Monday, July 14, 2008

The outpatient inmate

I received a fax this week from a corrections nurse in Saskatchewan, asking for details of a patient’s pacemaker so that he could receive appropriate follow-up at the pacemaker clinic closest to what I assume is a federal prison. I sighed – Bob was in trouble again – but at least he wouldn’t be selling drugs to teenagers in Yellowknife for the foreseeable future.

I remember distinctly the first time I met Bob; the GP on call consulted me from the emergency room for atrial fibrillation. A pleasant guard stood to the side while I asked Bob a few questions. “They think I’m faking it,” he told me defensively. “But my chest doesn’t feel right, especially when I lie down.” He had no medical history except for a pacemaker insertion a few months prior and took no medications. His distended neck veins and a soft precordial rub told me I wasn’t dealing with run-of-the-mill atrial fibrillation, and the chest x-ray showed almost a circular cardiac silhouette. We had no echo services, but fortunately the cardiologist in Edmonton agreed to see him if we sent him down by medevac for possible pericardiocentesis.

“I guess that means I’ll be going, too,” the guard commented politely. “How long do you think he’ll be in Edmonton?” I couldn’t tell him many details, but we arranged the flight; and I must admit I felt vindicated to learn that the skeptical cardiologist had removed several hundred ccs of fluid from the pericardium upon the patient’s arrival in Edmonton.

For months I didn’t see Bob again; he had been released from prison and tended not to come to appointments on his own accord. I did, however, see the guard again at a local coffee shop a few weeks later. We spoke briefly, and when he heard I was looking for a reliable old car, he directed me to a 12-year-old Subaru station wagon he had been thinking of buying. An amateur mechanic, he had considered its many selling points: “You know, Amy, I went hunting with one of my buddies who had a Subaru wagon. We got a huge moose, and the whole carcass fit in the back of that car! Great trunk capacity, those Subaru wagons.”

I was duly impressed and bought the car the next week. Although I haven’t used it for moose hunting, it was the designated transport vehicle for a double bass prior to a performance of Handel’s Messiah last Christmas. None of the choristers’ SUVs could squeeze in the bass and it was too cold (minus 43 without counting wind chill) to cart it around in a pickup truck.

When my patient surfaced again, he was back in corrections for drug dealing and some break-and-entry charges. (It’s hard not to notice when your patients keep showing up in the local newspaper.) He was clearly relieved to discuss his medications with me, specifically whether he needed to continue sotalol now that he had been free of palpitations for a few months. He also wanted to review options to treat his hepatitis C; I told him I would only consider initiating treatment if he was sober and out of jail for several months, or if he had at least a 1-year prison sentence to allow a full treatment course in corrections. He thanked me politely for my opinion “and for saving my life back in September.” I wondered privately what he intended to do with the life remaining to him, but kept my comments to myself.

Only once, in frustration during a clinic visit, did I tell Bob that it was difficult to care for someone who only came to appointments when incarcerated. “I’m tired of seeing your name in the papers,” I commented, and was surprised that he said nothing to defend himself. As a rural physician, it is very hard to ignore the impact that someone has on my small community. How many of my friends’ children have been tempted towards a path of destruction by my patient’s efforts, I will never know – nor would I dream of trying to find out. I can only hope to provide some degree of respect, hope and patience towards a man whom I have only ever encountered as a patient.

And that Subaru? Six years later, it’s still going strong. It needed a new transmission a few years ago, but the guard turned up again just in time to find me a great deal from a wrecking yard out of town. I guess I have my debts to Bob as well.

-- Dr. Amy Hendricks

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