Volume 56, Number 1 - Winter 2010

 

By Jonathan M. Levin, MD

Three surgeons from Marin County routinely go to San Quentin State Prison to evaluate surgical issues: Drs. Winthrop Hall (ENT), Bart Gershbein (urology), and myself (general surgery). Outpatient clinics generally occur every two weeks for each of these specialties. Most of the cases that require surgery end up in the operating room at Novato Community Hospital (NCH). Many of these operations are come-and-go, but occasionally an overnight stay in the hospital is necessary.

Surgery and inpatient care for San Quentin prisoners, who now number around 5,200, was originally delivered at medical facilities within the prison. When these facilities became outmoded, inpatient care was rendered at NCH for many years, and emergency cases were usually taken to the closest hospital, Marin General. The lockdown ward at NCH was recently closed, however, so inpatient care is now delivered in the East Bay.

Dr. Hall writes, “I began staffing the ENT clinic at San Quentin in 1976. I have continued in this capacity every other week to this day. I have found the patients to be on the whole appreciative and compliant. I have done all types of ENT surgery, often complicated and requiring hospitalization. We see many unusual conditions that are seldom seen in private practice. The overall quality of medical care at the prison has vastly improved in recent years. Specialty referrals are prompt and appropriate.” 

Delivering medical care to a community of this size requires a considerable commitment of staff and funding. All patients are screened by San Quentin medical staff and then referred for evaluation. A large percentage of these referrals merit operation.

What is striking is the thickness of the patients’ charts. Along with the usual problems, there is a preponderance of hepatitis and HIV. The most common outpatient surgical complaint is hernia, of all types. Inguinal and umbilical hernias predominate, though many of the inmates have had previous laparotomy, some with resultant incisional hernia. Less common issues include gallbladder, colostomy takedown, hemorrhoids, and removing metal fragments. 

The process for surgery has improved markedly in the past five years. Once a decision to proceed with surgery is reached, the surgeon submits separate forms for the consultation and the operation request. These forms are evaluated by the prison’s medical staff; and since these outpatient cases are elective or semi-elective, the operation may or may not occur in a timely fashion. When the case is authorized and scheduled, the patient is examined and cleared for surgery, similar to what happens outside the prison setting. 

Over the past five years, several new facilities have been constructed at San Quentin, including a mini-ER and temporary trailer-like rooms for outpatient care. A permanent clinic is also nearing completion. This will not encompass inpatient care, but it will include specialty clinics, along with SNF-type beds. Major surgeries will continue to be performed in private hospitals off the prison grounds.

The medical staff at the prison is assiduous about follow-up on their patients, often calling my office to discuss the case. An average caseload in the general surgery clinic is 10-15 patients, including a certain number of post-ops. As opposed to a normal office waiting room, simply getting inmates to the clinic poses certain problems because of security concerns. Guards are stationed either in the exam room or just outside the open door. A lockdown can occur at any time, bringing an end to the clinic. 

Despite these issues, the prisoners are overwhelmingly respectful and thankful for their care. An RN keeps the list moving along, assists when necessary in wound care, and makes sure the appropriate paperwork is employed.

Because I am an outside specialist, my follow-up on recommendations for tests or referral is limited. This situation differs greatly from my private practice. Ultimately, the permanent medical staff at the prison controls the patient’s course. 

I have been taking care of patients at San Quentin for many years, and I plan to continue doing so.