OTHER DISEASE VIRUS/CHLAMIDIAE
6. ABDOMINAL/PELVIC SYMPTOMS
7. DIABETES MELLITUS
8. DISORDERS OF LIPOID METABOLISM
9. URTICARIA
10. ESSENTIAL HYPERTENSION

I Saw This in a Book Once...

The patient sits down on the exam table and says he has allergies. My eyes glaze over. This is the millionth inmate with allergies this week. I start to go into my allergy work-up, which includes asking if he's tried the OTC meds available in the commissary. If not I can't prescribe anything yet. And if he says he can't afford to buy them then I have to check his account to see if he's truly "indigent" or if he's blown all his money on soda pop and lollipops.

He interrupts to say that he also has a rash on his neck and groin. He turns to show me his neck. Then pulls down his pants to reveal a similar rash. I see darkly pigmented skin. No pustules, no erythema.

Without saying a word I reach over to the bookshelf and flip open to a page showing exactly the same thing. My guy could be the same guy in the book. Young overweight Hispanic dude. Confidence radiating, I explain to him it looks like acanthosis nigricans, a common skin finding in overweight diabetics. I ask if he has diabetes, although I smugly already know the answer.

"No! I told them I don't have no problems with diabetes or high blood pressure. I exercise three days a week," he states emphatically.

I check his chart. He's been prescribed Metformin, an oral medication for diabetes, and Lisinopril to help lower blood pressure and protect his kidneys. Not feeling quite so confident, I ask if he's been taking the meds.

"Never started them," he says. "I don't have diabetes."

I pull up some recent labs. Blood glucose 234. Too high. I explain that the number should be closer to 100, and that he really should start taking the medication as prescribed. He disagrees and we go back and forth. He exercises, and says that's enough. I falter. I go ahead and check his blood pressure, which is pretty good, and look in his eyes, ears, and nose. I try again and he looks pissed. He just wants his allergy shot (which I'm not about to give him and I later found out raises your blood sugar), and he wants to go.

I point to the book again, the lab tests, the doctor's previous note, and say bluntly that the allergies won't kill him, but this could. Give it a few years and he won't be feeling as well as he is now. This requires more than exercise. He agrees to another blood test. I order a glucose level plus a glycolated hemoglobin, which will give a more accurate picture of his blood sugars over the last three months. I throw in another couple of blood tests and finally give him something he wants: some intra-nasal steroids for his allergies. Then he's gone.

I probably could have handled it better, but he wasn't in the mood for listening to anything, so maybe it didn't matter what I said. In his mind, he walked in with allergies and left with diabetes. Probably not the way he imagined it would turn out.

Not the way I imagined it either.

Board Review Question for Week 4:

Your patient states "I have mold growing on my penis." The most appropriate next course of action is:






A. Say to him, "If you don't use it, you lose it."
B. Tell him it has "gone bad" and he should throw it out.
C. Put on a pair of gloves and ask to have a look.
D. Check to see if he has a green thumb.

The answer is C. The exam reveals an almost indistinguishable, slight, purplish discoloration along the dorsal aspect of the glans penis, inconsistent with mold. No sign of trauma. No erythema. No discharge. No enlargement of inguinal lymph nodes noted. Patient states he has no pain or burning with urination and no increase in frequency. Order a few STD tests and reassure the patient it won't fall off before the next visit.

So this giant Rastafarian with no teeth walks in...

His prison ID card states officially that he is a Rastafarian, and he's allowed special oils and a Rasta hat to practice his religion.

He's in today because he wants a blood draw to prove that he has a vitamin deficiency. He believes that's the only way he'll get moved up the waiting list to see the dentist (The wait can be over a year for non-emergent cases). He says he must have a deficiency because he can't eat proper food, because he has only 8 teeth, most of which reside in the lower jaw.

The PA isn't sympathetic, and he gets a lukewarm referral to dental.

"NEXT!"

Halfway, Rotation One.

A little more than halfway through rotation one, and I should have just a little bit of wisdom in my back pocket by now, or at least been through some useful experiences. Here's a short list of things I've learned:

1. Be very careful where you put your penis. I knew this already, but seeing warts, sores, bleeding, HIV, traumatized testicles, and unrelenting itchiness really drives the message home.

2. If you don't follow up on something, it probably won't get done. Mentioning something to someone in the hallway, like "I think Mr. So-and-so needs a consult for his CHRONIC and HORRIBLE hemorrhoids, doesn't mean that a consult will magically happen.

3. I'm very comfortable looking up people's noses, and at their penises, and in their butts. And I actually think I know what to look for now, which I never thought would happen.

4. Prison (including the health clinic) belongs to the Correction Officers. It's their show, and we medical staff are just along for the ride.

5. Most things get better no matter what you do, or don't do, for your patient. Thank goodness.

Today's Top Headlines:

MAN LOSES TESTICLE. DOESN"T NOTICE IT'S GONE UNTIL PA STUDENT POINTS IT OUT.

Today during a routine physical exam, an observant PA student palpated a young inmate's testicles (that would be me, and it was for purely medical reasons of course). The PA student asked if the patient had ever had any surgery or problems "down there."

"Not really. I got in a fight with a guy three years ago in jail and I was beating the crap out of him when he grabbed my balls," said the inmate.

"Well, your testicle is pretty much gone. It must have been damaged and atrophied somehow," said the student after noting that the left testicle was about the size of a pea.

"I guess I never paid much attention," replied the inmate.

In other news...

IT TAKES A SPECIAL KIND OF PERSON TO BE A CORRECTIONS OFFICER

While eating lunch in the break room at the detention center, two officers were overheard discussing a Hamburger Helper commercial that came across the TV in the corner.

"What would you do if that hand (the Hamburger Helper mascot) showed up in your house?" asked one officer.

"I would break every one of his fuckin' fingers," replied the other officer.

"I would shoot him," said the first officer.

Transparent Patients

Prison medicine does offer an advantage providers on the outside might enjoy: Just about every detail of the prisoner's life is available with a few clicks of the mouse.

You might call it invasion of privacy, but the truth is there is no privacy in prison.

For example, have you ever wondered if the patient has been taking a medication as prescribed? Just call up the medication compliance report, and you'll see if he made it to pill line and downed that tablet of Wellbutrin (or whatever). And I do mean "downed" because they'll make sure he swallowed it and isn't "cheeking" it to hoard for later or to sell.

How about that diet you recommended to help with his diabetes? Click on the commissary sales report and you'll find out what he's been snacking on. Ho Hos and cookies? That explains the blood sugar of 334.

Dr. House tells us that all patients lie, and they do. So he sends his lackeys to break into patients' homes to find out what they're hiding. Patients here lie too. But you can't stray too far from the truth when your doctor knows where you are 24 hours a day, 7 days a week, and what you do for work, and play, and who you live with, and what shampoo you use.

... And how many little powdered doughnuts you've purchased in the past month.

And They Waterski too ...

Alcatraz had The Birdman. This facility will probably not have the Squirrel Man, if things keep going the way they did this week.

Prison isn't the most likely place to get bit by a squirrel, but it happened Sunday to one of the inmates. He showed up today sporting tooth marks from a set of squirrel incisors on his left middle finger.

"Me mordió una ardilla," he said.

Like many inmates, he is Hispanic and doesn't speak much English. He went on to say that he was minding his own business in his bunk with headphones on, listening to music (Squirrel Nut Zippers, maybe?), and eating a cracker. He had his hand up near his head when he felt something on him, and flinched. Bam! Bit by a squirrel, just like that.

The squirrel got away, and how it broke INTO prison I still don't understand, but the patient was left with the bite marks to prove the improbable.

Since squirrels are not a common source of rabies, and three days had passed without signs of any infection, I opted to send the patient away without any special treatment.

But the squirrel is still out there. And if he's crafty enough to sneak into and out of a locked-down prison compound, are any of us safe?

I'll Have to Look That Up.

... What to do for bloody ejaculate.

UPDATE, 6/9/09: There is a long list of potential diseases, conditions, obstructions, etc., for bloody semen (sounds like a naval horror film). Anyway, the patient never returned for his follow-up visit, so I guess it wasn't that big a deal for him.

Top 10 Complaints/Illnesses, Through Week Three Behind Bars

Hepatitis C viruses

1. VIRAL HEPATITIS
2. DISORDERS OF LIPOID METABOLISM
3. OTHER/UNSPEC DISORDER OF BACK
4. GENERAL MEDICAL EXAMINATION
5. DIABETES MELLITUS
6. HEMORRHOIDS
7. ALLERGIC RHINITIS
8. HERPES ZOSTER
9. OTHER DISEASE VIRUS/CHLAMIDIAE
10. ESSENTIAL HYPERTENSION

One thing that has really surprised me is that I have seen no one with a chronic pulmonary disease (excluding asthma). Not one.

There's no smoking in prison, and I guess being locked up for years with no access to cigarettes does wonders for your lungs.

Don't Mix the Colors

Each facility here has a different color uniform for its prisoners: Khaki, green and yellow, just yellow, blue, or orange (orange is for isolation, or "the hole"). When you see an inmate you know exactly from where he came and to where he's going. Makes sense.

One thing I'm still getting used to, however, is the great care that's taken to not mix inmates of different wardrobes. If you're seeing one inmate in an exam room, and a different "color" is about to be escorted through the hallway, you have to close your door and not let your guy out until the other color clears the corridor. Keep in mind this has nothing to do with race or ethnicity.

It's not so bad in the main clinic, but over at the detention center (or jail) where the new inmates are processed, it's a big deal. The jail is split into two populations, and each inmate is placed in one or the other after checking his name for incompatibilities against the names of all the other inmates already housed. They may be members of opposing gangs, they may be partners in crime on the outside, or one may even have been a victim of the other in their former lives. In the jail where there's a lot of movement, different colors can cross paths very easily. I've been told that guys from different yards who come in contact for as little as two minutes have had the crap beaten out of them. I've seen the tension myself when they do get near each other, as they quickly size each other up.

So, I'm in an exam room screening a new guy; asking if he has this disease or that, what meds he's taking, is he thinking about killing himself, etc.--and when I'm done and ready to take him back to the holding cell, I have to play this little game of sneaking him through the hallways while not running into anyone else doing the same with an inmate of a different color. And it's not like you can walk down the hallway and scope it out before you move him, because you can never, ever, leave an inmate in a room by himself even for a second.

So I literally peek around the corner, with the inmate right behind me, scanning the mirrors that give me a view in all directions, and we have to decide if we can make a break for it or not. We move and turn a corner before hitting the main hallway, and then I hear keys clanging and a door opening. Oh shit. Here come a guard with a blue guy! And my guy's yellow! Back! Go back! I put my hand up like a traffic cop and stop my guy. I direct him to stand against the wall in a side hallway, and I stand in front of him. What am I doing??? I firmly resolve that if these guys want to fight I'm out of here. Blue guy passes without incident and I hustle yellow guy back to the holding cell.

At the holding cell I call out for the next guy, grab his paperwork, and after a quick check in all directions, away we go again. That's prison medicine for you.

Can't we all just get along?

3 Days of Pain, Blood, and a Final Goodbye

It was a strange week behind bars.

On Tuesday, we had a staff member show up to the clinic with chest pain suggestive of a heart attack. 911 handled that one.

On Wednesday, we were winding down the afternoon when word came that someone was shot out at the firing range. The Doc grabbed the trauma bag and we flew through the various security checkpoints in record time (amazing, if you knew what we normally have to deal with). We quickly drove over to the shooting range where we found the scene exactly as advertised: a man down with a gunshot wound. I don't know if anyone actually uttered the phrase "Man Down!", that day, but if ever there was a moment where you could have, this was it. The story was, he shot himself practicing some kind of "quick draw" maneuver. The bullet went from lateral proximal thigh to medial mid-thigh. No exit wound but you could see the bulge of a .45 caliber round where it hadn't quite made it all the way through the flesh. Didn't appear to have involved the femoral artery, though there was plenty of blood initially. Considering what he was going through, he was in pretty good spirits. Someone joked with him that he'd at least have a good story to tell at his retirement party. Ah, Good Times. Life Flight whisked that one away.

Then Thursday, an inmate had a massive coronary event and died at one of the facilities. I wasn't there at the time, but arrived later to help with intake screenings for newly-arrived prisoners. Initially, they thought it was a seizure, but no. They called the PA over and he did what he could. The paramedics too. But he was a pretty sick guy, and didn't make it. I watched the funeral parlor personnel take away the body.

Is dying in prison worse than dying on the outside? I mean to ask, is it somehow more sad? More lonely?

I can't say, and I won't speculate. But if death is for the living and not for the dead, as Floyd McClure says, then in some way the man lying on the table, with only one eye open in a macabre wink, has a message for me and the others standing over his body: Come to terms with me. Come to terms with your inability to halt the inevitable. Come to terms with your own inevitable.

And most importantly, make worthwhile your freedom.

"When through the prison grating
The holy moonbeams shine,
And I am wildly longing
To see the orb divine
Not crossed, deformed, and sullied
By those relentless bars
That will not show the crescent moon,
And scarce the twinkling stars,

It is my only comfort
To think, that unto thee
The sight is not forbidden
The face of heaven is free."

Weep Not Too Much
- Anne Brontë

Then Don't Press There.

"I have this lump under my skin right here. And it hurts when I press on it." The inmate points to an area near his upper abdomen, just below his sternum. I feel his belly and the spot he's indicating. Then I take his hand and place it on my upper abdomen, just below my sternum.

"It's the same, no?" I say.

He looks a little surprised. Do I have the same disease he has?

"That's your xiphoid process," I say. "Perfectly normal part of your anatomy. Just don't press there, and you'll be okay."

Wish they were all this easy.

Don Quixote In Handcuffs

He’s been in prison since 1992, since he was 20 years old. He’s 37 now. He’s been isolated in SHU (Special Housing Unit) and on a hunger strike for 6 days, and has resumed eating now that he’s been granted an appointment with the doctor. He’s here sitting on the exam table, in handcuffs, with a guard looming in the doorway. He wants to see a neurologist. He wants an MRI. He believes something is wrong with his brain.

He also has a history of inserting razor blades up his rectum.

He says in 1987 he escaped from a juvenile detention center and was struck by a car while crossing a highway. At that time, he says, he suffered a brain injury and was in a coma for a month. Before that, he had two falls from heights as a child. Because his parents were uneducated, they didn’t get him proper medical care. We don’t have records of these events, so we have no way of verifying his story. He himself says that when his lawyers were planning his defense years ago in court, they could not gather all the data he describes.

At some point he had an EEG, an electroencephalogram. This test is common for people who suffer seizures, and the type and sequence of brain activity can sometimes tell us something about what’s going on in the brain. He says this EEG showed “brain dysfunction” and he wants an MRI to finally figure out what’s been wrong with him all these years. He believes he’ll get an explanation for the headaches, the problems concentrating, the mood swings, the difficulties with relationships, and the moments where he feels that he simply can’t express himself.

The more we talk with him, the clearer it becomes that he’s searching for an explanation of his life’s arc; for why he’s been locked up for twenty years.

“I would rather not be here talking about old problems,” he says. “I have better things to do.” He wants to move forward, and believes the answer may be an MRI away.

This is his creation myth, his legend, and his quest for a holy grail.

Now it’s our turn. The doctor is sympathetic, but focused. He explains that an EEG often shows nothing specific. He tells the patient he’s put too much weight on this one test done years ago. As for the MRI the doctor asks, somewhat rhetorically, what would happen if he gets the test and it comes back clean?

The doctor says, gently but without equivocation, that he believes the patient is mentally ill. He asks him to see the staff psychiatrist, and promises that we’ll investigate the MRI and medical path as well, just to be sure. Afterwards, he’ll say to me that this could be one of the better uses of the MRI here at the prison. It may bring some closure to this man’s searching and set him down a new path.

Who knows? … At least it will offer him an opportunity to write a new story, a chance at a new creation myth shaped from within rather than from without. I can’t say I’m terrifically hopeful: Being mentally ill in prison is no picnic. But I’m happy to give him the opportunity. In any case, it’s all I can do.

You Don’t See Me Laughing, Do You?

The patient has a common complaint, musculoskeletal pain of the knee.

“You probably need an MRI. We can put you on the list ... When do you get out?” the prison PA asks.

“2014,” answers the inmate.

“I don’t think we’ll get to you,” says the PA flatly.

The other PA student and I give a chuckle, as does the inmate. Good one.

“You guys are laughing. You don’t see me laughing, do you?” says the PA. “Let’s talk about it Friday. Stay behind the fence until then, okay?”

It turns out the MRI truck comes once, maybe twice, a year--Usually on a weekend. They’ll see seven or eight guys one day from this facility, and seven or eight the next day from the camp down the road. How they decide who gets an exam, I haven’t figured out. Many are called but few are chosen. I am sure not everyone who wants an MRI really needs one. In fact, I’m sure a large percentage of inmates don’t need an MRI. But … if you did need one … then, you’re kind of screwed.

I suppose my only answer at this point is to make sure I do good physical exams and give good patient advice, and refer for an MRI only when I’m sure that’s the appropriate next step. It’s a good rule for any clinician and a good lesson for me as a student.

And I guess I won’t laugh next time either.

"Security Will Probably Call the Sheriff."

That's what they said when I asked if I could walk over to the inmates' recreation area and get into a game of basketball.