by Ian Jenkins, MD
This article appeared in Psychology Today and is expanded from an earlier piece in the Annals of Internal Medicine
“I can’t breathe,” my 22-year-old patient said. He was the last patient I would see on a long shift at a jail where I worked occasional shifts as a medical doctor. He was breathing, fast and hard, frighteningly so. He said he was a type-one diabetic, previously well controlled on four tailored shots a day, but had been denied his usual insulin since he was arrested. A fingerstick showed his sugar was higher than the device could detect.
I asked the nurse if he was right. Had he been underdosed? She confirmed his story. They’d given him regular (the wrong kind of) insulin, on a low-dose sliding scale instead of based on food, and at half the frequency of the injections he needed. He was breathing hard because he had a potentially lethal diabetic ketoacidosis (DKA), acid blood from insulin deficiency.
“Call an ambulance,” I said. “He has DKA.”
But the staff didn’t want to. It would cost too much. They wanted to give him fluids at the jail. DKA, however, is usually managed with very frequent lab checks and adjusted doses of insulin and large amounts of fluid. It’s so complex, it often requires the ICU.
“No. DKA is an emergency. I can’t fix it in five 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 4:45 pm cannot provide that.” If they could have handled the emergency, they would have prevented it.
Then the nurse said something that nearly floored me: “He’s just a jail patient.”
The jail was a hectic place. I saw 42 patients my first day, most of them low acuity. Most, actually, didn’t need a doctor. They were demanding Benadryl for sleep, opioids they didn’t need, shoes or extra blankets that policy forbade. So I was told to turn them away, which meant they didn’t need to have come.
People wanted chronic conditions corrected during brief stays, as if a shoulder replacement was a reward for a felony. A person who committed murder asked me for cosmetic dentistry. And I also saw straight-up bad care. Over and over, a regular jail doctor showed they didn’t understand how to adjust seizure medicines. Staff put a woman with an obvious case of tuberculosis, coughing up blood and having fevers and weight loss, in a holding cell and then brought her to me without a mask on—showing fundamental gaps in knowledge.
I also saw severe conditions ignored by staff. Cancer patients couldn’t get clinic visits. A woman begged for help after surgery for days until her incision split and dumped bloody fluid into her lap. A man in obvious misery who’d been beaten until his jaw was fractured in multiple places was denied a doctor visit until an abscess in his jaw grew to 10 centimeters.
America has a real problem with incarceration. We jail citizens at a rate six times the world average. Many have severe psychiatric disorders or are simply suffering from substance addiction. Policing and sentencing are undeniably biased against minorities and the poor, while the rich benefit from top-notch legal teams.
Several prominent cases have shown that jail health systems can be woefully inadequate, with “widespread and systematic failures,” or allowed to be “critically short of care providers.” Riker’s Island in New York is dangerous, corrupt, and almost in anarchy. COVID spreads rapidly in jails; in one example, more rapidly than has been recorded anywhere else. Jail populations also die of COVID at three times the national average.
At Abu Ghraib prison and at Guantanamo Bay, maltreatment could take the form of psychological and physical torture, some of it approved or designed by psychiatrists acting in the interests of the government, rather than patients. The executive branch approved such “enhanced interrogation” methods, although citizens might have been outraged had they learned that domestic prisoners been subjected to them. Prison environments are ripe for abuse.
After that nurse said, “He’s just a jail patient,” I gave the only moral instruction I’ve ever needed to provide to a fellow health care professional: “What you just said was wrong. I have no idea what his sentence is, but I know it didn’t include ketoacidosis. Call an ambulance.”
My patient was safely treated that day. I reported the bad care, never heard a proper response… and then I let it go. I didn’t think of it for several years, but then something reminded me of it: George Floyd was killed by police officers including Derek Chauvin, who kneeled on his neck for eight minutes and fifteen seconds, even after Floyd lost consciousness and after paramedics arrived on-scene to assist. Chauvin suffocated him even though he posed no threat, and he was begging for relief: “I can’t breathe, I can’t breathe.”
Floyd had been arrested on suspicion of passing a counterfeit $20 bill. Twenty bucks.
That was state violence. But what I saw in jail was also state violence: An agent of the government, through malice or inexcusable negligence, put my patient’s life at risk until he was begging for help with exactly the same words: “I can’t breathe.”
When I was a child, I knew that being a good citizen meant I should interact with the police in two ways: obey the law, and comply with instructions. Post-Floyd, I know that good citizens must also be prepared to monitor and report unjust law enforcement officers. Our shared reality now is that we must be prepared to intervene if we witness an extra-judicial killing in progress. Can we… threaten media exposure? Throw something? Tackle the next Chauvin off the next Floyd? In retrospect, and to use the words of the late Rep. John Lewis, how much “good trouble” would have been appropriate that day?
And to doctors and nurses and aides and pharmacists and others everywhere: Let us all insist that the government provide safe facilities and adequate, timely health care to all persons it detains. Say it with me: No more medical violence.
Barsky BA, Reinhart E, Farmer P, Keshavjee S. Vaccination plus decarceration—stopping COVID-19 in jails and prisons. New Eng J Med 2021; 384:1583-5.
Coll, Steve. The jail healthcare crisis. NewYorker.com. https://www.newyorker.com/magazine/2019/03/04/the-jail-health-care-cris…. Accessed 4/30/21.
Wilper AP, Woolhandler S, Boyd JW et al. The health and healthcare of US prisoners: results of a nationwide survey. Am J Public Health 2009; 99(4): 666-72.
“It was Torture.” https://www.npr.org/sections/parallels/2016/04/04/472964974/it-was-tort…
Ian Jenkins is a hospital doctor and professor of medicine who works with patient safety, quality improvement, and improved value in healthcare. He lives with his two partners and children, a unique family detailed in “Three Dads and a Baby.”