Critical Diagnosis

If you think your HMO is bad, check out what Texas has created for its prison inmates

Scott added that he had been seeking a full-time medical director for the past couple of years, but hadn't found a candidate he liked. But two days after talking to the Press about Warren, Scott fired the doctor, and sent a secretary to Galveston to collect his state computer and car.

Critics say that the Health Services Division is understaffed for the volume of work it's charged with handling, but last fall, help seemed to be on the way when the prison system began trying to fill 38 new positions. But nobody ended up being hired because, Scott says, TDCJ decided to think about having the audit work done by a private contractor rather than by state employees.

In general, criticisms of UTMB's inmate medical care have been met with resistance and denial by UTMB officials. Alarmed by deaths at its Stiles Unit in Beaumont, where UTMB has moved convicts seriously ill from HIV and AIDS, in September 1996 the TDCJ board ordered its Health Services Division to conduct a "mortality review" of 24 inmate deaths. A task force of physicians and nurses who reviewed the unit's medical records found that 16 of the 24 cases had been handled improperly. Although the Stiles unit was supposed to specialize in dealing with AIDS, here are some of the findings concerning these deaths:

*"Poor recognition by ... staff of signs/ symptoms of acute infection."
*"Need for education of staff regarding signs/symptoms of HIV- related opportunistic infections."

*"Incorrect diagnosis of HIV made by Stiles physician."
*"Patient starved to death in infirmary."
*"Fevers were never addressed."
*"Chronic care was not performed according to policy for HIV disease."
*"Nursing staff did not refer significant findings to the physician."

*"Patient was left in his cell in general population despite recurrent fever, cough, disorientation and inability to walk to clinic."

*"Patient was housed inappropriately ... and was gassed in the infirmary."
When a peer review is this critical, most medical institutions would call for disciplinary action, but UTMB's medical director for the prison HMO, Jason Calhoun, overruled the physicians who found these problems, and no action was taken. Calhoun declared that the task force from the prison board had "no business" telling UTMB how to manage HIV care. Despite these problems, UTMB officials insist they have made significant progress, and that HIV care at Stiles is among the best in the nation; they also say they will soon be administering protease inhibitors, the most effective drugs yet found for the treatment of those with HIV.

But protease inhibitors are expensive as well as effective. And the high price of such drugs, says Leon Clements, the chief administrative officer of UTMB's correctional managed care program, may limit any further reductions in the cost of prisoner care.

When UTMB took over the managed care of Texas prisons, it had a lot of work to do. Some of the system's existing medical staff was incompetent, and had to be retrained. Turnover was high, something that has been reduced. Not that there aren't still plenty of job openings available. Take, for instance, the job description of licensed vocational nurse for the prison system. In December, Managed Care posted 28 openings for LVNs, who are the first line of defense in medical matters. An LVN, the job description says, is responsible for "respond[ing] rapidly to emergencies at any location on the unit, and if indicated perform[ing] CPR."

Unfortunately, rapid response wasn't the case at 5 a.m. Saturday, November 22, 1997, when a 48-year-old inmate named Virgil Kimble fell off a toilet in the H pod at the LeBlanc Unit in Beaumont. Kimble was knocked unconscious and soiled himself. Inmates called a guard, who called the unit's infirmary, and 15 or 20 minutes later, two LVNs came in, cleaned up Kimble and started talking to him.

According to a statement signed by seven inmates at the scene, the nurses seemed to be "goading and bullying" Kimble, who was gasping for breath. He finally managed to walk off the wing to the infirmary, about 400 yards away. (Because of a faulty design of the dormitory doors at the LeBlanc unit, neither a wheelchair nor a gurney can pass through them.) A half-hour later, Kimble walked back to his dormitory and said he thought he was all right.

At 4 o'clock that afternoon, he lay down on his bunk and died. Several inmates beat on the glass door and the guard immediately called the medical staff, but the afternoon shift, consisting of a male and female nurse, took an hour to get there. By the time they did, Kimble was cold.

According to one inmate, "they did two or three blows on the chest" and called for a stretcher. "Then they put an oxygen mask on him, but if a guy's not breathing, oxygen won't do him any good."

Kimble, who was serving a 12-year sentence for burglary and drug possession, seemed to have no family and few friends aside from some pen pals in other prison units. The final service he received from his HMO was not a trip to the emergency room, but an autopsy and (if no family claimed the body) a burial. The state economizes on the burial, too. Each grave at the cemetery at Huntsville is marked with a white cross, but the state wastes no money putting a name or even a number on them.

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