SAFETY FIRST
Obviously, one of the biggest issues in corrections medicine is safety and security. This is one area where, regardless of the specifics of a facility, the general “rules” are universal.
“There are certain things you learn through years of working with this population,” Gruenwald says. “It just becomes second nature—you never get yourself in a position where you can be pinned into a corner.”
Dotson, for one, has her exam room set up so that she is always positioned between the patient and the door. “You just have a heightened awareness with the patients, with your surroundings, with who is walking by in the hall,” she says.
Another commonality among correctional health services is that the exam room doors stay open in most instances. “If you have to do, say, a rectal exam, you will have another member of the medical staff come in and you’ll close the door,” Floyd says. If the patient is from a maximum-security unit, a security officer will remain in the room, although efforts are made to provide the patient as much privacy as possible.
At the Dallas County Jail, security officers are present when medical staff see patients in the housing area. If lengthy history-taking interviews are required, they can be conducted in the visitation booths where attorneys typically meet with clients, as these are designed with safety and privacy in mind.
“Many times, we will say we feel safer seeing our clinic patients here in the jail than we would if we were out in the community or over at Parkland [Health and Hospital System] in the emergency department,” Judd says.
While most corrections medicine clinicians share that sentiment, it doesn’t mean that safety concerns never cross their minds. “There are times as a clinician when you have to get right in there and listen to lung sounds,” Dotson says. “Could the patient take my stethoscope and wring my neck with it? Sure he could!”
To work in a prison, you have to be on guard without letting safety concerns compromise patient care. “You can’t just blindly trust people,” Dotson says. “I don’t think I’m paranoid; I’m just cautious.”
Providing care to an incarcerated population often means working around security limitations. For example, in some facilities, the hours when clinicians can see patients may be dictated by the rest of the prison schedule—when inmates are required to be at meals or in the place designated for daily counts. Many corrections clinics will limit the number of patients who can be in the waiting area at a time, with a security officer as a “gatekeeper.” For patients who require transfer to an outside facility, this can be scheduled, but the exact details may be withheld for security reasons.
THE TRIALS AND LIBERATIONS
Caring for an incarcerated population may raise an ethical dilemma for some. While inmates’ right to health care is guaranteed under the Eighth Amendment, how do clinicians manage to overlook the crimes for which their patients have been convicted?
“That’s one of the things I’m careful about—I see them as patients,” Floyd says. “I make it a practice that I don’t ask, and I don’t look to see what they’ve done. I don’t want that to potentially influence me.”
“I’m not going to lie; it’s a challenge,” Gruenwald admits. “But I’m not here to judge—they’ve already been judged.”
“The bottom line is, I’m a health care practitioner, and this is what I do,” Dotson says. “If I find that I am unable to be objective, I have to pass those difficult patients on. Now, someday, if those patients start becoming too many, maybe it will be time for me to move on.”
For Judd, working in a jail as opposed to a prison means that she encounters people who have been arrested and are waiting for the court system to deal with their charges. “It quickly became apparent to me that so many of the mentally ill people who are in jail wouldn’t be here if we had better mental health services in the community,” she says. “They wouldn’t be in jail for criminal trespassing or theft, for stealing food because they didn’t have any money to buy it or for burglary of a vehicle because they were looking for a place to sleep.”
Working specifically with the mentally ill population highlights challenges that are echoed elsewhere in the corrections system. “One of our biggest challenges is sorting out those who need medication and will benefit from it from those who are just manipulating the system and possibly drug-seeking,” Judd says.