As per tradition, the surgeon decided to ask me a question. I was the junior trainee in the room, and so I was expected to answer anything. Knowing this was my first surgery, though, he tossed me an easy one.
“What’s that?” he asked, as the camera turned toward a dark, shiny lump in the abdomen.
Suddenly, I was totally disoriented. What was that dark organ? I knew we were supposed to be taking out the gallbladder.
“Um, the gallbladder?”
“That’s the liver,” he said. Of course, the liver: the most obvious organ in the abdomen. He didn’t ask me any more questions, apparently realizing it would be fruitless.
The surgery proceeded tidily, as the doctor trimmed carefully through the tissue that connects the gallbladder to the bottom of the liver. He worked entirely through tiny incisions in the belly, guided by the camera as he snipped and clipped away with long-handled tools. He clamped the artery that provides blood to the gallbladder, as well as the duct that carried bile from the gallbladder to the intestine. When he finally grasped the gallbladder itself and pulled it through the incision and out into the world of the operating room, that final motion was clean and bloodless.
There was the organ itself, shiny and purplish, smaller in real life than it had been on the screen. A surgical tech put it into a silver tray, then sliced it open lengthwise so I could see the stones hidden inside.
Back under the lights, air escaped from the woman’s inflated belly as the surgeon removed his tools. He neatly sewed up the three small incisions. All that would be left for the world to see of our time inside this woman’s body were three tiny scars.
POM TOOK ME, for the first time, into Hospital Galveston. UTMB students undergo security clearance and training for prison work during their first year. The training includes, among other things, an armed prison guard in uniform opening up a box full of ordinary items that had been weaponized by prisoners: pens filed into sharp points, plastic forks with razor blades attached, metal reflex hammers somehow sharpened to resemble ice picks. The handiwork is sophisticated, and the demonstration left us medical students impressed. The guard was proud to say that no medical student had ever been harmed at the prison hospital—although one had been briefly taken hostage. If we were taken hostage, we were to keep quiet and let the guards handle it.
Although our orientation to the prison hospital did not include the history of medical care for Texas prisoners, I was aware of some of that. In 1976, the Supreme Court ruled that prisoners’ access to medical care is protected by the Constitution. Technically, the judges wrote that “deliberate indifference to a prisoner’s medical needs” constitutes a violation of his or her Eighth Amendment right to freedom from cruel and unusual punishment. The case—Estelle v. Gamble—actually came out of Texas. A prisoner named J. W. Gamble had been assigned to unload cotton bales from a truck, and he was crushed by a falling bale. His back pain after the accident was ignored, and he was even put in solitary confinement for refusing to work because of his pain.
For a while after 1976, the TDCJ continued to run its own prison medical care. UTMB was a marginal part of the system, seeing prison patients along with other patients at John Sealy Hospital. But in 1979, Judge William Wayne Justice ruled that medical conditions in Texas prisons were unconstitutionally bad. He ordered an overhaul of the state prison medical system. This led to Hospital Galveston being built, in 1983.
The War on Drugs began in the 1980s, and prison populations skyrocketed. The TDCJ medical system was struggling, and multiple lawsuits showed that Texas prisoners had been mistreated or their medical problems had been ignored. UTMB signed a contract with the state in 1994, formally taking over medical care for about 80 percent of Texas prisoners. This arrangement is called “Correctional Managed Care.”
Correctional Managed Care has not been without its failings, the most notorious of which occurred at a private prison called Dawson. Dawson State Jail was a women’s prison, and most of the women there were serving short sentences. At least three women—Shebaa Green, Pamela Weathersby, and Ashleigh Parks—are reported to have died after their treatable medical conditions were ignored by guards. Another woman, Autumn Miller, went into premature labor while serving a yearlong sentence for violating probation. Miller was a mother of two, and she recognized the cramps when she went into labor. But the guards ignored her, tossing a menstrual pad into her cell. She gave birth to Gracie Miller on the toilet in her cell. Gracie was only twenty-six weeks along, and she died four days later.
The problems at Dawson were not with the medical care per se. In most cases, the problem seemed to be that guards were ignoring serious complaints instead of relaying them to the medical staff.
But the prisons are notoriously short on medical staff. A glance at the TDCJ unit directory shows, for example, that many units don’t have twenty-four-hour medical care. A prison with thirteen hundred inmates averages eleven medical staff members. That number may include only one physician, with most staff being vocational nurses and medication aides. And prisoners are a bit more likely to be sick than your average Texan: not only do many come from poor backgrounds but the prisons have high rates of infectious diseases, including tuberculosis, HIV, and hepatitis C. The state is always trying to cut the cost of prison medical care, and UTMB struggles to keep up with the need, just like the TDCJ did in the eighties. In 2006, the chief of UTMB Correctional Managed Care told reporters that “Right now, the system is constitutional . . . but we’re on a thin line.”*
So it was with some trepidation that I took my first steps into the prison hospital. I knew I had a lot to learn in there, but I wasn’t sure exactly what the lessons would be.
TO GET INTO THE PRISON HOSPITAL as a provider, you take the elevator to the fourth floor of John Sealy Hospital. You walk down a normal hospital hallway and turn left. Then you push open a perfectly ordinary door marked “TDCJ,” and you find yourself at the entrance to a maximum-security prison.
Before coming through this door, I had emptied my white coat of the usual tools, including my cell phone. All I had was my badge, a notebook, and a pen. The double door swung open to admit me into a small, rectangular space. Directly in front of me was a wall of bars with a gate in the middle. To my right there was a cabinet that held a few purses and sets of keys, and to my left, behind another wall of bars, a guard sat in front of a computer.
“Badge,” he said.
I passed him my badge, which he ran through some kind of scanner. Then he looked at the computer to make sure I had security clearance.
“Empty your pockets,” he said. I had only the paper and pen.
“No phone, right?” he asked.
“No phone,” I said. In the early mornings, when a rush of physicians and nurses comes through, a second guard is on hand to search everyone. But I seemed to have missed that, and after handing my badge back to me, the guard pressed a button and the gate slowly opened.
I passed into a long hallway—the sky bridge that connects John Sealy to Hospital Galveston. There were no windows. A partition ran the length of the hallway at chest level, separating people going into the prison from those leaving. On the other side, an elderly man in white was being pushed in a wheelchair toward the gate I had come through. His lips sagged inward over a toothless mouth with no dentures. He was shackled at the wrists and ankles. Neither he nor the guard pushing his wheelchair looked up at me as I passed.
At the far end of the hallway, I waited for another gate of metal bars to buzz and open for me. Then I found myself truly in a prison for the first time. I was in a large room with barred, gated hallways leading off at angles. In the middle of the room was a guard stand, also surrounded by bars. From there, guards could watch all the gates as well as the elevators and the doors that led to the stairwell. I asked a guard how to get to my assigned unit, and she pointed me to the elevators marked “Staff Only.” As I waited for my elevator, a guard pushed another man in a wheelchair out of the opposite elevators. This man was sh
ackled with thick chains, and he had a mask over his face.
It was a relief to meet up with the medical team. They introduced me to the patient I was assigned to interview, leading me past the guard who watched the door to his room. He was a lower-security patient, so the guard didn’t have to come into the room with me, but she watched us through the glass wall. All I had to do was take a thorough history, write my note, and I could go.
My patient was a Spanish-speaking man in his early forties. He was in the hospital because his heartbeat was irregular, and a cardiac monitor was strapped to his chest. He’d fainted in his cell a week ago, and he was transported to Hospital Galveston after getting emergency treatment at a local ER. The bus ride from his prison unit to Hospital Galveston had taken two days. I know that sounds improbable, but it’s true—the buses stop at various prisons along the way, picking up and dropping off people. It takes a long time.
There was no chair in his room, so I stood a bit awkwardly looming over his bed. Even so, we fell easily into talking. He told me that his heart troubles had started the first year he was in prison, but that he was going to get out next year. “I am afraid, though,” he said.
“Why are you afraid?”
“I want to be able to do things when they release me. And with my bad heart, I don’t know if I’ll be able to.”
“What kinds of things do you want to do?” I asked.
“I want to climb mountains!”
This made me smile, but he was totally in earnest. My patient was not only an inmate of the state of Texas but also a potential mountaineer.
“What can I do now,” he asked me, “to take care of my heart?” In the free world, this is a dream question. Doctors can seem like we’re always nagging people about diet and exercise, but here was a forty-year-old patient who wanted to know what steps he could take to protect his heart so he could climb mountains! I was eager to help him out.
“Well,” I said, “you want to take your medications if they prescribe them.”
“Oh yes,” he said.
“And aside from that, a healthy diet and exercise are good ways to take care of your heart.”
His face fell. He explained that his access to space for exercise was very limited. “And the food in prison is very bad,” he said. “I am sure that it’s high in fat. It’s just . . . It’s very bad. I do not believe it is healthy for my heart.”
“Oh,” I said. There was nothing I could do about that; he was probably right about prison food not being the healthiest option. What else could I say, when my best advice was useless to him?
“I want you to climb mountains when you get out,” I said, trying to console him. “I’ll keep hoping for you.”
“Thank you,” he said.
When we were almost done with his history, a guard came into the room. It was time for my patient to go downstairs for cardioversion—a procedure where they use electric shocks to convert an irregular heartbeat into a normal one. I had never seen anything like that before, so I tagged along.
My patient was placed in a wheelchair and shackled at the wrists and ankles. The guard took him down the patient elevator, while I took the staff elevator. Then we passed separately back down the long hallway and into the regular hospital. The white-coated people passing in the hallway hardly glanced down at my patient, and I trailed behind the guard into another hospital room. There, my patient was moved onto a bed and shackled again. The guard waited close by.
A nurse stopped by the bed and swiftly placed an IV line in my patient’s arm, saying nothing to him. She put some kind of medication in the IV.
“What is happening?” my patient asked me.
“Um, let me find out. I think they’re going to shock your heart.”
“To shock my heart?” he repeated, sounding terrified but also a little slow. The IV medication must have been a sedative.
“I mean, gently. So it returns to a usual rhythm.” I tried to sound confident and calming, but the truth is I wasn’t sure exactly what was happening. Nobody else in the room—a busy room with four beds separated by curtains, and doctors moving from bed to bed—spoke to my patient. Did anybody speak Spanish? Could they explain to me or him what was about to happen?
“Okay, let’s go,” a doctor said, having materialized at the bedside. He drew the curtains shut and began doing something to my patient, but my understanding of what was going on was very vague, and I could hardly see between the guard and the doctor. They must have given him another sedative, because my patient was asleep before his body jerked from the electric shock.
The doctor turned to the heart monitor, which began to show a normal rhythm. Then he moved away from the bed. The guard picked up a magazine. Everything, it seemed, was over.
I backed out of the room and hurried down the hall toward the hospital entrance. My note was written and my patient was asleep. I felt like there was nothing I could do for him—I couldn’t insist that he get a better diet in prison, or help him find ways to exercise, or cure his underlying heart condition. I couldn’t give him the freedom he needed to care for his illness, or ensure that he would have medical care once he got out of prison. All I could do was have a sort of human conversation with him, and hope that it mattered.
I know now that the care my first prison patient received—sedated cardioversion for an arrhythmia—was technically competent and appropriate for his condition. But without the human touches that I was learning to offer at St. Vincent’s (or even the basic courtesy of explaining what we were doing to a patient’s body), technically competent medical care could be a terrifying experience.
* Texas Civil Rights Project, “A Thin Line: The Texas Prison Healthcare Crisis and the Secret Death Penalty” (Austin, TX: Texas Civil Rights Project, 2011), accessed June 25, 2016, https://www.texascivilrightsproject.org/en/wp-content/uploads/2016/04/tcrp_ thinline_2011.pdf.
CHAPTER 8
ONE DAY IN APRIL WHEN THE ISLAND WAS BLANKETED IN fog, I went to neurobiology lab to dissect a human brain. The last hour was a slide show, running through slide after slide of dissected slices of brain. They all looked the same to me: gray and featureless, reduced. I needed to memorize their names and locations, their functions, the other brain structures in communication with each. What are these structures? I thought to myself. This is nothing. We replaced the brains in their vats, and I walked from campus toward my house. I was moving down an alley paved with broken oyster shells. I could hear the buzzing of the laboratory buildings, and my bag was heavy on my shoulder. This is not a symptom of depression, I realized. This is who I am. I have always wanted to die.
I know now that it was depression, the affliction that comes on about a third of medical students at some time. But then, I thought I had made a great realization. It was almost psychotic in its clarity, as when my schizophrenic patients would describe the moment they realized they were in fact telepathic, or would gaze out the window of the clinic and casually note the particular pigeon that was in fact an angel, bringing a message from God. It was more lucid than most of my moments: knowledge revealed, perfectly clear.
I got home, checked on my dog, and the message faded out a little bit. It grew less compelling, but it didn’t go away. This is not a symptom of depression. This is who I am.
It had been a difficult semester. I’d had falling-outs with my two closest friends in medical school. Looking back, it’s hard to know if we fell out because I was depressed, or if I was depressed because I didn’t have my friends. We’re all friends again, in the long run of things, but that spring was bad. I lived in a creaky second-story apartment of a Victorian house with my dog, who would balefully watch me study and, if he thought I couldn’t see him, eat a shoe.
Charlie is a good dog, but he is not much for emotional cues. One day that April I was sitting on the edge of my bed crying, and Charlie came up and began licking my cheeks. This is it, I thought. This is the breakthrough. He’s trying to comfort me! But then he got excited, and bit my face.
&
nbsp; I was probably not very emotionally supportive to him at that time either, to be fair.
The apartment got pretty fetid. Galveston has a recycling center at the end of the island, and you have to drive down there to drop off your recycling. Like a good Austin gal, I aspired to recycle. But when I was depressed, the trip down the island became too much for me. So piles of newspaper, empty bottles, and half-washed cans of Ranch Style Beans built up in my kitchen, and roaches built up behind them. Margaret would come over occasionally, and—in a true act of kindness—take my recycling downstairs and throw it away.
I had gotten Charlie with a boyfriend (now defunct) and occasionally late at night when the conviction became too much for me—I have always wanted to die—I would walk over to the yellow house where my ex-boyfriend lived, and ask to come talk in his room a while. But sometime in April he told me that I was not welcome there unless I was willing to sleep with him, so I stopped going. Then the yellow house was no longer my territory, and I was more alone.
I was not actually (I say now) going to kill myself. I learned my lesson from Frank: It’s cruel. But the simple fact that I wanted to, that I was perfectly convinced that not-life was preferable to life, itself depressed me. I failed a test, was late to class, and stopped caring what I looked like. And nobody noticed, because in medical school it is possible to be surrounded by people and remain truly alone.
THREE THINGS GOT ME THROUGH IT. To be perfectly honest, the first was cigarettes. Smoking was like scratching an itch, inviting a little death into me. It took the edge off, and after smoking a cigarette I would find that my mind had turned to some other preoccupation. I do not recommend smoking, of course, but I came to understand one reason why people do it.
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