Friday, July 21, 2006

The CIC ICU

Everyone once in a while we get someone coming into the facility fresh off the streets who, as the correctional officers put it, "ain't looking too good". That's a correctional euphemism for "totally out of it". This can be a problem if the person is too psychotic to give his name or to cooperate with fingerprints. It can be very hard to book these guys, particularly if they're in a fighting mood. These are the folks I worry about---the inmate with no available record, who can't give a history, and whose mental status change is unexplained. These are the folks who end up having meningitis or neuroleptic malignant syndrome or delirium tremens or benzodiazepine withdrawal and who can end up DIC (Dead In Cell).

The challenge is to get the guy out of the facility and into an emergency room where the appropriate diagnostic workup can be done. Now you would think, since they're in custody already---in handcuffs---that this shouldn't be an issue, but it is. The physical transportation is the easy part---the bureaucratic nightmare is figuring out who should do the transportation. You see, the legal boundary line for jurisdiction between the local police and correctional staff is somewhat fluid, particularly for pretrial detainees who haven't been booked into the facility. Custody's view is that the arrestee belongs to the police up until the booking process is complete. The police believe that the arrestee becomes the property of the correctional facility as soon as they're dropped off and the officer has left. The police officer isn't going to want to come back, and the correctional command staff isn't going to want to give up an officer to stand watch at an emergency room. If you have someone with the appropriate licensure available you can do the paperwork for an emergency psychiatric evaluation, but then you have to deal with the hospital bureaucracy---not all hospitals accept emergency psych patients. If you don't do the emergency evaluation paperwork, they may refuse the patient completely---they "don't accept" psych patients from the jail. (Wow, where can I get away with saying we 'don't accept' someone at the jail?) Eventually I can get the inmate transported by pulling aside the duty lieutenant or the major and using the DIC issue. As in, "Look, I know this is a pain in the butt but this guy could end up being Dead In Cell if we don't do this." At that point the reaction I get is, "Oh, you mean he's not a psych patient?" and I go through an explanation of idiopathic versus non-idiopathic psychosis. Quickly summed up, I say: "I have to know what's wrong with his brain." Out they go.

So anyway, this is why I developed the CIC. Every correctional clinician with a fair amount of experience has one of these carried around in the back of his or her head. It's a short list of every well-known psychotic inmate who gets arrested in an "ain't looking too good" state. I call it my Comes In Crazy list. The CIC list does what the facility can't or doesn't do---it's an institutional memory of our sickest patients. The nursing staff turns over frequently enough that they won't know these guys, but give me a name and I can sometimes even remember the first time I met the person. Sometimes I can make an identification based on delusional content alone. And the inmates like that. They like being remembered. Like Cheers, they are coming to an institution where "every doc knows your name". Welcome to the CIC ICU.