I just found out today that somebody died.  An inmate. A patient.  I feel a wide range of emotions.  A few things I want to talk about here include:

Medical Errors.

Inmates in the Hospital.

  I wasn’t there when she was sent to the hospital, I might have had a lower “holy shit threshold” because I am still young in my career and probably would have sent her to the hospital sooner, but we still don’t know exactly why she died a few days later.  And, it’s really not conclusive that anyone did anything truly wrong.  It’s terrifying to all of us that we may, and likely will, even with our best medical judgment, make decisions that are wrong, and end up causing harm, or delaying treatment.  However, I’m part of a team.  A really great team that has done amazing things to provide care to this very-marginalized community.  But,.. a team comprised of humans nonetheless, who make mistakes.

I knew when I got into this profession that the stakes are pretty high when you screw up, which you inevitably will.  But, working at a jail makes things incredibly complicated,..now proceed my torrent of thoughts:

Let me just launch into the multitude of complicated reasons why this absolutely sucks.   

Patients have very little control over their healthcare in jail, or prison. they can refuse medications, and refuse treatments, but they cannot demand them. Some very tenacious patients with resources manage to force a facility’s hand via the avenue of a very good lawyer, but this is rare.  Because inmates have few resources and few powers, their ingenuity becomes legendary.  Aside from sneaking all manner of contraband into and out of facilities through visitors and dirty employees, many of whom are conned,. inmates become extremely manipulative.  How else do you get what you need or want?   Manipulative behavior takes place for all manner of things, but in my world, not the least is in getting medical attention, treatment, and trips to the hospital.

I wanted out of my cell, that’s why I said I was going to kill myself.

Oh that?  Those hysterics were just an act.  I wanted off the unit. 

I swallowed four batteries. I need to go to the hospital.

So, officers and medical providers become extremely suspicious, especially when someone is known to display manipulative behavior multiple times. The problem is, when the boy is crying wolf and there really is a wolf there, we have all the power to decide whether something will be done about it.

 Out on the street, if you go to a clinic and they tell you, “go home, don’t worry,” and you really believe something’s wrong, you can keep going to clinics and hospitals until you finally get some conclusive answers.  I’m sure we’ve all heard stories of people who needed several second opinions and come to find out, they were RIGHT, there really was something wrong, and previous providers, despite their best judgment, missed it.  An inmate doesn’t have that luxury.  On a given night, I’m it.  I’m the provider.  I’m making the call.  And I could be wrong.  And if I am wrong, you could be screwed.

Ok,.. I’m being a little dramatic- in reality, if an inmate gets worse, I’m going to know about it,.. and can re-evaluate them later and call the other clinic to consult with the doc on duty if I need to, but from the inmate’s perspective, and I’ve heard it many times before,

I am just afraid my medical problem will not be addressed.

How can I get this procedure?  Can I use my own insurance?  Can I talk to my lawyer? 

I think something’s really wrong with me!

Even though our inmates get better healthcare than at many MANY prisons across the country, there is still a lot of fear that a medical problem will not be addressed.  And truly, we can’t do it all.  If it’s a medical necessity, we can do it.  If not, you’re probably going to have to wait until you are discharged to (fix that hernia,… replace that knee,… fix that rotator cuff,… have those warts frozen off,….)

So back to our case in question, the patient was well known to our staff.  She has used many drugs, for many years.  She had come in, quite ill and withdrawing many times, and had recovered without any complications.  It’s very likely that she would have died even if she’d been sent to the hospital immediately- there’s only so much abuse one body can take from poor health and substance abuse.  It’s likely that we will never know.  If she was at home, or on the street, she might have died without anyone knowing she was ill- it happens all the time.  People overdose and that’s it.

What is scary to me, as a provider, is that the weight of my decisions is much heavier, because I have the power to determine if and when someone goes to the hospital.  The inmate doesn’t have the option for a second opinion, like they might on the street.

And what if they ARE sent to the hospital and are very ill?  Most people want to die in the presence of their loved ones.  Inmates, unless released early on compassionate care after an advanced, terminal diagnosis, do not get that opportunity.  They are shackled to the hospital bed, their family and friends have no idea they are there, because if they did, it would be a security risk.  If they die, it’s in the company of a corrections officer and hospital staff.  We can’t even call their spouse to let them know their loved one is acutely ill.

If discerning the difference between someone who’s serious ill and someone who’s not, or is being manipulative without messing up is the scary part, then sending someone who’s really sick to the hospital, knowing they may not come back, and knowing they will be without their loved ones is the sad part.

Now, you may think, “well aren’t they criminals?!  They deserve it!  They got themselves into jail, now they have to deal with the consequences!”

And certainly, there is truth to that.  But, I work in a JAIL- most people are awaiting trial.  Meaning,.. many have not even been found guilty of a crime.  I feel like that changes things.  I have so many patients who were just in the wrong place at the wrong time.  Do they deserve to die like that?  Imagine if it was you or your family member- in jail for a stupid mistake- got tipsy and drove home, etc,… never done anything like it before,.. never will again I swear,… And some weird medical emergency happens while you’re in jail overnight,… appendicitis?  perforated ulcer? stroke even?  It might seem totally inhumane to not allow family to even at least KNOW, let alone be there.  Sure, a law was broken, but medical emergencies complicate things, and this may no longer seem like it’s “fair” or “deserved.”

And to push the “deserve” issue further- I am not convinced that even convicted criminals “deserve” to die in this manner.  Isn’t the prison sentence the punishment?  This is one of those crazy bleeding heart questions, but it’s part of the conversation at least.

Another thing- did you catch that part about how inmates in the hospital are shackled to the bed?  Female inmates giving birth- shackled to the hospital bed?  I had a patient who was chained to his bed for 11 days.  Never got up.  As a former hospital employee, I am SHOCKED that this happens, because physical therapy, getting up and out of bed is a PIVOTAL part of the recovery process.  Inmates are only allowed up if their inpatient hospital team writes orders for them to get up.  My guess, sadly, is that the reason this doesn’t happen much is because of fear.  They don’t know what that inmate is in a jumpsuit for!  Maybe they’d have a change of heart if they knew it was for using drugs, and not killing someone!  And even then, a killer with acute pancreatitis isn’t going to get very far,.. I’m just saying.  I have trouble with agreeing that chaining someone to a bed for the entirety of their hospitalization is either humane or medically appropriate.

One final discussion point for this vastly complicated issue.  When a person with means suffers due to a medical error (real or conceived), they often make a move on it legally.  They and their families witnessed it all, have all the records, and were most likely well involved in the person’s medical journey.  They were in those doctor’s office visits, met with the specialists, and had their questions answered.  If shit hits the fan, they’ve got what they need to file suit. An inmate, however, who suffers from medical errors may not have the same options.  Often, it’s pure socio-economics.  Someone who’s poor, on drugs and alcohol and homeless probably doesn’t have family members with the means or motivation to sue.  They may have burned all bridges there, they may have family members who are also struggling with addiction.  So who is going to sue, or force accountability for medical errors on their behalf?  What about our patient?  Like I said earlier, it doesn’t seem like there is clearly a medical error on our end, however, it has prompted heated debate among our staff and different providers feel strongly about how they might have handled it, often disagreeing with one another.  But what if we HAD made a big error?  Where would the justice be for her? Or is she just another casualty of poverty and addiction, with no one available, or with the resources to ask any questions. Indeed, in many areas of justice, the poor and powerless are left behind.

I remind myself that all I can do is my best, ask for help when I need it, and be honest when I mess up.  I just always hope and pray that I don’t mess up on a massive scale- the Hippocratic Oath rings true-

First do no harm.

Postlogue: We received the autopsy, she died of something completely unrelated to how she presented- something totally out of let field.  It’s not about absolving us of responsibility, although it feels great to know that as a team, we did not fail her.  However, her death was as I discussed earlier- due to the complications of a life of poverty.  A body dragged through hell and back by drug, malnourishment, abuse and neglect.  I do believe this is why she did not recover.