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.