Scratch Marks

Been slow on the blog. 106 degree afternoons and hot laptops don’t mix. 1 week left of this rotation. Don’t really type in full sentences any more. Interesting habit. Lazy. Hot.

Amidst the average, have been a few noteworthy patients in the last few days:

On intake history and physical exam find large firm, mobile cyst-like protrusion under the skin of the dorsal aspect of el pene and the patient tells me, “es un mármol. Para las mujeres.” I wonder if that procedure is covered by insurance.

Photokeratitis vs. the ocular manifestations of the great masquerader, syphilis. I was like, really?

Due to a scheduling error, completing a sleep apnea work up on the wrong patient, in Spanish. Turns out that when you simply answer “sí” to every question, as my patient did, I could diagnose you with paroxysmal nocturnal dyspnea, when all you needed was your GERD meds renewed.

Frothy urine.

Hemochromatosis (diagnosed through trans-oceanic collaboration with the most famous PA-S in Norwegian-Hawaiian history)

Epididymitis vs. Spermatocele. I never thought I would actually perform the physical exam test known as transillumination of the scrotum. How wrong I was.

Time in prison is dwindling down. Scratch marks are approaching thirty.

Before Lunch

Long week of "chronic care" patients. Nothing exciting enough to jump up and down about. Nothing funny enough to laugh out loud about. Nothing depressing enough to vent about. Just a long week of HIV, Hep C, DM, HTN, chronic pain, and hypothyroidism. OK maybe a bit of subconscious venting there....

I went with the doctor to the special housing unit where patients are on lock down 22 hours a day, and can walk back and forth in a little kennel like structure for the other 2 hours. We practiced medicine in what seemed like a dusty closet. A musty concrete smell clouded the body odor. I could hear the showers down the hall from where I was seeing patients. The whole building echoed loudly with the sounds of guards and radios and showers. The orange of the inmates jumpsuit was a sharp contrast to the gray and white metal of the cells, the floors, and the handcuffs they wore throughout the exam.

Awareness of surroundings is critical in this environment. But this heightened attention creates a shifting of senses. The mindfulness leads to a sharpness. The background becomes just as important as what as in front of you. The ink scratch.. of the tattoo.. on the arm.. of the patient.. in the jumpsuit..on the table.. in the jail cell..with a window..to the outside..with it's blue sky....all individual pieces that make up the terrain that my senses navigate.

Then I went to lunch.

No sign of Bernie today, I guess they sent him to another FCI in North Carolina.
Release date: year 2139.

Had 3 patients today that were being released within the next 2 months. Through similar grins, each told me the exact number of days they had left.

27 yo with recent diagnosis of HIV will get out without an opportunistic infection, but with a rapidly dropping CD4 count.

44 yo with chronic Hepatits C will get out with only half the anti-viral treatment he needs. I doubt he is willing to stay for the remainder. I also doubt he will complete the treatment in Mexico, where this gringo plans on heading after his halfway house stay.

71 yo with hypertension, hyperlipidemia, and "a 50 year old wife waiting for me on the outside." His blood pressure is the last thing on his list of things to take care of when he heads to Portland in 23 days.

I/M

Most SOAP notes start with: 55 yo gentleman.... or 40 yo female....19 yo patient....or 23 yo man....a way to convey an image in the reader's mind, a quick identity for the patient. Sometimes other descriptors are added to enhance the image: well-appearing....pleasant.....morbidly obese.....Hispanic......Caucasian......you name it.

In prison, the doctors simply write I/M .

Inmate. That is what they are. That is the only image that they wish to convey and the only identity that they permit them to have.

I refuse and still write "patient" (gender is assumed in an all-male facility). A subtle difference, perhaps. Maybe just a shortcut they use to save a few key strokes. Or with the first word of the entire assessment, are they are setting the tone early? Maybe with three key strokes: I/M buys them the excuse they were looking for. The excuse to blow off a nagging symptom, to refuse a CT scan, to withhold a new medication. Maybe it is a reminder to them, the first thing they and future readers will see when they open the chart: Inmate, Inmate, Inmate.

I can't be sure. But for now, I'm writing "patient" not I/M, because it feels like that's why I am here. To help a patient. To not harm a patient. To listen to a patient.

(((((((My next post could easily be a rant about how I think it is absurd that the 50 million people without health insurance (and without a prison sentence) don't have anywhere close to the access to health care that these inmates, er, patients have. So before you label me a complete Hug-a-Thug, know that I am conflicted to say the least.)))))))))))

Black Hairy Tongue

	Apparently most people take a photo when they get Black Hairy Tongue.
	Judging by the hundreds available on Google Images. My patient lives in prison, where they don't have cameras. At least not the point-n-shoot type Plenty of surveillance cameras. None of which caught my guy's intermittent symptoms Better luck next time.

The Jovial Jailer and a Pair of Undies

First time to the "jail" today, which is where they house inmates who have not been sentenced, or are waiting to be transferred elsewhere. The "elsewhere" could be anywhere from the "camp" down the road (think Club Fed) or a maximum security prison (think Not Good).

While the duties of the PA at the Jail are minimal and the learning opportunities scarce, it was good to see a different side of the facility. The prison clinic, where we were last week is akin to any clinic. Inmates come to us. They sit in a waiting room until we call them in. We treat them (or don't) and then they leave, wander off back to their "cellie" (cell mate) and go about their life in prison.

In the Jail, we go to them. First thing in the morning, the PA drags me around to different cells to hand out medication, check blood sugars, and administer insulin to those who require it. We wake some up and they scramble out of bed in their boxer shorts, to come to the giant metal door that we have just swung open. Others are already up, pacing in their cell. 22 hours of lockdown per day, translates to precious minutes outside the tiny cell, on the basketball court, or shopping in the commissary.

The PA is a large, jovial man who laughs with the inmates, remembering little tidbits about each one. He acts like a tour guide, happily pointing out things of interest, maybe hyping things up a little bit to give an edge of excitement. His sense of humor evaporates when a Body Alarm goes off over his radio. The Body Alarm is a staff members lifeline and they wear it on their belt. Pushing it when in danger triggers an immediate and very serious swarm of staff. For about 60 seconds, things got very chaotic. When it went off, we were out in the jail, outnumbered by blue jumpsuits about 40 to 2. The once jolly PA just starts running. Guards are yelling, the PA is yelling, we are all running towards the door. I pause for a second, not knowing if we were running away from trouble or towards trouble. I contemplate the consequence of both. If I am supposed to be running toward trouble, at least I have lots of "my kind" that will be there. If I am supposed to be running away from trouble then I.....then why am I pausing to contemplate this? Keep running!

About 7 of us are crammed up next to the giant steel exit door yelling for it to open. When it opens with a buzz, we rush through it and slam it behind us. It is at this point that we hear "False Alarm" over the radio. And everybody takes a deep breath. I learn that, in fact we were running toward trouble. That's what you do I guess. I knew the anti-climatic False Alarm would be a disappointment to my blog readers (except my mother), so I apologize for that and will end this post on a different note.

We were supposed to do a full History and Physical exam on a man who disrupted a commercial flight, forcing it to make an emergency landing, by wearing women's underwear on his head, among other things. He couldn't make the appointment because he was using the Law Library and the PA didn't want to disrupt his Law Library time. I was trying to figure out what obscure statute he was referencing that pertained to his innocence. Are there legal precedents set for this? Is he planning an appeal that will change the face of improper underwear-wearing flight disruption convictions? I just pictured him perusing the aisles of the Law Library, maybe taking a book back to his desk with one of those little green Law Library lamps on it, all the while with a pair of pink underwear on his head, just knowing that he is going to find that nugget of legal information that will set him free one day.

In the background....

After the intense background investigation paperwork that was completed months in advance, which included accounting for an address and place of work for every single day of every single month for the last 7 years, and providing a name and address of somebody who could verify that you lived at address X and providing yet another person who could verify that you worked at job Y, and creating a mountain of paperwork for somebody that has had a lot of jobs and a lot of addresses and also creating frustration for somebody who is not a big fan of run-on sentences who is now forced to write a very long one, as this is the only proper way to describe such a thorough background check that in the end....DIDN'T GET DONE.

So after a week, I don't have computer access. And the warden looks like he wants to fight me. And he looks like Chuck Norris, except he has this big Oval Office overlooking the prison grounds and he is in charge of fighting anybody that doesn't have their background check completed.

But they still let me use liquid nitrogen to freeze warts off another man's penis. Which is nice of them. I guess they assume that nothing in the unfinished background check will create an urgent need to prohibit me from such enlightening clinical activity.


Long weekend for this Govvy Employee!