My first year as a physician, I served as an intern in the hospital where I now work and teach, as an attending physician. One of my least favorite rotations during that intern year was the four weeks i spent in the Emergency Department, the ED. Despite the fact that my training closely tracked the path of Noah Wiley’s character in the hit show of the 90’s, ER, and lots of my classmates were heading into Emergency Medicine, I’ve always disliked the ED.

You have to have a certain personality to work in an ED. A big part of that is that you usually don’t know what the end of the story is, and one of the biggest bonuses to me of practicing medicine is getting to know my patients over time, and finding out what the “answer” is to their list of symptoms and physical findings. The ED is about dealing with crises, and anything that is not immediately life-threatening gets either discharged for followup in an outpatient clinic, or admitted for further work up.

And, there’s an attitude.

One of the features of our hospital, which has changed in recent years, is that we used to have a contract with the Maryland Prison system, and provided most of the care for incarcerated patients from all over the state. We used to have a dedicated unit in the hospital with the double gates sliding open and shut, just like you see in prison movies (and, I suppose in prison, although I’ve never personally visited a prison before).

And Sundays in the ED often found us with an influx of orange-suited inmates, usually because a recreational baseball game would have devolved into inmates beating each other up with the bats, and we would see all kinds of lacerations and injuries. And, one of these Sundays found me on duty, and I picked up the chart of a 17-year-old kid with a large scalp laceration. I can’t recall who handed me the chart, whether it was a veteran nurse, or one of the supervising ED residents, or maybe even the attending physician in charge, but I vividly remember whoever it was telling me “Go staple this kid’s head, and don’t use any lidocaine – he’s a murderer – a piece of s#!t, and he deserves all the pain he gets.”

I was shocked.

I went to see the kid, and he did have a cut across the top of his head, about 6 centimeters long.

He was not a nice kid. He was sullen, and had no interest in giving me any of the answers to the history questions I was supposed to ask to record in his chart. He just demanded curtly that I fix his head. And I did, with all the care that I gave to any other patient, including numbing his scalp with lidocaine before suturing his laceration! Every other authority figure in this kid’s life might be treating him like garbage, but I wasn’t interested participating in that drama.

As I moved along in my training, and as my interest in HIV infection grew, I had increasing opportunity to care for prisoners (HIV and incarceration go hand-in-hand in Maryland, and probably other parts of the US as well, thanks to our War on Drugs, that leads to lots of IV drug users ending up serving time). One of my personal rules has been: I never ask a prisoner what he or she did to get arrested and locked up. I don’t want to know. Knowing that someone is a murdered, or a rapist, or a child molester, does not allow one to provide good, humanistic medical care, and that’s my job.

Our hospital no longer has the prison contract, and so my contact with the prison population has declined. Prison still plays a role in my clinic population, as many of my patients go in and out of the revolving door of incarceration. The usual reason for one of my patients to “disappear” for 6-12 months is because they got arrested, often, they tell me, on “old open warrants” (rarely will a patient admit to me that they committed a new crime that resulted in their arrest, and my policy is still not to ask.)

Some of my more cynical colleagues, jaded by years of working with this population, will look up new patients (and sometime returning ones) on a website of the Maryland judiciary system, which lists all court cases and arrests. I’ve only used it once, with a patient who frightened me, and has instilled fear in everyone who has worked with him. His record was worrisome, and just about a year ago, I got a call from his wife that he had raped her and threatened her life! She was asking for my help in filing a restraining order (something med school never trained me for!).

Incarceration does strange things to humans. It is a dehumanizing experience, from what I’ve seen.

And yet, some people do seem to do better in prison than “on the street”. With some of our patients, who can never seem to get their lives together, who are homeless, and addicted, and never able to take their medications regularly enough to get healthy, we sometimes joke that they really need to get arrested, and that would solve their problems. Many lives in the inner city are marked by chaos and unpredictability, lack of social structure and lack of the ability/skills/knowledge to impose order on one’s own life.

I’ve met prisoners and ex-cons who were complete idiots, and others who were incredibly bright and introspective. I’ve met everything in between.

I’ve seen people turn their lives around, and that is incredibly gratifying. And I’ve seen more people stuck, in cycles of addiction and violence. I have patients who spent a lot of time in jail, and now their adolescent or adult children are spending time in prison.

And, if you know me, you can probably guess that I strongly oppose the death penalty. Both Judaism and Islam share the notion that by saving one life, you save the whole of creation. I believe the reverse must also hold true – that if you put someone to death intentionally, you destroy creation, you destroy the world. Yes, there are arguments which are compelling, about those proven innocent, too often after it’s too late. And, so many studies showing how inequitable the American justice system is, far more ready to incarcerate African Americans, and administering harsher judgements on someone who is black than white. But I think even if someone is guilty of the most heinous act, it’s not for any of us to pass judgement and end that life. I believe in redemption, even if it’s unlikely in any given individual. You just never know…

---

And, if this post seems a little too serious and intense, forgive me, and don’t let it dissuade you from reading the book that prompted these thoughts, The Execution of Noa P. Singleton, by Elizabeth L. Silver. The book is surprisingly funny at times, and serious at others, and gave me so much to think about – more even than could fit into this post.

Mere months before Noa’s execution, her victim’s mother changed her mind Noa’s sentence and vows to help stay the execution. Join From Left to Write on July 30 as we discuss The Execution of Noa P. Singleton.   Given the multiple layers operating in this story, the discussion should be particularly interesting.

As a member, I received a copy of the book for review purposes.