On May 31, Isidro Pacheco, a 31-year-old restaurant worker serving six months in the Manhattan Detention Complex on a drug charge, collapsed in his cell. It wasn’t the first time. In the previous two weeks, Mr. Pacheco had collapsed three times in the facility, known as the Tombs. In this time period, according to medical records obtained by The Observer and interviews with medical staff, he had gone on at least six occasions to the clinic in the Tombs, complaining of severe chest pains. A chest X-ray taken on March 14 noted a “prominence of the media stinum with tortuosity of the ascending aorta”–in other words, his aorta was dangerously enlarged–and called for further evaluation with a CAT scan in order to rule out “an acute dissection,” or rupture.
He was never taken for the evaluation that was scheduled for him at Bellevue Medical Center, which has a prison ward and is where most of the city’s sickest inmates are treated. Instead, he was repeatedly given a Motrin-like pain reliever for what his medical records described as “musculoskeletal pain,” and was sent back to his cell.
After his collapse on May 31, at about 10:30 A.M., he was taken again, cold and sweating, to the facility’s clinic. It was not until 2:30 P.M. that an ambulance took a gravely ill Mr. Pacheco to Bellevue Medical Center. Less than 12 hours later, at 1:02 A.M., following emergency heart surgery, he was pronounced dead. A few days short of completing his six-month jail term, Mr. Pacheco had died from a massive build-up of blood around the heart, a condition known as pericardial tapanade. A source at Rikers said the X-ray impression had clearly warned of this condition, which is treatable with prompt medical attention.
Last January, at the same time that Mr. Pacheco began his detention, a new health-care provider, St. Barnabas Medical Center, a small, profitable Bronx hospital with no prior prison-care experience, assumed care of the city’s inmates–more than 133,000 annually–most of whom reside on Rikers Island, but some of whom are housed in borough facilities like the Tombs. Since then, said several clinicians, two detainees, Mr. Pacheco and Benjamin Campbell, 51, have died from conditions that required urgent hospitalization. Through interviews and medical records, The Observer has identified nine more detainees who were held in correctional facility clinics, or their cells, for time periods of up to two months after presenting serious symptoms to clinic staff.
Now, two investigations are under way. The New York State Commission of Corrections, an agency that regulates correctional facilities throughout the state, is specifically investigating Mr. Pacheco’s death. A spokesman there declined to comment further, citing the ongoing investigation. The Prisoner’s Rights Project of the New York City Legal Aid Society, a watchdog group, is also investigating. “We have had a number of complaints from prisoners with serious medical conditions stating that their hospitalization was excessively delayed,” said project director John Boston. “We have been investigating these complaints, and we believe that some of them are quite correct.”
These probes, and the death of Mr. Pacheco, are a troubling reminder of a time when public health concerns in jails went unaddressed and inmates were left to languish. Federal laws such as the Federal Civil Rights Act entitle prisoners to medical care that meets the standard of the community.
The Observer consulted an emergency medicine expert who reviewed seven patients’ cases. Dr. John E. Prescott, chairman of the department of emergency medicine for the Robert C. Byrd Health Sciences Center of West Virginia University, said that Mr. Pacheco’s condition warranted immediate hospital evaluation. “If a patient is having persistent pain and had a chest X-ray that is highly suggestive of a dissection [a rupture], the course of action is very clear.”
Dr. Harry Schuman, who began as St. Barnabas’ program director for correctional health services on May 4 after serving as medical director for the Illinois State Department of Corrections, said of any investigation, “I welcome it. I don’t know of a correctional system that is not under scrutiny. Part of working in correctional health is working in a fishbowl.”
St. Barnabas’ three-year, $342 million contract–the country’s most lucrative prison-care deal and the result of a competitive and now legally contested bidding process–departs from the previous detention center contracts held by St. Vincent’s and Montefiore medical centers in one key respect. Whereas the city previously picked up the tab for prisoners’ emergency hospital visits, St. Barnabas must now pay the costs. While the new arrangement is standard health maintenance organization-operating procedure aimed at reducing unnecessary hospital visits, it may have created an incentive to delay hospitalization of inmates.
“There are many prisoners coming from Rikers Island in the last six months who are sicker than any I’ve seen in the last 15 years,” said Lewis Goldfrank, emergency medicine director of Bellevue Hospital, who has long treated the city’s poor. “We’ve seen individuals with infections that appear to have the manifestations of days, if not weeks, of neglect. It appears that patients with complex disorders who need urgent care are being delayed in their access to it, and this delay has resulted in increased morbidity and mortality.”
Dr. Schuman said that he could not respond to questions about specific cases but said he strongly disagreed. “[Previously] there was a disincentive to keep anyone on [Rikers Island]. Once a physician could get a patient to the hospital, he washed his hands of it.… We’re asking people to use their training,” he said, and “not … to simply refer people to the hospital.”
A reliable source told The Observer that the Health and Hospitals Corporation, the city agency that oversees public hospitals and was placed in charge of prison care in 1996, is reviewing 30 cases of prisoners who, since Jan. 1, may have been medically mistreated. Dr. Audrey Compton, the agency’s medical director for correctional health services, said, “There is no investigation. There is simply an ongoing quality-assurance process.”
Reducing the Fat in the Prison System
Under St. Barnabas’ management, the number of prisoners being sent to Bellevue for emergency care has dropped significantly. According to Bellevue’s Daily Restraint Update Reports, a census of prisoners sent for medical attention, in December 1997 the hospital’s medical ward averaged 21 prisoners a day and the psychiatric ward averaged 20. In January 1998, those numbers were 12 and 16, respectively, representing a drop of 43 percent in the medical ward and 32 percent overall. In a March 9 profile of St. Barnabas president Ronald Gade, The New York Times also cited the remarkable decline. In February 1997, 345 Rikers prisoners were admitted to a hospital; a year later, half that number were hospitalized. In the article, Dr. Gade observed that the drop was an impressive trimming of fat; prisoners were no longer sent to the hospital for minor problems.
However, on one surprise visit to Rikers several months into the St. Barnabas contract, doctors employed by Health and Hospitals Corporation determined that some prisoners with major problems were also not being sent to the hospital. During their visit, according to Rikers medical staff, the H.H.C. doctors intervened and sent five inmates to the hospital for emergency care. (Dr. Compton challenged this interpretation of the visit and said that her agency works collaboratively with the St. Barnabas doctors.)
The Observer obtained the medical records of five detainees, interviewed four inmates and spoke with family members of two others, in cases that raised concerns about delayed hospitalization. Richard Franz, 45, a Rikers detainee, became crippled when bone cancer ate through his vertebrae. Though an X-ray revealed a spinal compression fracture, and Rikers medical staff knew of earlier treatment for cancer, Mr. Frantz was not sent to the hospital for more than two months after the onset of symptoms. He is now terminally ill.
For Yukon Shoulars, 21, who has sickle-cell anemia, a sonogram taken at Rikers revealed that he had severe gallstones. Yet he was kept in the clinic there for three weeks, unable to eat or drink or move his bowels, according to concerned medical staff and family members, and was only sent to the hospital when he began to vomit blood. A 60-year-old detainee who complained of an infected hand for a week, did not receive treatment until gangrene reached the middle of his palm. Several fingers were finally amputated at Bellevue, where he was admitted on Feb. 27, 1998, and kept for almost a month.
Shipping inmates to the hospital does come with a security risk. In 1994, an inmate sent to King’s County Hospital for a minor problem stole a police officer’s gun, which resulted in a shootout in the emergency room.
St. Barnabas has created a new system for screening emergency hospitalizations of inmates. Now, doctors within the detention system must get approval from a medical gatekeeper, termed an “Urgicare” physician. There is one such physician on site at Rikers in any given shift to oversee the medical care of more than 15,000 inmates, who tend to be far sicker than the general population. Urgicare policies state that prior to transporting patients to the hospital, medical staff should contact an Urgicare physician who can recommend hospitalization, see the patient or recommend continued treatment in the correctional facility. While the Urgicare doctor has the power to veto the medical staff’s decision, the policy says that this process should not unduly delay the needed hospitalization.
Dr. Schuman described the Urgicare physician, who is board-certified in emergency medicine, as one additional resource, particularly when doctors at the clinics are unsure whether a detainee needs hospitalization.
Medical staff in the clinics talked about overworked Urgicare physicians who do not return emergency pages and are difficult to locate among the 10 different jail buildings that comprise Rikers Island.
One clinician in the detention system who requested anonymity said, “You have to go through this charade. You have a qualified physician on the spot with his hands on the patient. Then you have to call another Urgicare physician who hasn’t seen the patient and say, ‘Please let me send this guy to the hospital.’ It’s insane.”
Now, the overseeing physicians are there to advise a transfer to the hospital transfer, see the patient or recommend continued treatment in the correctional facility.
The Urgicare policy states that senior medical personnel are “fully authorized” to call Emergency Medical Services and that “we will support the documented good judgment of the facility medical staff.” The memo goes on to state that while all E.M.S. runs will be reviewed, “[i]nterventions will be educational and professional, not punitive.”
However, three clinicians in the detention system told The Observer that sending out patients to the hospital can result in negative evaluations or a reduction in work hours. “They ream you the next day,” said the clinician, who added that the staff’s judgment is often retrospectively challenged on patients they send to the hospital. He said that he and a physician agreed to do an overtime shift at Rikers. But after he sent out two seriously ill detainees, he said, “They never asked me back.”
“The word is clear,” said one of the employees, who described a Faustian conflict between the unspoken cost-cutting imperative and the needs of the patients.
This conflict played out in the case of 21-year-old Yukon Shoulars, who is currently in the North Infirmary Command. He was arrested in April for a parole violation and was taken to the Tombs, where he soon began to complain of pains in his right side and stomach. After a week, he was sent to Rikers Island, where a sonogram indicated gallstones. “The doctor said I had to have an operation,” Mr. Shoulars told The Observer in a telephone interview. Yet in his three weeks at the infirmary, he was maintained on Demerol, which dulled the pain and made him sleep. “Everything I ate I would throw back up,” he said, his weight plunging during this period.
Mr. Shoulars said that he asked at least twice a day to be sent to the hospital, only to be told that he was either faking, or that the pain medication would help him pass the gallstones in a bowel movement, which he was unable to have. “Still, I might have been waiting had I not lost so much blood,” Mr. Shoulars said.
Dr. Prescott said people with sickle-cell anemia are at a high risk for serious complication. “After two or three days with belly pain, he needs to be evaluated medically and probably hospitalized.”
On May 1, a month after he first complained of pain, he began to vomit up blood. “The [physician assistant] said, ‘Hey, we’ve got to get this guy out of here,'” Mr. Shoulars recalled. He was sent immediately to Bellevue, where surgeons removed his gallbladder and left him with a bag that drains bile from his liver. “Before [St. Barnabas] came in,” said the clinician, “we erred on the side of caution. We didn’t second-guess it.”
Under Montefiore’s old policy, any doctor in the detention system who believed an inmate was in dire condition simply made the decision to hospitalize him or her. But the costs of that system, which often required overtime payment for corrections officers, were astronomical. With Montefiore’s contract due to expire, it seemed likely that some form of managed care, which has been sweeping the nation’s prisons, would take hold at Rikers. However, when St. Barnabas was awarded the contract over St. Vincent’s, which has more than 10 years of prison experience. There was talk that the bidding process had been rigged. Last December, St. Vincent’s filed a lawsuit against H.H.C. in State Supreme Court in Manhattan, alleging that political considerations had outweighed merit and experience in the process of selecting vendors. The suit is still pending.
John Boston at the Prisoner’s Rights Project noted that when his attorneys requested eight medical records, his investigation was slowed by an H.H.C. requirement imposed on May 24 that all requests for medical records be notarized. He suggested that obstruction may be the cause and said, “We’ve been getting medical records from H.H.C. with non-notarized releases for 20 years.”
While H.H.C. initially denied that there was a notarization policy, Dr. Compton, when presented with the letter written by H.H.C. legal counsel to the legal aid society (and copied to Dr. Compton) insisting on notarization, said, “We’re going to ask the person who wrote it to retract it, and I don’t know why it was imposed at that time.”
Staff Cuts and Chaos
While law-abiding citizens feel that they are held prisoner by H.M.O.’s and given limited access to doctors, the inmate’s dilemma under these same circumstances is even more acute. “[Prisoners] can’t call up a doctor if they feel sick,” said Dr. Ronald Shansky, medical director for the Illinois Department of Corrections, who provided an affidavit for St. Vincent’s in its lawsuit. “A doctor has to arrange for access to the service, so there is much less ability to control one’s own destiny.”
This feeling of helplessness may be what led a sick Rikers inmate, Gerald Stallings, to send a typed “Letter of Urgency” headlined “Please Help Us” to the Daily News in February. No article resulted. The letter chronicled filthy, chaotic and understaffed conditions in the North Infirmary Command Center, and identified two prisoners with H.I.V. and high temperatures who, in Mr. Stallings’ view, needed immediate care and were being neglected.
One excerpt from the log they maintained, dated Feb. 2, 1998, at 8 A.M., says, “No doctors on site in Unit Dorm 4.” They go on to list sick-call patients in Dorm 4, the AIDS unit, among them “Benny Campbell.” Campbell was the inmate who died at Bellevue from a blood infection known as septicemia. He was admitted on April 6 and died on April 10, two months after his appearance in Mr. Sprague’s log. The Observer obtained Campbell’s medical records, and a doctor’s note in them reads, “Patient states weakness for one month presents himself to infirmary at Rikers.” The records also say “treated for pneumonia for two weeks,” and the treatment listed is “PCP, got Bactrum.”
“PCP can be a life-threatening pneumonia for patients with AIDS. The standard of care is to place him in the hospital with IV antibiotics, in isolation,” said Dr. Prescott.
According to public health experts, incarceration should be viewed as an opportunity to provide much needed care to a captive audience who, if untreated, will likely return to their neighborhoods and spread diseases.
However, one clinician described a medical environment at the Tombs as so dispirited and understaffed that prisoners are actually refusing care.
“Doctors from one shift to the next don’t know what the guy’s in there for. There’s no formal baton-pass of information from shift to shift. There are no rounds. There was an H.I.V. patient who was laying on a stretcher for two days with 104-degree temperature. You shake your head in utter awe over this,” he said, adding, “Third world medicine does a better job.”
Recently, this kind of treatment of a mentally ill 18-year-old inmate, currently in critical condition in the Bellevue intensive care unit, led to outrage among the Rikers staff. The boy was too sick to be interviewed, but, according to his Rikers medical records, he suffered a life-threatening reaction to Haldol, an antipsychotic medication. Despite a potentially fatal diagnosis of neuroleptic malignant syndrome–a reaction to psychotropic medication–he was observed in the Rikers clinic for five days before being sent to Bellevue on June 10. Dr. Prescott, who expressed shock at this delay, said that this syndrome left untreated, can quickly cause respiratory and renal failure and neurological disintegration. “There are some diagnoses where when you think about them, you need to act, and this is one of them.”
Isidro Pacheco was no saint. But he is recalled at the Tombs as a kind man who once gave a fresh set of clothes to a disheveled new inmate. When news of his death reached the corrections officers, two of them sent a condolence card to his girlfriend Dina Vaccaro. The day before his death when she came to visit, she was apparently turned away. “They told me he was too sick,” she said. She has retained a Manhattan attorney, Paul Layton, who said he plans to file a lawsuit against the city of New York, the Department of Corrections, H.H.C. and St. Barnabas for wrongful death, conscious pain and suffering, and violation of civil rights. “Mr. Pacheco was given Tylenol instead of coronary care,” said Mr. Layton.