The Secret Language of Doctors

by Brian Goldman

  Booker was convicted of possession of crack cocaine with intent to distribute and was sentenced to five years in prison. However, in August 2013, the Sixth Circuit U.S. Court of Appeals overturned his conviction because the paralysis, intubation and anal search violated Booker’s Fourth Amendment rights. The court said the police “effectively used LaPaglia as a tool to perform a search on Booker’s person.”

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  With health professionals like Nicole Donaldson and Jeff Keller, you get the sense that, in a perverse way, they admire the ability of inmates to secrete contraband in a rectum or vagina. But as keen observers on the front lines of prison or jail culture, they know quite well that this sort of behaviour has a very serious side.

  A 2010 study by the National Center on Institutions and Alternatives (NCIA) found the suicide rate in county jails to be three times that of the general population. Despite a decrease in the overall rate, suicide continues to be a leading cause of death among people in custody.

  And it’s not just inmates with suicidal thoughts who are at risk of premature death; incarcerated individuals in general are five times more likely to have mental health problems. Donaldson says she looked after inmates at Wilkinson Road Jail with mental health problems, including bipolar affective disorder, as well as issues related to drug addiction. One of Donaldson’s duties was to give prisoners their regular doses of antipsychotic medications.

  Part of Donaldson’s hardened view comes from the fact that on more than one occasion she’s had to stare down an inmate who was threatening her.

  “One time, I walked into segregation where inmates are housed in little matchboxes the size of your bathroom,” Donaldson recalls. “That’s where they are locked up when their behaviours are inappropriate.” A prisoner yelled obscenities at her. “They were absolutely the most vulgar words I’ve ever heard in my life and I said to the officer, ‘I want him charged.’ That sent a wave through the jail that you don’t mess with this nurse.”

  That’s when Donaldson discovered something else about prisoners. She’s good with them because she can get inside their heads.

  “I have a son with ADHD [attention deficit hyperactivity disorder] and I’ve been surrounded by people who have acting-out behaviours,” says Donaldson. “I didn’t realize how much I loved behaviours until I was at the jail for a little while.”

  By behaviours, Donaldson means assaulting fellow inmates with makeshift weapons, screaming, even rioting. One day she was on duty in segregation when a riot broke out in a large common area the size of a hotel lobby. “You could feel the energy in that room. I swear that the room was breathing,” she says. “The boys were chanting and banging on the doors. All of a sudden it’s lock-down. I’m standing there and about eleven officers in black riot gear come busting through the door. I’m thinking to myself, ‘This isn’t a movie. Back up!’”

  After the riot was put down by armed police, Donaldson stood calmly as the inmates were escorted out the door of the room, popping antipsychotic pills into the mouths of most of them as they walked by.

  Many of today’s inmates are quite used to popping psychiatric meds. Nearly 15 percent of male offenders and an astonishing 30.1 percent of female offenders have been admitted previously to a psychiatric facility. The widespread use of antipsychotic medications has helped to fuel the deinstitutionalization of psychiatric patients—which in turn resulted in the closing of many psychiatric facilities. In the absence of community supports, these psychiatric patients inevitably act out; in the absence of a psychiatric bed, they tend to be prosecuted through the criminal justice system.

  Some say cutbacks to welfare entitlements are also a factor in the incarceration of people with mental health issues. A former social services worker says she saw first-hand the devastating effects that cuts and being thrown out of the system to fend for themselves had on patients: “I had the experience of being cornered a few times in the office by raging and ranting clients with mental health issues, one of whom actually was wearing a tin foil hat to ward off the voices. It was so sad and such a shame that so many end up in the prison system because of their displacement and having nowhere else to go.”

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  Since 2002, the United States has had the highest rate of incarceration in the world. According to the Bureau of Justice Statistics, in 2011 the number of prisoners in state and federal correctional institutions was just under 1.6 million. Many have substance abuse issues and have never taken good care of their health.

  “I think we’re up to about 40 percent of my patients have some chronic health problem,” says prison doctor Mike Puerini. “They’ve got high blood pressure, diabetes, cholesterol and hepatitis C. I had a guy who had a heart attack last year.”

  And the prison population is getting a lot older. According to the Oregon Department of Corrections, in 2012 the state had 674 prisoners older than 60, up from 258 a decade earlier. A budget report by the state’s Legislative Fiscal Office blamed the increase on mandatory minimum sentences and other changes in sentencing policy.

  “Young healthy guys make a mistake,” says Puerini. “Except that now, my average population is in the forties and fifties. I’ve got people in their sixties. I’ve taken care of people in their eighties.”

  Puerini even had one patient live long enough under his care to develop dementia. “In Oregon, because they get a mandatory minimum sentence, they’re going to serve their term,” says Puerini. “Try to figure out how to deal with a guy who is incontinent. If the guy is pooping his pants, the corrections officers say they can’t have him in a cell.”

  As president of the Society of Correctional Physicians, an organization set up to establish high ethical standards in providing health care to those incarcerated, Puerini is arguing to have frail and elderly inmates released from prison: “There has to be the political will to get early compassionate release for elderly and very sick people and I don’t see that. We need to push legislators to at least consider it.”

  Sooner or later, patients like these need to be transferred to an ER for further assessment. When he hears ER doctors and nurses use slang like incarceritis and find it amusing, Puerini wonders whether they assume every incarcerated patient is lying for secondary gain.

  “That doctor in the emergency room sees the guy in manacles and chains and thinks this guy wants to use him,” says Puerini. “He isn’t thinking as well as he should about doing real medicine.”

  This is not just one kind of health-care professional ranting about another. In a document titled Recognizing the Needs of Incarcerated Patients in the Emergency Department, the American College of Emergency Physicians had this to say regarding preconceived notions prevalent in the ER: “Many healthcare providers (including nurses, physicians and technicians) view incarcerated patients as unreliable (especially with regard to providing honest personal histories), dangerous and manipulative malingerers.”

  That, says Puerini, leads ER doctors to send the patient back to prison without diagnosing the problem. “If they’re sent back from the emergency room, we may assume they did a thorough assessment and so he must be okay. The next thing you know, the guy dies in his cell.”

  Puerini knows the risk. He likes to talk about a case that shows just how easily a thing like that can happen.

  “The guy’s in the segregation unit, and I got called in there to see him,” recalls Puerini. “It’s a lot harder to see the guys when they’re in segregation. They have to come out in manacles and chains. It’s a big problem for everybody. We try to put off routine care, because if they’re in segregation, it’s a big hassle. The prisoner complained of numbness and tingling in his leg. I did a full evaluation and didn’t find any objective illness.”

  Numbness and tingling can be caused by diabetes, a stroke, or a host of other neurological problems. The symptoms can also be faked. Puerini’s comment about finding no objective illness is code for saying h
e found nothing to suggest the segregated prisoner had anything seriously wrong with him.

  Puerini decided to wait and see if his patient developed any new symptoms. Four weeks later, the officer in charge of the prisoner asked Puerini to see the prisoner again. In the interim, the prisoner had complained of weakness in the legs. When he began getting a fellow inmate to carry him from his bunk to the toilet, the officer became suspicious.

  “He can walk, I know he can walk,” the corrections officer said when he asked Puerini to see the prisoner again. “Get this guy to walk to the toilet. He’s bullshitting.”

  Puerini had the prisoner pulled out of segregation and into a room where he could re-examine him. The prisoner couldn’t move his legs. He was rushed to hospital.

  “The guy had a very aggressive spinal-cord tumour and was dead within six weeks,” says Puerini. “I think it’s a perfect story because these are the pressures on a physician trying to do correctional medicine. The officer is telling me this guy is bullshit, and I go there and I find very strong evidence for a horrible disease process.”

  I’m struck by a paradox. As I’ve shown you, on the outside of the correctional system, most doctors and nurses treat drug seekers with undisguised contempt. Inside the prison wall, doctors like Puerini advocate for the incarcerated felons under their care, and nurses like Nicole Donaldson delight in using humour to get along with hardened criminals with mental health issues.

  Dr. Zubin Damania is one doctor on the outside who almost learned the hard way how important it is at least sometimes to check one’s suspicions at the door. Damania developed a deep distrust of drug-seeking patients while training as a resident in internal medicine at Stanford University in Stanford, California.

  “Working at the County Hospital in Silicon Valley, I was repeatedly dealing with drug seekers and heroin users—to the point that I trusted no one. We would often just say someone was FOS, as in full of shit,” says Damania, echoing the slang word SHPOS Bergman first heard in New York City forty years ago.

  But sooner or later, everyone gets seriously ill, even drug seekers. “A 30-year-old dude comes in,” Damania recalls. “He had a history of heroin and Dilaudid abuse. When I examined him, he complained of pain everywhere. All of the muscles on his face were clenched and he could barely talk.

  “I thought he was full of shit. In fact, he had this creepy grin on his face that made me think he was totally effing with us to get Dilaudid. I thought he was a terrible actor. I totally blew him off after telling him I wouldn’t give him any narcotics. I even told my intern that he was a classic drug seeker and we shouldn’t give in to his nonsense.”

  Damania gave his assessment to his attending physician, who decided to see the patient for himself. “The attending comes in, takes one look at him and diagnoses tetanus related to the patient’s abuse of intravenous drugs.”

  The grin on the patient’s face was a classic sign of tetanus known as risus sardonicus, or sardonic smile. It’s a clinical term that describes the appearance of the face when the facial muscles are locked into a painful contraction.

  Instead of being kicked out of the ER, Damania’s patient was intubated and placed on a ventilator in the intensive care unit, where he remained for several weeks. Damania says he thinks about the man often. “He could well have succumbed to complications. I can think of many community hospitals where the doctors would have given the patient narcotics just to get him out of there. That would have been a fatal decision in his case.”

  You could argue that drug seekers and incarcerated patients are often one and the same. It’s health professionals who treat them differently. On the outside, I think, drug seekers make doctors and nurses feel threatened because they remind us that in some doctor-patient relationships, we aren’t in control.

  Some would say it’s the correctional patients’ lies that come back to haunt them. Any way you look at it, doctors like Mike Puerini must find the sweet spot between suspicion and trust.

  9. Harpooning the Whale

  On November 24, 2011, the British newspaper the Daily Mail reported that Arthur Berkowitz, a 57-year-old passenger on US Airways Flight 901, had to stand for most of the seven hours it took to fly from Anchorage, Alaska, to Philadelphia. The reason? His 400-pound seatmate was so large that when both armrests were raised to accommodate him, the man’s bulk spilled over onto Berkowitz’s seat.

  “He was a real gentleman,” Berkowitz told reporters. “The first thing he said to me was: ‘I want to apologize—I’m your worst nightmare.’”

  Patients as large as the man seated next to Berkowitz are many a doctor’s worst nightmare too. Obese and overweight patients represent a plentiful source of new and ongoing business for doctors—and a rather rich source of recent medical slang that is often vicious and pointed. Anesthesiologists have a telling bit of medical argot they use to describe the exercise of inserting an epidural catheter—a flexible tube that’s placed through the back into a space in the spinal canal to deliver pain-relief medication—into an obese woman in the late stages of labour. They call it “harpooning the whale.”

  “I’ve heard it many times,” says Dr. Jay Ross, an anesthesiologist, who is quick to point out he doesn’t utter the phrase himself.

  The harpoon is the extra-long Tuohy needle used to insert an epidural catheter. A hollow hypodermic needle with a slight curve at the end, the Tuohy was developed to get through the extra layers of tissue in the back. It has to be threaded precisely between the vertebrae in the back. The whale part is self-explanatory.

  “You have to get through the skin, the fat and all that,” says Ross. “A lot of obese patients have so much fat on their back that you’re often struggling to even feel the spinous processes to insert the epidural or the spinal needle in the first place. Sometimes I’ll actually ask the patient if it feels like I have placed the needle on the left or the right of the midline.”

  Increasingly, anesthesiologists use a portable ultrasound machine to locate the epidural space that is the destination of the needle. However, for the many anesthesiologists who don’t have one, it’s a matter of guesswork. Ross says that with a pregnant woman of average weight, it takes about fifteen minutes to insert an epidural. For obese women, it can take as long as forty-five minutes—even longer. The longer it takes to put in an epidural, the less likely the pain meds will kick in time for the critical stage of labour in which the woman is encouraged to push. Increasingly, Ross and his colleagues warn obese patients up front that there’s trouble ahead.

  “I used to be very reticent about doing that,” says Ross. “I’m a lot less so now because I think there’s no real point in beating around the bush. If you don’t do it, then they’re sort of wondering why you’re stabbing their back multiple times for forty-five minutes. It can be very frustrating.”

  That frustration has turned anesthesiologists into slangmeisters. “The [terms] I’m aware of I try not to use,” says Ross. Before he arrived at the hospital where he did his residency, he says, “They used to have an award called the Prince of Whales award. It was awarded to the resident on call who placed obstetrical epidurals in the most tonnage in one shift.”

  And Ross’s hospital wasn’t unique. A resident told me there was a Princess of Whales award at the medical school he attended. “It was for the anesthesiologist who put an epidural into the woman with the highest BMI [body mass index]. It was a plaque and it was awarded every year.”

  Whale isn’t the only slang noun used to describe obese patients. And anesthesiology isn’t the only hospital domain to boast a flourishing slang directed at obese patients. Dr. Christian Jones recently completed a residency in general surgery in Kansas City. He plans on becoming a trauma surgeon and expects to fix up a lot of obese patients.

  “I think in surgery in general—and certainly more and more in trauma over the last ten or fifteen years—there’s been a lot of concern about what we euphemi
stically call ‘excessive soft tissue’ (a more subtle bit of slang) in the obese patient,” says Jones. “I think especially in trauma there are more and more euphemisms being used for that.

  “There’s cow. There’s fluffy, which is a relatively benign one, I suppose. One that I hadn’t heard before I came to the University of Kansas was the seal sign. That is when we do an X-ray or CT scan of a patient and find a large amount of soft tissue outside their body cavity. They’re just like a seal, with lots of surrounding blubber. The one that I particularly liked, I hate to say, was that on the X-ray it looks like they’re a killer whale that just swallowed a seal.”

  Dr. Mark Ryan, a family doctor in Richmond, Virginia, finished his residency in 2003 and began his career in rural Virginia before moving to Richmond. He’s now splitting his time—40 percent teaching and academics, 60 percent patient care. He confirms that surgeons use fluffy frequently: “If you’re going to do a surgery on somebody and they’re obese, the surgery will be a little more difficult because you have to get through the layers of fat tissue before you can get down to the muscle. So the surgeon might describe the patient as being a fluffy person.”

  Derogatory? You bet. No surgeon would ever refer to a patient as fluffy, a seal or a whale within earshot. Most wouldn’t even insinuate it. One resident recalls a time when he and a fellow resident did just that and got busted.

  “One of my colleagues referred to a patient as a big fat chick,” a resident who trained recently in the U.S. told me. “This was a trauma patient that had come in after a motor vehicle accident. She had relatively minor injuries—some extremity fractures—and no chest, abdominal or pelvic injuries. She didn’t have a head injury. Unfortunately, obese patients don’t tend to be as injured initially but do have significantly more complications after trauma. And this was a textbook presentation of that.

  “She ended up getting a urinary tract infection and a skin ulcer that was very difficult to manage. A new attending trauma surgeon asked, ‘Why are all these things happening to her?’ My younger, more junior colleague said, ‘It’s basically because she’s a big fat chick.’ A couple of us chuckled. There weren’t any major laughs or guffaws but there certainly wasn’t any admonishment or embarrassment either.”