The apprentice

On entering the Juvenile Detention facility, I was first struck by how cheerful and up-to-date the medical facility was. The white board was filled with dry-ink drawings of flowers and notes about the greatness that was Nurse Debra. The teenage patients gossiped with the guards and giggled out loud, often breaking out into hysterics. Perhaps what struck me as odd about the whole experience was the normalcy of it all.

During the shadowing experience, I had the opportunity to see three patients with the PA. The first two patients were two rather sweet and charming girls. Prior to being seen, they were occupying themselves by drawing clouds on the board and joking about a baseball game that had taken place earlier. Their gentle smiles belied the frustrations of being institutionalized into the system. As I palpated their red swollen hands and knuckles, they nonchalantly mentioned that they had punched the wall after a frustrating altercation with a staff member. Apparently, this was a weekly occurrence and one of the girls had previously fractured her metacarpal bones.

The third patient was a young teenage boy suffering from daily “migraine” headaches. No photophobia, no sonophobia, no nausea or auras. It didn’t really fit the bill of a migraine headache. After further prodding, I learned that he had been living on the streets for the past two years and was living in a camp in the woods until the levees broke after the storms and destroyed his meager possessions. He was running from the law and used fantasy defense mechanisms to help him cope with his current situation. It was inadequate and unsophisticated at best, but it got him through the day. The stress was getting to him and it resulted in the development of chronic tension headaches.

Similar veins ran through the stories of every patient that I saw on that day. They all came from difficult backgrounds and each had found inadequate ways to deal with their stress. Some lashed out in anger, while others used chemical substances to feel good, even if only temporarily. At the risk of sounding a bit condescending, I truly believe that what these kids needed more than anything else was a simple hug and confirmation that they were special.

The health system in the detention center is not too much different from health care at any other out-patient setting. The patients have their $3 co-pay and they make appointments to come into the clinic to see the PA about their chief complaint. The main difference is perspective. Many people, myself included, think of dangerous criminals and sociopaths when the penal system is mentioned. The assumption is that prisons are filled with bad people who do bad things, in contrast to people like ourselves, who are good people who occasionally make poor decisions. This is not to say that the prison does not house sociopaths, but for the most part, the people that I interacted with in the detention center simply lacked the basic coping mechanisms that most people learn through socialization in their homes and schools. They react violently when confronted and internalize all of their stress. This doesn’t excuse their behavior, but I wonder what role if any the physician has in facilitating the development of those skills. Per detention hall rules, the PA is only allowed to address the specific complaint of the patient. I just always thought prevention and maintenance always came standard.

After shadowing the PA, I had a chance to interview a member of pod B, who I’ll refer to henceforth by alias “Hector.” Hector fascinated me. Either that, or it was his ADHD taking me for a ride. His background included a lot of work training/breaking horses and riding bulls in rodeos. In addition to riding large, angry, violent mammals, he is also proficient at team lassoing and has ambitions of entering trade school and becoming certified in equine care. He seemed happiest when we talked about horses.

Unfortunately, Hector’s life was a perfect example of what happens when things go wrong in middle America. He grew up in a tweak house (home where the parents are metheamphetamine abusers). He started using marijuana in the 4th grade by stealing the drugs that his father stashed away in the closet. Soon after this, he became more involved in the movement of drugs and started stealing to feed his addiction. He had success in rehabilitation institutes and in times when he moved to areas of lower drug prevalence. However, he didn’t do as well when he lived in areas that were saturated with meth.

This was definitely a memorable experience I would never have otherwise encountered. I walked away from the experience a bit sad and perhaps a tad bitter. I had just observed another setting where there was a high level of complacency in the medical system. No actions were taken to curb the rampant use meth and fix broken homes. I’m not sure what can be done. Only epidemiologic measures can help a lot of these patients. Either way, I will now get off of my soap box.

Hector is once again participating in a rehabilitation program. He will be released next week. I wish him well.

bender