Off the Rails

When I stepped of the elevator onto the medical wing I heard loud gospel singing, then a hard kick into one of the steel doors of a medical cell and I knew Mr. J had gotten worse. I had first encountered him on med rounds down in one of the pods. When I entered his pod I was met by the bald sociopath with glittering blue eyes and my initials tattooed into his neck barking at me about why he didn't have his asthma medication. "You should already have the records in my file, I shouldn't have to do this," he said when I tried to get him to sign a release of records so I could fax his doctor for his asthma history. He narrowed his eyes and leaned on the med cart until I put the paper away. Mr. Skinhead Sociopath had arrived at my fine jail without his inhalers and hadn't had an attack at the jail requiring medical intervention, so no records, no inhalers. When the officer next to me leaned in on the other side of the med cart and put his hands on top of my cart the inmate backed away into the pod. Then Haldol Boy approached the cart, "My mom says I should get back on my meds," he told me. His face looked smooth and white, his thin lips quivered only slightly. "You are looking so much better!" I told him, "But I think it is a good idea to look into some medications for you," I agreed and gave him a form to fill out for the Psych NP. I instructed him to fill it out in as much detail as possible and I would take it back up with me. Then an older black man came to the cart, Mr. J, he projected the imagine of a gentle giant standing over six feet and weighing over a two hundred pounds. "How are you today young lady?" he asked me as I handed him his meds in his little cup. "Just fine today sir," I responded, giving him a smile. He was a welcome relief from the assault of the sociopath and deep sadness of Haldol Boy. The next week he was brought to medical for his deteriorating mental health condition.

"He's the one who stabbed that guy in the neck, a friend of his," another nurse told me during report. I knew I had to develop some source of local news, I had no idea what she was talking about.
"No shit," I replied, glancing over at Mr. J in his cell. He had his back to us, staring out the toaster-oven sized window.
"Yeah, he's been doing OK here so far, but now he's pacing all around the pod and the officers feel like he might be dangerous, so they brought him up. So far he hasn't been any trouble up here, but he's bored."

He paced his cell and looked out the window with a strange intensity for my entire 8-hour shift at the desk. Occasionally he would gesture for me to come over. I stood at the door of his cell and listened to him through the crack between the door and the doorframe. The deathrow inmate at the women's prison taught me to listen at the crack when I was a a Newjack back in seg. "If you just need to talk to someone in here, don't drop the slot," she instructed me, "don't ever put your face near a slot, listen and talk into the crack." When I put my ear to the crack between her solid steel door and the steel doorframe I could hear her perfectly. From then on I communicated exclusively through the crack, even if the slot was dropped for meds or some other purpose. When I put my ear to Mr. J's doorcrack I heard pressured words pour out of his mouth "I need to go back to the wing, back to the wing, I could play cards there, walk around, do something, you know, back on the wing." When I tried to make eye contact with him and assure him he could go back to the wing once he was doing better he looked through me and kept talking as though he was addressing someone four feet behind me.

I worked the prison for a few days and when I returned to the jail and stepped off the elevator I knew immediately things had gone from bad to worse. Mr. J had refused all psychoactive medications from the start of his decent into mania, but now he refused all of his cardiac meds as well including some very serious blood pressure medicines and blood thinners. He thought he was fine. Jesus talked to him and told him that we were all crazy and he was fine. "What the hell are we going to do with him?" I asked the Psych NP.
"Well, since he's over 65 we can't get him committed at one of the regular state mental hospitals for meds over objection, he has to go to a special gero-psych facility, there is only one in the state with not that many beds. We can't do meds over objection here, and he can't go to the university hospital because he is an inmate, he has to go to a forensic unit now."
"This mental state is probably just an extension of his stabbing his friend, and now he's gone completely off the rails," I said.
"He doesn't have too much of a history before this, it seems like he was a pretty solid family man, I've met his family, they are very nice and very concerned. It sounds like from talking to them that he's had episodes of hypomania for a long time, having lots of energy, spending more than they could afford at times, but this is the first time he's really crossed over."
"How sad, to have your first decent into mania-induced pyschosis at such an advanced age, like, you'd like to think if you make it to your 30's without any sort of psychotic break then you can assume you're in the clear."
"It is unusual to have a first psychotic episode so late in life and not secondary to dementia, that's a whole other thing," he replied.
"Right, right," I nodded my head. I'd like to think there was a window between psychosis from mental illness and psychosis from age-related dementia. Like a break between acne and wrinkles. Mr. J made me feel less safe for myself, showing that after a long life of slow-simmering mania, the pot could still boil over at any time.

The Psych NP got Mr. J placement at the local gero-psych state hospital. By the time the social worker from the hospital came to evaluate him he would dress only in his boxers and pull his penis out at anyone who approached his cell, which was thoughtlessly assigned next to the high-traffic supply closet. When the transportation team took him to the hospital he kicked out the side window of the cruiser and they had to pepper spray him to subdue him, so he arrived with pepper spray covering his transportation orange. He is committed for 30 to receive meds over objection. The court order can be renewed for another 30 days as many times as needed.

Misty Valley Morning

No Back Up

Yesterday I met some of my friends at the gym, three nurses who all used to work at the prison. None of us work there anymore, one is in the university ER, one at the jail with me, and one on a digestive health floor at the university hospital. The ER nurse used to be a cop, and she brought on of her cop friends along. The cop told great stories about the ER nurse from back in the day, "I always knew she'd be a nurse, we went to a scene one time, a man on a bike was hit by a car, she gets down there like she's about to do CPR and I pull her back up 'get up girl, he dead' I told her." We all laughed from our various treadmills, stairclimbers, and ellipticals. "When I get to a scene, I just say, help's coming baby," she continued, gesturing with her long, elaborately painted nails as though she was petting an imaginary dog on the head.

After warming up on the machines we went to BodyPump class, a fusion of strength training and techno music during which the participants plow through extended sets of low-weight high rep intervals. After BodyPump we all hurt all over. They went to lunch and I went out to run errands. When I got home from errands a wave of exhaustion hit me. I put my bags of food, water, even a new toaster from Target down on the ground near the kitchen. I had planned to do laundry, cook, and clean on this day off, I had just completed two 50-hour weeks working 25 hours a week at both institutions. I had plenty to do around the apartment, but that would all have to wait until I had a nap. I knew better than to nap in bed. I am not one of these people who can fall asleep and spontaneously wake up 30 minutes later bright eyed and ready to continue on with the day. If I nap in bed then I might sleep for 4 hours and then not be able to sleep again for 2 days. Even setting an alarm doesn't really work, I'll just sleepwalk and shut it off. So I learned a few years ago to nap on the floor. You are only going to sleep but for so long on the floor, usually an hour, then you pretty much have to get up. There is no alternative, you have to get up off the floor because it's uncomfortable. I usually nap on my Persian carpet. Sometimes I allow myself a pillow or a blanket, depending on how difficult I project it will be to rouse myself. When I used to work nights and convert back to daylight I would just lay down on the rug with nothing, if I woke up cold, so much the better. That meant I woke up.

So I stretched out on the floor at 1:30 and woke up a little after 3. I did not wake up feeling rested, I felt groggy and dazed as I watched the clouds through my sliding glass door. Groceries, cleaning products, new pens for work, and the toaster still in it's box blocked the way to the kitchen when I tried to get up and get a drink of water. I could not deal with it, I could not pick up one thing and put it in it's place. I knew there was nobody else coming to put the things away either. Nothing really needed to go into the fridge, nothing was going bad sitting around. I had to just let it be until I was rested enough to deal with it. I got back on on my carpet with a book and a cup of tea nearby.

After another hour of reading on the carpet I felt I could get up and at least put the groceries away and corral the laundry for the drive down to the machines in the basement. After working hard for two weeks and in an advanced state of exhaustion I could not call or wait for backup. The toaster would stay in the box until I unwrapped it. The laundry pile would continue to grow. And the next day I had to go back to work. It all didn't seem like much of a life as I separated my laundry across three machines in the building basement. Waiting for the elevator I reminded myself that I'm doing everything right. Not seeing the ill-suited guy from work, moving on to a less stressful job, and I joined the local Outdoor Social Club. I was taking beginner rock climbing, beginner kayaking, and going on hikes with the new group. I was getting out there. I was staying in shape. On my way back up in the to my floor I stopped to get my mail. I got a handwritten letter from the new owners of my apartment, they had recently purchased it from the company that managed the building. When my lease was up in May they wanted me out, and if I could leave before, so much the better. It was nice of them to give me advance notice and total freedom, but the idea of finding another place and executing another move, horrific. I decided to make sure I stayed on good terms with the manager of the local health foods store so I could have access to boxes down the line.

Once I got the laundry going started to pick up speed, putting food away, rounding up tea cups from every piece of furniture in the apartment and washing them, pulling out my long-sleeve shirts and light sweaters for fall, hanging up fleeces and sweaters on new hangers from Target. I was done by nine at night and ready to read myself to sleep again.

Hot Air Balloon Blows By

Haldol Boy

Each new inmate at the jail must get a test for tuberculosis done before he or she can be moved to the housing unit. The test is called a PPD, Purified Protein Derivative, or Mantoux test. A sterilized extract of tubercule bacilli is injected intradermally (just under the skin) and read 48 to 72 hours later. The reading is a check for an inflammatory reaction from the serum. If you have a reaction, then you've been exposed to TB. If the injection site welts up beyond 10mm in non-immunocompromised people and 5mm in immunocompromised people the test is considered positive. I have only seen a few positive reactions in the hundred of PPDs I've placed, and the best one was on my own arm when I was twenty-two years old. I completed a course of antibiotics and now have a chest X-ray every two years.

An entire family of Spanish speakers had been arrested and R&D called up to medical to get the PPDs done so they could be cleared out to the housing units. None of them spoke English, but we have the PPD and medical consent to treatment sheet translated into Spanish. The family consisted of a crying daughter, her gloomy husband, three of four other cavalier men who were perhaps brothers or brothers-in-law, and even the matriarch of the family. The matriarch couldn't read and I had to get her sobbing daughter to translate the consent form. The matriarch seemed oddly calm and smiling politely in her red jumpsuit, as though she had seem far worse than this before.

After I had dispatched the family, an R&D officer told me they had one more. They brought me a young white man with thin lips blinking his watery eyes at a rate I found distracting. I took down his information from this wristband and asked him if he was allergic to any medications. "Haldol," he told me and started to cry. He had a strange, exaggerated way of moving his mouth when he spoke, which made me suspect he had experienced a tardive reaction to Haldol at some point in his young institutional life. Tardive dyskinesia is a side effect of high-potency antipsychotics such as Haldol and is characterized by repetitive, involuntary, purposeless movements often including grimacing, tongue protrusion, lip smacking, puckering and pursing of the lips, and rapid eye blinking. Often these symptoms do not go away once the medication is withdrawn. At age twenty the man already bore the mark of aggressive antipsychotic treatment in his body.

"I want to be dead, like my dad," he told me after I had gone down the list of Tuberculosis symptoms.
"Did your dad kill himself?" I asked. He nodded his head "yes." I decided I would deal with his suicidal ideation after I placed the PPD.
"OK, I need to give you a little shot in your arm to test for TB," I said, pulling a wrapped TB syringe out of my breast pocket. He smacked his lips and let out a shrill screech. "I don't like needles," he said staring at the needle in my hand and leaning away from me. The R&D officer came over to the door of my office and I gestured with my other hand for him to come in.
"Hey Buddy, what are you in for anyway?" the officer asked, coming into the room, filling half of the possible floor space with his bulk. The inmate turned to look at him and I stared to draw up the tuberculin serum.
"Stealing GPS's from cars," he answered.
"Well, did you at least steal anything good?" The officer asked. The inmate smiled and I walked over to his left side. He started to look at the needle again, smacking his lips. "Look at me," the officer said, "The nurse is going to give you a little shot, like a little bug bite, now, where're you from buddy?"
"I'm from Minnesota, I want to go home to my mom," he replied as I alcoholed off a spot injected the serum under his skin.
"All done," I said. "He mentioned he wanted to be dead like his dad, can you call the Psych Nurse Practioner while I finish up here?" I asked the officer. He nodded yes and returned to the R&D desk to place the call.
"You people are all the same," Haldol Boy said, pointing a finger at my chest, "Now you're just going to put me in a strip cell, my dad warned me about all you people."
"Well sir," I said, "Seeing as how your dad killed himself, I'm thinking that was really shitty advice. Maybe if he had told someone and toughed it out for a few hours in a strip cell he'd still be here with you and your mom and things would be better for you. We need to keep you alive down here so you can make it out and return home to your mom. How do you think it will be for her if you hurt yourself in some jail down here?" He was completely still and quiet. No tears, no movement in his mouth. His face was red and puffy from the exertion of crying. "Suicide is often an impulsive act, there is some research to suggest that if we can get someone through the intense, impulsive stage then they can make it pretty well after that," I continued as the R&D officer re-entered the office.
"We'll keep him here in R&D for the weekend, we'll keep a good eye on you buddy," he said and escorted the inmate out of the office. I felt satisfied with this solution. R&D contained several single cells where inmates could be easily continuously monitored by the R&D staff. A housing unit would be too much stress for him and not enough supervision. I finished up my paperwork on the PPD's, emailing the classification staff of the PPD's. On my way out I thanked the officer for backing me up in the office. "You did a great job or re-directing him for me," I told him. "Oh, that's just my job," the officer replied, folding his arms across his chest and resting them on his belly.

Picture from a Recent Hike

The Flirt

When I thought about working with the men I was afraid they would flirt with me and I would blush. Or I would have to over compensate and be bitchy to set boundaries. Since I started at the jail last month this fear proved to be ungrounded, I was able to engage the men and give the same level of attention and care I would give the women without losing control of the interaction in any way. Most men showed gratitude with a simple thank you and went on their way out of respect. Then I encountered Mr. Cocaine-Bipolar Man for a physical. In my experience, mania usually does not feel all that good by itself. The excess energy feels very disorganized unless it can be focused in some way. Sometimes work or cleaning the apartment is enough, sometimes it's not and something more dramatic must captivate the mind like a new crush, using cocaine, a shopping spree, or walking across a dam. Using cocaine when manic is basically like pouring gasoline of a grease-fire in the kitchen, it burns hot and bright for awhile and leaves permeant damage to your home.

When they brought me Mr. Cocaine-Biplolar man he looked twitchy as he walked, raising his hand to rub his jaw as he crossed the high-polish linoleum floor. He was young and handsome, like someone I might have met at the local mountain bike club, someone I might date. "Do you work at Anna's Natural Foods?" he asked when he sat down in the molded plastic chair, cocking his head to the side. "No, but I do shop there," I replied. As soon as I heard my own words I knew I had blundered, like playing chess and allowing my opponent's knight to fork my queen and my king. I had given something away. He smiled. "I knew I'd seen you there a bunch, so much I thought you worked there."
"No, this place keeps me busy enough," I replied, strapping him into the blood pressure cuff and shoving the thermometer in his mouth. I doubted he actually recognized me from Anna's, he probably just thought I looked like someone who shopped at Anna's. For some reason people often guessed I was a vegetarian without ever seeing me eat, I could never figure out what gave it away. I decided to start shopping at the other hippy-crap co-op in town.
"Did you just get back from vacation?" he asked as soon as the bell rang to indicate the temperature was reached.
"No, why, so I look particularly relaxed?" I asked sarcastically, trying to erect a wall of humor as I wrote down his vitals.
"Your forehead looks sort of tan," he replied.
"Oh, that's a genetic hyper-pigmentation skin condition I have called melasma, it never goes away and gradually gets worse as I age, there's no cure. Thanks for bringing it to my attention," I replied. Even though the uneven coloring of my forehead didn't really bother me, I tried to sound embarrassed to make him feel bad. He was quiet as I began the dental exam. I communicated with him as little as possible, speaking only to give simple commands like "open your mouth," and "open your mouth again."

When we reached the mental health portion of the history he told me he was diagnosed bipolar and was in jail for possession of cocaine. I gave him my cocaine and bipolar is like pouring gas on a fire speech. "I know, I know, it just feels so damn good," he said, looking into my eyes. I felt like he was searching me, asking me to tell him something he didn't already know. "You're doing permanent damage to your brain each time you use, you're burning things away, you really need to stay on your meds and not use cocaine, and that's it," I told him as I turned the page and began the physical exam. "You're done," I said after I'd peered down his throat, felt for lymph nodes, and checked his lung and heart sounds. "I'm going to refer you to mental health, hopefully we can get your meds going again while you are in here."
"Thanks, and I'll see you at Anna's," he said, winking. I kept my poker face on and turned to fill in a few more blanks on the sheet.

The next week I was giving meds on his side of the jail, the trusty block. He had been started on a mood stabilizer and from the look of the medical record he had been compliant. When we reached the front of the line I handed him his pills in water in a little 30cc medicine cup, the sort of little cup that comes attached to the top of a bottle of Pepto Bismol. Most inmates gave the pills a little swirl with a flick of the wrist before throwing the cup back into their mouth. Some stirred the meds with their fingers or tapped the bottom of the cup to keep the pills from sticking. Mr. Cocaine-Bipolar man looked me in the eye and plunged his tongue down into the little cup, sweeping the sides of the little container. I wasn't embarrassed, it was so gross it was liberating. "Oh, he's working that cup!" I heard the man behind him say. "I hope that was for your benefit sir," I replied to the man behind Cocaine-Bipolar man in line and poured the next man's meds in water. I wondered if I had not given him that little in about shopping at Anna's, if that would have made a difference. Probably not, I decided as I moved on to the next block.

Saving Face

The time had come to break me out of the cocoon of polished linoleum and plastic moulded chairs in medical and strike out into the rest of the jail to give meds in the housing units. The jail housed approximately 500 inmates, about 150 of which received meds. The day shift arrived at 5 AM, two nurses pull pills for the jail and try to hit the floor around 7:30 AM, one going to the East side and one going to the West. The old jail was the heart of the structure, built in an "H" shape with new additions added to one side and the back if the "H." On my first day of med pass I would do the West side and the adjacent new housing pods.

The West side looked like a jail out of a 1940's movie. Men in black and white jumpsuits lived without the benefit of airconditioning behind worn steel bars in a series of small blocks. Each block was different, either dormitory style, semi-lockdown or total lockdown blocks. I half expected to see James Cagney rattling the bars when I stepped onto the catwalk. When the officer opened the heavy steel door to the block men stuck little mirrors through the bars. "It's a nurse," I heard them say. "Which nurse?" Another would ask. "I don't know, a new one. She's pretty. She's got brown hair, brown eyes...um..glasses, She's small," one with the mirror would describe me. "Hey new nurse, what's your name?"

I would tell them my last name while I arranged little medicine cups of water on the crossbeams of the bars for the dormitory blocks and walked down the catwalk to the individual cells of the lockdown blocks. The officer was not allowed to go into the lockdown blocks with me, "In case something happens, he needs to be able to control to block from the outside," the pharmacy manager had explained, showing me the manual controls for the doors and gates within the block embedded into the wall outside the block on a previous tour. "Nurse who?" they would ask, my name is unusual and I would often have to repeat it, sometimes a spelling was required to satisfy the curiosity of a certain block. Most of the men wished me well and told me they hoped I stayed. If there was someone masturbating in the far corner of a dormitory block or after I left a lockdown block, I decided I would not notice this.

Then I moved on to the pods. Each pod was a modern, two-tiered housing unit. I pushed the medcart just inside the door of the pod and the officer stood next to me while the inmates lined up to approach the cart one by one. Giving meds in the pod was a more chaotic experience, some men resting a hand on the cart while I poured the meds. The officer was often distracted by the phone. Sometimes I felt myself leaning back, wanting to take a step back. But one of the most important laws of corrections is to never take a step backwards. Either you stand your ground or you turn and run. I missed the bars and controlled structure of West side. As I poured one man's meds into the little medicine cup of water I noticed some of the foil backing from the blister pack floating in the water. I tried to fish it out with the edge of the little manilla pill envelope. I couldn't snag the foil, so I dipped the edge of my pinkey into the water and extracted it. The man looked at me as if I had just thrown up in his meds. "I'm not taking that, I don't know where your hands have been," he said, taking a step back from the cart. I wasn't sure how he thought the meds got from the blister packs to the business card sized manilla envelops. Angels from heaven? Fairies? Machines? "Fine, that's your choice, that's a refusal," I said. "No, it's not a refusal, you put your hands in my water," he said. I threw his pills still in the water in the trash can attached to the cart. "Next," I said. I had his meds in the cart and the medical record on the cart as well, I could have easily re-pulled his two pills. Granted that would have been with my bare hands as well. But I didn't want to stop and pull his pills, I wanted the line to move. Either he took it or he didn't.

I completed the rest of my med pass without incident. As I rolled through intake on the way back to the medical floor I wondered if he would write a grievance on me. I envisioned myself in the Health Services Administrator's office. She'd tell me that wasn't how we did things here. I'd nod my head and tell I'd do better next time. Back in medical I started to sign off my book, signing my initials in the little block for the day. The phone rang, the floor officer in the pod asked me if there was any way the man could get his medication, he was upset. I told him no. I didn't want the inmate to think that I had come back up to medical and been made to turn tail and take him his meds. Then I realized this was stupid. Part of my whole raison d'être for working in corrections was to show compassion and model good behavior for a population that had perhaps not seen much of it. I knew I was intimidated by the new environment and compensating with rigidity. I needed to take him his meds, he could think what he wanted about my reasons.

I put his two little pills in a new manilla envelope and took a little medicine cup of water along with me back to the pod. I stepped onto the floor with no med cart between me and the men. I waited while the officer called the inmate. I didn't know if he would taunt me for returning, or give me another lecture on hygiene in the correctional setting. "Sorry for all the trouble," he said when he stood before me. "It's OK," I told him, pouring the meds into the little cup. "Thank you for coming back," he said after he swallowed his melting pills. I left the pod and returned to medical for the rest of my shift.