Restellini: Maximum Security Hospital Ward 337
Maximum-security Hospital Ward J P RESTELLINI Institut Universitaire de Meaectne Legale, 1211 Geneve 4, Switzerland INTRODUCTION
The Division of Prison Medicine is attached to the Department of Forensic Medicine of the University of Geneva. Its three components are the dispensary at Champ-Dollon Remand Prison, an extra-mural maximum security psychiatric ward and an extra-mural maximumsecurity medical and surgical ward. The maximum-security medical and surgical ward provides a full range of medical services to prisoners under the jurisdiction of the courts in French and Italian-speaking Switzerland. It is situated on the ground floor of the University Hospital. Because it is housed in a modern, well-equipped and academically oriented facility, its physicians have ready access to sophisticated medical and surgical services equal in every respect to those available on other wards in the hospital. Specially trained prison guards ensure security on and off the ward. BED CAPACITY AND OCCUPANCY RATE
Between 110 and 120 patients are admitted annually to the medico- surgical ward, which contains five semi-private rooms with a total of ten beds. Several factors - some clinical, some nonclinical - combine to restrict the maximum occupancy rate. For instance, isolation may be ordered to prevent the spread of contagious diseases or to protect a patient affected with immune-depressive disease; departmental policy prohibits assigning a male and a female patient to the same room; examining magistrates have the authority to impose isolation of a patient on the ward, for example, to protect a minor or to enforce a gag order. Moreover, prison officials are empowered to require isolation of patients for security reasons:
experience shows that confining persons with personality disorders - more prevalent among prisoners than in the general population to close quarters with others for extended periods of time often leads to physical violence or other undesirable behaviours. And the real admittance capacity is largely reduced, to a half sometimes, when the five hospitalized patients must be kept in isolation. AVERAGE AGE
The average age of patients admitted to the medico-surgical ward is about thirty years, the same as that of the general Swiss prison population. This contrasts sharply with the higher average age, near geriatric, for patients admitted to other wards in the hospital. MOST FREQUENT DIAGNOSES
The graph (Figure 1) shows the 682 admissions divided into different categories, depending on the kind of ailment, from January 1984 through December 1989. We have divided the total number of admissions into two broad categories, i.e., those requiring mainly medical and those primarily requiring surgical (including orthopaedic) management. The graph represents the percentages of total admission accounted for by each entrance diagnosis category. FINDINGS AND INFERENCES Orthopaedic Management
Admissions requiring orthopaedic management clearly predominate. The overwhelming preponderance of traumatic injuries diagnosed in prison is attributed to two main factors: the more energetic physical activity of a youthful
338 Mad. Sci. Law (1992) Vol. 32, No.4
Figure 1. Types of disorders requiring hospitalization
Medical
Gastrointednllp U 6.3
C8rdIoYucuIar Neurological Rheumalologlcal
U
5
p~
3.2 2.9 2.5
Onco-inmunologlcal Infeclioul Endocrinological
2.2
Drug liluse (ovtrcloS&llCU1l wihlrlwlll)'lllpbnl) NepIvoIogical
1.8 1.5 1
Hemalobglcal
Sur lcal
Or1hopedic!EE~;:==:-::-10.6
GaslroinIMtinaI Recol1llructlon of Itle hand Maxllofacial CardioYlSCUIar
Others
__
17'3
3.5 2.2
Neurosurgical
1.9
Genilourinaty Plastic surgery Thoracic
1.9
lallUes
--===~~.
Psychiatric 6.6 3.8 ENT-J Dermatological 1.3 Gynecological 1.2 Ophtalmological ~.....!1--'-_---Y _ _~_-r-_-.-_-._---.-_--I
o
5
10
15
20
In" in relalkJn 10 /he total ofhospi1alisaJlons
group and the above-average tendency towards physical violence found in a prison population. Sports Injuries are frequent among prisoners, particularly among those still under investigation and awaiting arraignment, because they are confined to closer quarters and are allowed less time for physical exercise than other prisoners. As a result, they may plunge into strenuous sports activities without ade-
quate warming-up exercises and often sustain severe sprains, bruises, pulled muscles, ligaments and tendons. Acts of violence are more frequent among prisoners than in the general population and resulting injuries may be serious enough to require hospitalization. Significant injuries may also occur during resistance to arrest. Persons treated for injuries
Restellini: Maximum Security Hospital Ward 339
sustained in automobile accidents may be detained by the police in the emergency room of a hospital if they are found to have been driving under the influence of alcohol. If their condition is serious, persons injured in these ways may be sent directly to the medico-surgical ward rather than to gaol. Gastrointestinal disorders
While trauma constitutes the largest single final diagnosis in either broad category responsible for hospitalization on the medico-surgical ward (17.3 per cent of total admissions), gastrointestinal disorders follow close behind, whether surgically (10.6 per cent) or medically (8.9 per cent) managed. Taken together, surgically and medically managed gastrointestinal disorders constitute the overall most significant cause for hospitalization, accounting for over 19.2 per cent of total admissions. Among the medically managed conditions are liver disorders related to intravenous drug use, a frequent cause of hospitalization; it is estimated that at any given time from 20 per cent to 60 per cent of the prison population may be made up of habitual or occasional intravenous drug users. Lesions of the gastroduodenal lining are frequently caused by the stress associated with incarceration and the excessive use of tobacco (tabagism) in which confined persons with unstructured time on their hands are likely to indulge. Significant weight loss due to psychophysiological disorders of the digestive system also account for many hospitalizations. Surgically managed conditions include abdominal stab wounds, a classical lesion in the practice of prison medicine. Proctological lesions, attributed on the one hand to a lowfibre diet, and on the other to the incidence of homosexuality in prisons, are a frequent cause of hospitalization. While managed surgically, the ingestion of foreign bodies such as nails, needles, forks and the like in suicide attempts is, in general, treated conservatively; it is usually only necessary to keep such patients under observation until the objects are eliminated by natural processes.
Psychiatric disorders
Psychiatric disorders at the maximum-security hospital ward, shown here to account for only 6.6 per cent of admissions, represent only those conditions requiring psychiatric intervention alone; suicide attempts resulting in serious harm are classified according to the final physical diagnoses. While hunger strikes are included in this category, psychophysiological disorders and suicide attempts resulting in injuries or illnesses which must be medically or surgically treated are not. Cardiovascular disorders
The symptoms most often found in cardiovascular disorders, which account for 6.5 per cent of medical and 2.2 per cent of surgical admissions, is retrosternal pain. In some cases, myocardial ischaemia can be readily demonstrated, but often the persistence and intensity of subjective complaints makes it difficult for cardiologists to establish a definitive diagnosis, even by exclusion in cases where solid clinical evidence is totally lacking. In some cases the exaggeration of the symptomatology is directly related to the judicial situation of the patient. Neurological disorders
Neurological disorders (6.3 per cent of hospitalizations) are essentially represented by seizures, most frequently due to withdrawal from alcohol, and by organic impairment of the central nervous system, which more and more is seen to be the neurological manifestation of AIDS. Reconstructive hand surgery
Reconstructive hand surgery accounts for 6.3 per cent of total hospitalizations. This is due to the high incidence of suicide attempts by wrist-slashings, resulting in severed tendons, nerves and blood vessels. Such self-destructive acts are particularly common among young drug addicts and are considered an acute reaction to the stresses associated with incarceration. HIVvirus
It was not until 1987 that infection of the HIY virus has been considered to require hospitaliz-
340 Med. Sci. Law (1992) Vol. 32, No.4
ation. In 1987, 6 patients were hospitalized; in 1988, 8 patients; and in 1989, 14 patients. It is important to distinguish the various causes for hospitalization, for instance, cases of serious opportunistic infection, major low platelet count, etc. Positive HIV infection is found among 10 to 15 per cent of the Swiss prison population. CORRELATION OF OFFENCES AND MEDICAL DISORDERS
While this comparison may appear surprising at first glance, practice suggests a possible correlation between type of offence and (clinical) type of disorder. Prisoners charged under federal narcotics laws are nearly always drug addicts and, consequently, their hospitalization is nearly always directly related to their addiction, i.e. hepatitis or AIDS. Even more striking is the correlation between white-collar crime (breach of trust, embezzlement, fraud) and psychosomatic or psychophysiological disorders, whether of the gastrointestinal or the cardiovascular system. In the large majority of cases, those accused of white-collar crimes belonged to middle or toplevel management and were socially prominent prior to their arrest. Most have been arrested for the first time and initially find it very difficult to adjust to prison life. They may experience intense psychological and emotional suffering related to the social stigma and humiliation of imprisonment. Those who cannot or will not allow themselves to talk about their inner suffering appear to be the most severely affiicted. Clinically, their anguish is manifested in such symptoms as atypical chest pain, anorexia, dyspepsia, significant weight loss, disorders of the urinary tract and the like. As a result, physicians are likely to see quite different clinical pictures in persons arrested for armed robbery, and those accused of fraud. It has also been observed that persons arrested in Geneva for not paying their hotel invoice, very often display total confusion. For this reason, the courts frequently dismiss the case against them and order them committed to a psychiatric facility for treatment. Chronic alcoholics are the one class most frequently arrested for unpaid fines. Physicians
alert to this correlation are in a better position to take measures to avoid the onset of lifethreatening delirium tremens. Despite often misleading appearances, it should be emphasized that imprisonment generally entails genuine emotional pain and suffering, particularly in the first few weeks or months of confinement prior to arraignment, because of the social stigma attached to it or merely because of the hardships associated with confinement in a prison setting. Physicians treating prisoners in a hospital should always bear in mind the reality of this two-pronged source of suffering and acknowledge its implications for the outcome of case management. The part played in illness by the ~ailhouse blues', clinically manifest as more or less latent depression and anxiety, should never be overlooked. Prisoners, like others, need to express their anguish; it would be unconscionable to ignore their formulations of suffering and doing so could result in total failure of treatment, even where purely medical measures have been carefully planned and carried out. CONCLUSION
Medical practice in a prison setting is specific in several respects. The most obvious measure of this specificity is the type of medical disorders for which prisoners most frequently seek treatment. But just as specific is the therapist's ability to acknowledge and accept prisoners' expressions of pain and suffering. On a small prison ward such as the maximum-security medico-surgical unit in Geneva, physicians and nurses constantly interact with security personnel. The roles and objectives of the medical and security teams often enter into direct conflict with each other, so that it is necessary to renegotiate mutual relations and goals on an on-going basis. Minimum standards for the treatment of prisoners recommended by the Council of Europe clearly define prisoners' rights to health care. The level of care should be equal to that available to the general population. This condition can be fully implemented when prison medicine is completely co-ordinated with the services of a general hospital.
Maximum-security Hospital Ward J P RESTELLINI Institut Universitaire de Meaectne Legale, 1211 Geneve 4, Switzerland INTRODUCTION
The Division of Prison Medicine is attached to the Department of Forensic Medicine of the University of Geneva. Its three components are the dispensary at Champ-Dollon Remand Prison, an extra-mural maximum security psychiatric ward and an extra-mural maximumsecurity medical and surgical ward. The maximum-security medical and surgical ward provides a full range of medical services to prisoners under the jurisdiction of the courts in French and Italian-speaking Switzerland. It is situated on the ground floor of the University Hospital. Because it is housed in a modern, well-equipped and academically oriented facility, its physicians have ready access to sophisticated medical and surgical services equal in every respect to those available on other wards in the hospital. Specially trained prison guards ensure security on and off the ward. BED CAPACITY AND OCCUPANCY RATE
Between 110 and 120 patients are admitted annually to the medico- surgical ward, which contains five semi-private rooms with a total of ten beds. Several factors - some clinical, some nonclinical - combine to restrict the maximum occupancy rate. For instance, isolation may be ordered to prevent the spread of contagious diseases or to protect a patient affected with immune-depressive disease; departmental policy prohibits assigning a male and a female patient to the same room; examining magistrates have the authority to impose isolation of a patient on the ward, for example, to protect a minor or to enforce a gag order. Moreover, prison officials are empowered to require isolation of patients for security reasons:
experience shows that confining persons with personality disorders - more prevalent among prisoners than in the general population to close quarters with others for extended periods of time often leads to physical violence or other undesirable behaviours. And the real admittance capacity is largely reduced, to a half sometimes, when the five hospitalized patients must be kept in isolation. AVERAGE AGE
The average age of patients admitted to the medico-surgical ward is about thirty years, the same as that of the general Swiss prison population. This contrasts sharply with the higher average age, near geriatric, for patients admitted to other wards in the hospital. MOST FREQUENT DIAGNOSES
The graph (Figure 1) shows the 682 admissions divided into different categories, depending on the kind of ailment, from January 1984 through December 1989. We have divided the total number of admissions into two broad categories, i.e., those requiring mainly medical and those primarily requiring surgical (including orthopaedic) management. The graph represents the percentages of total admission accounted for by each entrance diagnosis category. FINDINGS AND INFERENCES Orthopaedic Management
Admissions requiring orthopaedic management clearly predominate. The overwhelming preponderance of traumatic injuries diagnosed in prison is attributed to two main factors: the more energetic physical activity of a youthful
338 Mad. Sci. Law (1992) Vol. 32, No.4
Figure 1. Types of disorders requiring hospitalization
Medical
Gastrointednllp U 6.3
C8rdIoYucuIar Neurological Rheumalologlcal
U
5
p~
3.2 2.9 2.5
Onco-inmunologlcal Infeclioul Endocrinological
2.2
Drug liluse (ovtrcloS&llCU1l wihlrlwlll)'lllpbnl) NepIvoIogical
1.8 1.5 1
Hemalobglcal
Sur lcal
Or1hopedic!EE~;:==:-::-10.6
GaslroinIMtinaI Recol1llructlon of Itle hand Maxllofacial CardioYlSCUIar
Others
__
17'3
3.5 2.2
Neurosurgical
1.9
Genilourinaty Plastic surgery Thoracic
1.9
lallUes
--===~~.
Psychiatric 6.6 3.8 ENT-J Dermatological 1.3 Gynecological 1.2 Ophtalmological ~.....!1--'-_---Y _ _~_-r-_-.-_-._---.-_--I
o
5
10
15
20
In" in relalkJn 10 /he total ofhospi1alisaJlons
group and the above-average tendency towards physical violence found in a prison population. Sports Injuries are frequent among prisoners, particularly among those still under investigation and awaiting arraignment, because they are confined to closer quarters and are allowed less time for physical exercise than other prisoners. As a result, they may plunge into strenuous sports activities without ade-
quate warming-up exercises and often sustain severe sprains, bruises, pulled muscles, ligaments and tendons. Acts of violence are more frequent among prisoners than in the general population and resulting injuries may be serious enough to require hospitalization. Significant injuries may also occur during resistance to arrest. Persons treated for injuries
Restellini: Maximum Security Hospital Ward 339
sustained in automobile accidents may be detained by the police in the emergency room of a hospital if they are found to have been driving under the influence of alcohol. If their condition is serious, persons injured in these ways may be sent directly to the medico-surgical ward rather than to gaol. Gastrointestinal disorders
While trauma constitutes the largest single final diagnosis in either broad category responsible for hospitalization on the medico-surgical ward (17.3 per cent of total admissions), gastrointestinal disorders follow close behind, whether surgically (10.6 per cent) or medically (8.9 per cent) managed. Taken together, surgically and medically managed gastrointestinal disorders constitute the overall most significant cause for hospitalization, accounting for over 19.2 per cent of total admissions. Among the medically managed conditions are liver disorders related to intravenous drug use, a frequent cause of hospitalization; it is estimated that at any given time from 20 per cent to 60 per cent of the prison population may be made up of habitual or occasional intravenous drug users. Lesions of the gastroduodenal lining are frequently caused by the stress associated with incarceration and the excessive use of tobacco (tabagism) in which confined persons with unstructured time on their hands are likely to indulge. Significant weight loss due to psychophysiological disorders of the digestive system also account for many hospitalizations. Surgically managed conditions include abdominal stab wounds, a classical lesion in the practice of prison medicine. Proctological lesions, attributed on the one hand to a lowfibre diet, and on the other to the incidence of homosexuality in prisons, are a frequent cause of hospitalization. While managed surgically, the ingestion of foreign bodies such as nails, needles, forks and the like in suicide attempts is, in general, treated conservatively; it is usually only necessary to keep such patients under observation until the objects are eliminated by natural processes.
Psychiatric disorders
Psychiatric disorders at the maximum-security hospital ward, shown here to account for only 6.6 per cent of admissions, represent only those conditions requiring psychiatric intervention alone; suicide attempts resulting in serious harm are classified according to the final physical diagnoses. While hunger strikes are included in this category, psychophysiological disorders and suicide attempts resulting in injuries or illnesses which must be medically or surgically treated are not. Cardiovascular disorders
The symptoms most often found in cardiovascular disorders, which account for 6.5 per cent of medical and 2.2 per cent of surgical admissions, is retrosternal pain. In some cases, myocardial ischaemia can be readily demonstrated, but often the persistence and intensity of subjective complaints makes it difficult for cardiologists to establish a definitive diagnosis, even by exclusion in cases where solid clinical evidence is totally lacking. In some cases the exaggeration of the symptomatology is directly related to the judicial situation of the patient. Neurological disorders
Neurological disorders (6.3 per cent of hospitalizations) are essentially represented by seizures, most frequently due to withdrawal from alcohol, and by organic impairment of the central nervous system, which more and more is seen to be the neurological manifestation of AIDS. Reconstructive hand surgery
Reconstructive hand surgery accounts for 6.3 per cent of total hospitalizations. This is due to the high incidence of suicide attempts by wrist-slashings, resulting in severed tendons, nerves and blood vessels. Such self-destructive acts are particularly common among young drug addicts and are considered an acute reaction to the stresses associated with incarceration. HIVvirus
It was not until 1987 that infection of the HIY virus has been considered to require hospitaliz-
340 Med. Sci. Law (1992) Vol. 32, No.4
ation. In 1987, 6 patients were hospitalized; in 1988, 8 patients; and in 1989, 14 patients. It is important to distinguish the various causes for hospitalization, for instance, cases of serious opportunistic infection, major low platelet count, etc. Positive HIV infection is found among 10 to 15 per cent of the Swiss prison population. CORRELATION OF OFFENCES AND MEDICAL DISORDERS
While this comparison may appear surprising at first glance, practice suggests a possible correlation between type of offence and (clinical) type of disorder. Prisoners charged under federal narcotics laws are nearly always drug addicts and, consequently, their hospitalization is nearly always directly related to their addiction, i.e. hepatitis or AIDS. Even more striking is the correlation between white-collar crime (breach of trust, embezzlement, fraud) and psychosomatic or psychophysiological disorders, whether of the gastrointestinal or the cardiovascular system. In the large majority of cases, those accused of white-collar crimes belonged to middle or toplevel management and were socially prominent prior to their arrest. Most have been arrested for the first time and initially find it very difficult to adjust to prison life. They may experience intense psychological and emotional suffering related to the social stigma and humiliation of imprisonment. Those who cannot or will not allow themselves to talk about their inner suffering appear to be the most severely affiicted. Clinically, their anguish is manifested in such symptoms as atypical chest pain, anorexia, dyspepsia, significant weight loss, disorders of the urinary tract and the like. As a result, physicians are likely to see quite different clinical pictures in persons arrested for armed robbery, and those accused of fraud. It has also been observed that persons arrested in Geneva for not paying their hotel invoice, very often display total confusion. For this reason, the courts frequently dismiss the case against them and order them committed to a psychiatric facility for treatment. Chronic alcoholics are the one class most frequently arrested for unpaid fines. Physicians
alert to this correlation are in a better position to take measures to avoid the onset of lifethreatening delirium tremens. Despite often misleading appearances, it should be emphasized that imprisonment generally entails genuine emotional pain and suffering, particularly in the first few weeks or months of confinement prior to arraignment, because of the social stigma attached to it or merely because of the hardships associated with confinement in a prison setting. Physicians treating prisoners in a hospital should always bear in mind the reality of this two-pronged source of suffering and acknowledge its implications for the outcome of case management. The part played in illness by the ~ailhouse blues', clinically manifest as more or less latent depression and anxiety, should never be overlooked. Prisoners, like others, need to express their anguish; it would be unconscionable to ignore their formulations of suffering and doing so could result in total failure of treatment, even where purely medical measures have been carefully planned and carried out. CONCLUSION
Medical practice in a prison setting is specific in several respects. The most obvious measure of this specificity is the type of medical disorders for which prisoners most frequently seek treatment. But just as specific is the therapist's ability to acknowledge and accept prisoners' expressions of pain and suffering. On a small prison ward such as the maximum-security medico-surgical unit in Geneva, physicians and nurses constantly interact with security personnel. The roles and objectives of the medical and security teams often enter into direct conflict with each other, so that it is necessary to renegotiate mutual relations and goals on an on-going basis. Minimum standards for the treatment of prisoners recommended by the Council of Europe clearly define prisoners' rights to health care. The level of care should be equal to that available to the general population. This condition can be fully implemented when prison medicine is completely co-ordinated with the services of a general hospital.
