This past week, I had a patient who is incarcerated but had a health problem that exceeded his prison's infirmary's capacity to care for him, so that he had to come to my hospital. He has very many racist and obscene tattoos, including on his face. Their content represents a worldview which I find abhorrent and especially offensive to many of those who are directly trying to safe his life.
Yesterday, he had series of seizures, during which he became apneic for an extended period. I was holding his airway open with a vigorous and painful jaw thrust, that he would not have tolerated had he been "faking" his post ictal state. Still, other members of the team (whose counsel I greatly respect!) told me that my concern was misplaced. "No, he doesn't need supplemental O2. He doesn't need help protecting his airway. He's faking it. Breath holding. Desaturating? Faking. Nystagmus, yeah, I can fake that, too, see?" Yes, I am just a med student, but at the beginning of my career, I was also a neuro/epilepsy monitoring unit nurse. This is a patient who has documented hx of epilepsy, with multiple big gun antiepileptic agents onboard, and whose hospital course included a pharmaceutical exposure that could well have lowered his seizure threshhold. So, with my excellent resident telling me that I was being bamboozled (and judging me for allowing it), I persisted in helping this hateful man, keeping his airway open and protecting his head until the seizure was finally aborted with IV medication.
Today, even though I acted in accordance with my principles... even though I would always rather provide potentially lifesaving treatment to a malingerer than risk denying aid to someone in genuine distress... I'm feeling some kind of way about it all. If I met this man on the street, some part of me would wish to punch him right in his swastikas. But on a stretcher? He's my patient and I'm training to be a doctor, not a judge. Still I'm deeply conflicted about it all, especially if he was getting on over on me. (I really don't believe that, but it is hard to differ with the assessment of a respected mentor.)
On one hand, I think that prisoners need to have access to physicians who care about them as human beings and are able to remain professional no matter how foul the patient's actions. On the other, I know that there are people who will ruthlessly exploit others, and that a lot of those folks do end up in jail for various reasons. Their skill at manipulating and extracting secondary gain will sometimes exceed my skill at detecting guile. One answer is to just trust no one, and the folks I know who have worked for long times in corrections medicine are all extremely jaded, likely with good reason.
I'm pleased to have gone through all that I have in life and to still retain my faith in humanity and the endless potential for redemption. That is both what leads me to wish to be available to the worst of us in their time of need... and the quality that may make it impossible for me to do so beyond a certain point. If a single encounter with this kind of incident has produced this much need for debriefing and aftercare, then I'm not sure that I could cope with it day in and day out.
