We, the PA’s on the medical staff, kept things going 24 hours a day. At the end of the shift we wrote in a log, which had a space for security concerns. The design of the prison included a very large lawn traversed with walkways. The warden was obsessed with keeping the grass pretty, so one winter he decided to demarcate the walkways with steel fence posts, the kind pushed into the ground with a flat square on one end. In other words, a readily available ax- pull it out of the ground and you have a deadly weapon. Some of us iconoclastic PA’s reported these as a security violation, which did not please the warden. Nevertheless, it was difficult to justify giving inmates free access to weapons, no matter how nice the grass would look in the Spring, so they were removed. But only to be replaced by long wood cylinders with sharpened points. After a period of being described repeatedly in the shift log as “spears,” the warden finally caved, thinking perhaps that impaled inmates or staff would have worse optics than some trampled grass.

The Developmental Center

From 1986 to 2001 I worked at a NY State facility for mentally retarded/developmentally disabled people called a “developmental center.” Our residential population ranged from mildly retarded people who walked and talked and could take are of themselves with supervision, to profoundly retarded people who often had major medical co-morbidiites, and required what’s called total care; my caseload mostly involved the latter.

The investigation: At one morning report from the supervising nurse I was told that one of my total care people, who happened to have breast cancer, suffered a finger injury the evening before resulting in one of those blood under the fingernail things that are enormously painful but fortunately easy and quick to treat. The on-call physician had been notified but had said it could wait until morning. My hackles went up: how could he not relieve this condition at the time and make her spend 12 hours in significant pain.

Like most corporations and large institutions, we had a Board (the Board of Visitors) whose role is to oversee the administration and keep an eye out for poor practice and corruption, etc. I filed a complaint with the Board, stating the situation was unacceptable from a basic medical ethics standpoint. I assumed the result would be a reminder from the Medical Director that those on-call should deal with such cases and not defer them to the next day.

Keeping in mind that appointments to the Board are 1) great honors and 2) often rewards to cronies, officially made by the Governor, with the understanding they will serve as a rubber stamp for the Director. A few weeks after my complaint a Board member approached me- someone who was an Episcopal priest in his real life- and told me they had investigated and I had no basis, that if the resident was in so much pain she could had made her own way to the clinic that evening and sought treatment! Sound reasonable? Well, we did have a clinic of sorts, but that was mostly to deal with employee concerns and was only open during the day. Suggesting this profoundly retarded lady navigate her way on her own to a closed clinic was like telling a person who wanted cheese to get themselves to the moon. It showed the absolute ignorance the Board had of the institution, their contempt for our residents, and their willingness to stand up not for the mentally retarded but for the highest paid staff.

“If she gets hungry enough...:” Another of my patients, a profoundly retarded older female but relatively high functioning had major surgery for an often serious gastrointestinal condition common in our population. Her recovery was slow as expected, and she needed help with feeding. We had a system called the “team process” led by a “team leader” that involved “team meetings;” fortunately at the time the medical staff didn’t necessarily have to be a “team player.” The “team leader” at a “team meeting” was quite upset that this person was not feeding herself, which was apparently the most important issue for her; certainly it wasn’t the patient’s health (the “team process” was predicated on the absurd idea that there would be continual functional improvement in our population. Career advancement was sometimes based on documenting this mythical progress, which led to a fair amount of fabrication). This particular “team leader” insisted the patient not be given any feeding assistance, stating “If she gets hungry enough she’ll feed herself!!” This, of course, was not realistic, and there was some satisfaction in my rebuttal that “this is not the Gestapo Developmental Center.” Our resident continued to receive the help she needed and eventually recovered.

Another investigation: In 1998 I picked up an additional caseload that included a moderately retarded middle-aged female who could reasonably talk, perform most of her self-care, and was absolutely crazy: she was the very definition of anxious and hyperactive, and had been this way for about a year during which time she had significant weight loss. I reviewed her records and discovered about a year previously there was a decimal point error and her dose of thyroid supplement had been increased by a factor of 10 (she had been on a very low dose associated with another medicine she was taking). In other words, she was thyroid toxic. In a way this was an understandable mistake, but was missed by everyone, including her primary physician at the time. I found that about 6 months into this I had been on call and asked to see her for being absolutely crazy, and that I ordered thyroid tests. I then reviewed the results of what I had ordered and found the tests clearly showed she was thyroid toxic. The results were reviewed by her primary physician at the time and ignored. This poor lady had her life devastated because a lazy/incompetent (but well-paid) physician was lazy and incompetent.

The administrative environment had changed drastically by this time, and I was too naive or stupid to realize it. The Director who took over a few years prior had a management vision and philosophy that discounted competence and emphasized her boots be licked, and there were plenty of people willing to lick them. By then we no longer had a medical director, but a bureaucratic cog in the form of a deputy director, whose key function was to protect the incompetent as long as they licked the Director’s boots: competent people were a threat and incompetent ones were compliant. I asked for a meeting with her- the deputy director- and expressed my deep concerns over this case. She assured me there would be an investigation. Several weeks went by and I hadn’t heard anything so I approached her and asked about the status. She told me there had been full investigation and that there had been no wrongdoing. I mentioned I hadn’t been contacted, and was told the “investigator” didn’t think it was necessary. Ever since then when I hear on the news that some politician was cleared after an “investigation,” I think of this and realize the goal is to maintain the status quo. Little did I realize at the time this event- the temerity I displayed in reporting an incompetent superior for malpractice- was the first in a cascade that would change the course of my life.

He’s Fired: A couple years later I found myself sitting in on a probationary employee review committee meeting, my presence there explained by the aforementioned event and all that followed. Basically, during the first year of employment at the Developmental Center person was on probation and had no employment protections, fair enough because there were some real losers (I once did a new employee physical on someone who was totally drunk). The process was that a supervisor would show up, describe the employee’s progress and report any problems, and the committee could decide to continue or discharge. So...the supervisor presented the person, said he was progressing well, dependable with good evaluations at all levels, etc, and the committee recommendation was to continue his employment. At this point we were told the next supervisor was running a little late, so there was one of those uncomfortable bureaucratic periods of silence, broken by someone who said something like, “I’m not sure, but I might have heard something bad about the last person we reviewed, but I can’t say it was him or someone else.” The initial group response was, “his evaluations have been good and he had the support of his supervisor.” The silence in the meeting resumed, still awaiting the next supervisor, when someone felt obligated to say, “If you’re right, maybe we shouldn’t keep him.” Like an evolving abscess, the pressure of the silence grew and, weak people figuring out the change in wind direction, started to pile on, and soon enough, “He’s fired.”

I really did try to point out the pernicious ridiculousness of this situation, that someone might have heard something about someone but really wasn’t sure, and that we had just been told by a supervisor who actually knew him he was doing well, but the committee had spoken. I could imagine this poor guy, who after 6-months or so of being told he was doing well was told he was fired: “how was work today, honey? We’re so fortunate you have a steady job that pays the bills, and where you are well regarded.” My supervisor, whose career advancement had progressed the browner his nose became, told me I had no business questioning the committee’s decision.

The Kenyan Ministry of Health

Events that began at the Developmental center in 1998, alluded to above, led me to several places in life, including Matoso, Kenya, as the volunteer medical director of a remote clinic Oct. 2002- Sept. 2003. This was a place of suffering and almost daily tragedy beyond comprehension for most Americans: malaria, AIDS, pneumonia, bizarre tropical diseases...a long list of misery and death. One common way malaria kills, especially in babies and children, is by destroying blood cells to the point there is no usable blood, though it all happens internally.

One weekend afternoon a father carried his son into the clinic as the boy was taking his last few breaths (malarial hemolysis). For the sake of the father, we went through the usual medical motions when the outcome was already known. The clinic had a vehicle policy to not use them for favors, but I couldn’t see making the father carry his dead son back to the family compound, so I pulled out the old Suzuki jeep-like vehicle and put the body in the back. I tried to climb the hill leading out of the clinic, but the feeble Suzuki couldn’t make it, and the body rolled around the cargo area. I made another fruitless attempt of two with the same result and finally switched the body to another vehicle. Just another daily tragedy with some morbid slap-stick thrown in.

One of the medical director’s responsibilities was to insure a supply of vaccinations, as the clinic had a wellness role in addition to treating sick people. These were obtained from the local health ministry office in the nearest city, Migori. I went there to obtain the supplies but had done the unthinkable- I had forgotten to bring the OFFICIAL rubber stamp of the clinic. The people at the health ministry knew us well and had the vaccines ready for pick-up, but without the OFFICIAL rubber stamp they just couldn’t release them. Fortunately, at the entrance of the building there was a cottage industry for making OFFICIAL rubber stamps. I went outside for a few minutes, went back in brandishing the coveted rubber stamp, and all was well.