Medical Violence

Abstract

His name was one of these: Raul, Ryan, or Rakim. It doesn t matter. The sheriff s deputy sat him on the edge of the examination table and left. He was the last patient of my shift at a county jail. The 22-year-old man sat there, waiting for me to initiate the encounter, taking disturbingly fast, deep breaths. “Whoa, what s happening?” I asked. “Diabetic,” he panted. “Been asking for insulin since I got arrested.” I asked for a fingerstick blood sugar while I interviewed him. He had one problem: a 5-year history of type 1 diabetes. He took long-acting insulin and four individualized doses of lispro a day. His glucose control had been excellent, with a hemoglobin A1c level of 6.7%. He had experienced no episodes of diabetic ketoacidosis since his initial diagnosis. However, his sugar levels had immediately shot through the roof after his arrest. Now, they were beyond the detection range of the clinic glucometer: more than 500 mg/dL. He said he had begged for an appointment and his usual insulins but had been left underdosed. “Is this true?” I asked the nurse. “What s his regimen?” “We put him on protocol. Twice-daily regular insulin, sliding scale.” Wrong medicine, wrong frequency, wrong dose. I threw up my hands. “Call an ambulance,” I said as our patient continued his Kussmaul respirations. “He has diabetic ketoacidosis.” A chill went through the clinic. The nurse exchanged a worried look with the deputy. “Uh, doctor, that s expensive. We can just give him some fluids here. Don t you think?” “No. DKA is an emergency. I can t fix it in 5 minutes at the end of my shift. He needs infusions and frequent lab tests. A clinic that ignored him for days and brought him to see the doctor at”—I glanced at the clock—”4:45 p.m. cannot provide that.” “We have high sugars sometimes,” the nurse said. “We treat in the medical bay.” “Call an ambulance,” I repeated. “Not a question.” I hope the next words the nurse said, whispered while she leaned over my shoulder, have never been uttered at any acute care hospital in the United States. “He s just a jail patient.” That s a quote. I wish it weren t. I m a hospital doctor who trained in a high-intensity academic medical center in Boston where typical patients had complex coronary artery disease or a transplanted organ and three unusual pneumonias at once. When my hospital started sending us to jail clinics, I feared I d be practicing community medicine out of my comfort zone. I shouldn t have been worried. I found myself handling endless requests for sedatives so inmates could sleep the day away or skin cream to compensate for excessive showering. Then, a theater of the absurd: Numerous inmates sought sneakers and extra blankets and mattresses, which policy forbademe from ordering— so why bring these patients to clinic? A man facing 1 week in jail wanted his chronic shoulder injury repaired for free. A woman who had stabbed her husband to death wanted cosmetic dentistry. Mixed with absurdities, I saw warning signs. One stable patient with a low phenytoin level from nonadherence had her maintenance dose of this agent increased. Another patient with a low phenytoin level (this patient adherent but having seizures) received a one-time additional dose with measurement repeated in a week. I saw patients with cancer who couldn t get specialist appointments. I saw an unmasked patient with a history of a positive PPD who re-presented with weight loss, fever, and hemoptysis—after she had waited in a holding cell with a dozen other women. Then there was the moaning postoperative patient whose abdomen had swelled progressively until her incision split. She leaked copious amounts of oily, red fluid into her lap for days before she got an appointment. Then, I saw a patient severely beaten in jail who developed a 10-cm jaw abscess after fracture repair, was unable to eat, and was said to be “seeking pain meds.” He was—for severe pain. I sent these patients to the emergency room, too. Each of these seriously ill people was brought to me at the end of a long day spent deflecting demands for Benadryl and mattresses that did not require a physician. The United States incarcerates over 2 million people— six times the worldwide average—and many of these people have complex medical or mental health problems. Although all inmates have access to some care, it s not always good. Judges have found “widespread and systematic failures” of prison health care in Arizona and called a for-profit health care system in Maryland “critically short of care providers.” Lawsuits have documented critical delays in managing emergencies like stroke, sepsis, and, in a case at Rikers Island, death from diabetic ketoacidosis. Many inmates lose access to prescription medications or suffer injuries and chronic conditions that go unevaluated and untreated. Overcrowded prisons with inadequate precautions have subjected inmates to a death rate from COVID-19 three times the national average. One jail held the record for the fastest coronavirus transmission. Poor conditions and delayed care have also been reported at immigration detention facilities, harming detainees charged with nothing more than crossing the border to seek a better life or protect their children. Still, crowding and resource limitations don t explain indifference. “He s just a jail patient,” the nurse had said of our patient with diabetic ketoacidosis. I ve never experienced a moment of moral clarity as obvious as that one. “What you just said was wrong,” I told the nurse. That remains the only moral instruction I ve given to a colleague in 20 years of practice. “I have no idea what his