Last Human Standing

I woke up this morning thinking about my friend Farina Endfen, certainly because of our plans to have lunch today. But I think about her a lot, with great admiration for the work she does. Farina is a Physician Assistant in a prison in Ohio.

Before she made a mid-life career change to be a PA, she was a medical social worker. She worked in a hospital in Detroit, on a unit for closed-head injuries. Many of the patients had been gunshot. At least once, they had two patients at the same time who were members of rival gangs, and when their friends came to visit them things could be...tense. One of her jobs was finding people long-term placements when their time in the brain injury rehab unit ended. All the social workers knew that people's options were limited, and that they sometimes--often?--placed people into substandard facilities because there were no other options. But they would keep looking, hoping to find something better.

Except, it seemed to Farina, that in staff meetings to discuss case dispositions, her boss was more inclined to encourage the social workers to keep looking if the patient was white, and more likely to encourage them to make a quick and easy placement into a bad facility if the patient was black. So she said so. And then she started refusing to disclose her patients' race during these meetings.

Because that is the kind of thing she does.

She worked as a social worker in a community health center, and, after earning her second master's and becoming a PA, in the worst hospital in Detroit. Resources were scarce, there were more patients than beds, and many of her patients were gun shot victims or addicts, some of them with septic wounds from injecting with dirty needles, some of them with assorted diseases and injuries, and some of them just drug-seeking.

One of the things I've always respected about her is that she has always worked with poor people, with addicts, with criminals, and it's not that she doesn't judge so much as she is able to maintain her sense of these folks as human beings. Even when a drug-seeking addict is trying to manipulate her into giving him drugs, she still feels compassion. And on the occasions when they succeed--like when a patient at the prison clinic got her to write a Vicodin prescription for him and then was seen playing basketball in the yard an hour or so later--she doesn't take it too hard. She figures they don't get past her too often.

She likes some things about her work at the prison. One benefit of working with underserved populations is that she has more independence as a PA than she would have elsewhere. She gets to diagnose, for instance, which she likes. And she gets to do lots of minor surgical procedures, which she loves and is good at, in part because the guys at the prison get lots of boils and infected toenails (which she is terrific at removing, but whatever you do don't let her describe the process, and for God's sake don't let her show you the pictures). They also get lots of wounds that need to be stitched up, and while she doesn't like it that they go around poking each other with sharpened things, she does a great job fixing them up.

She likes being able to say to me, "Hey, wanna see what I took out of a guy today?" and pull a bullet out of her pocket. She has a whole collections of bullets she's taken out of people. Over months or years they work their way near to the surface, or into an uncomfortable place, and if one is bugging a guy, she'll remove it for him.

Other things, she doesn't like so much. She hates the bureaucratic stupidity that bans anything that could be a potential weapon, but then issues heavy padlocks to the prisoners. A padlock in a sock, it turns out, makes a great bludgeon and leaves a very distinctive crescent-shaped would. Farina has treated many of these wounds.

She doesn't mind the murderers, she says. And, while she can spot a domestic abuser right away because of their transparent attempts to dominate her space, she can hold her own with them. What she has more and more trouble dealing with are the child molesters and rapists. I remember she had one guy, a rapist if I remember correctly, brought to her with a broken leg. All she had to do was relieve his pain and stabilize him for transport to the ER. She didn't want to. She didn't want to relieve his pain. She didn't want to handle his leg in the least painful way possible.

She did it. She made herself do it. But she didn't want to.

A few months ago she had a patient who had drowned his two toddlers in the bathtub, not all that long ago. Uncharacteristically, she asked the corrections officer who accompanied him to come into the exam room--usually they wait outside. "Scared of this guy, huh?" the officer said to her. "No," Farina said. "I'm afraid if someone else isn't in there I won't behave appropriately."

Usually the patients are well-behaved with her. She has something they want, she says, and she treats them well. Indeed, she has a reputation among the prisoners for being competent and respectful. She's been at the prison a few years now, and the rotating staff of doctors have one important thing in common: they are all incompetent. More than once she has resolved a patient's long-term problem by making a diagnosis that, she says, is "first-year med school stuff," but which had been missed for months or even years. But the doctors just don't look at the patients enough. They just don't care enough. And they just don't know enough.

One day, on her way out of work, a prisoner called from the yard to thank her for arranging for his transport to the nearby city hospital for a test he needed. But when would he get his results? he asked. "Oh, you're scheduled with Dr. So-and-so on Monday, he'll take care of you," she answered. The man said, "He'll see me, but we all know it's you who takes care of us."

One patient did grab her breast one time. She stepped back, yelled, and pushed her panic button. Nearby staff, hearing her yell, also pushed their panic buttons. This shuts the whole prison down: the officers get the prisoners back to their cells, a little squadron comes on the trot to where the button was pushed. The prisoner ends up in solitary.

It's not funny, of course. But she was getting ready to remove a growth on his neck at the time. I can't help wondering how stupid or desperate you need to be to grope a woman who is literally bending over you with a scalpel to your throat.

All of this is old news. Farina's been telling me these stories all along, usually with a good dose of gallows humor. But a month or two ago, we were out to dinner with an old friend who was passing through town, and in response to some of his questions, she got talking about dealing with rapes.

The corrections officers, she says, collude so as not to witness rape. The staff on the night shift see nothing and hear nothing. All rape victims are found in their cells by the morning staff. The assumption is that there was a fight, and both parties are treated as potential perpetrators until there can be a hearing, usually after a week or more. In the meantime, they're brought to the clinic in shackles and then kept in isolation until the hearing.

If Farina is on staff that morning, she will treat the victim on-site. This means examining him in shackles, with an officer present, and doing any treatment she needs to--stitches, for instance, are common--under those conditions as well. But the benefit of treating them there instead of transporting them to the hospital is that she knows she will do a good job of stitching, and she will be as compassionate as she can be, and she won't add to their trauma by being abusive.

The corrections officers, she says, are exactly as the stereotypes would lead you to expect. They are ignorant, brutal, racist, and homophobic. But it behooves her to cultivate good relationships with them. She does this by treating minor wounds, and by writing them antibiotic prescriptions for the STDs they routinely acquire.

She keeps a careful mental tally of just how high her standing is with the officers. "If it's high enough," she says, "once in awhile I can ask for something that will make things easier for a rape victim. I can get his shackles removed for his exam, or I can get the officer to step outside so he can tell me honestly what happened, or I can just show him more sympathy when he cries than the officers would normally let me get away with."

"How often do you deal with this?" I asked.

She said, "Two or three times a week." Two or three days a week she comes into work and examines a shackled and brutalized rape victim who will then be put into isolation for a week or more. Once in awhile, if she writes enough antibiotic prescriptions for a bunch of guys who don't know enough to wear a condom, if she ignores enough racial slurs and homophobic cracks over enough days and weeks, she can take this little pellet of goodwill she has earned and spend it to make that exam just a tiny bit less terrible.

She can do nothing, she says, for the gay prisoners, for the trans prisoners. The culture is too toxic; there is not enough goodwill in the world. There is a crack she can pry open just a hair so she can get this prisoner a CT scan, or that prisoner a better diagnosis and appropriate treatment for a leg injury, or the shackles taken off one rape victim in, what, 20? 30? But the homophobia is an impenetrable wall.

She's going to leave the prison before too long. I hope so, anyway. I'd like to see her working in a nice clean well-stocked suburban clinic, treating, oh, poison ivy and splinters, doing punch biopsies on suspicious moles and stitching up the cuts people get trying to open cans of cat food. Where nobody gets shivved, and she doesn't have to carry a panic button in her pocket or be searched on the way into work, and rape is not part of her daily life. She has done her share, and more. She deserves the easy job now.

But I'll be sorry, too, just like I was when she left the addicts and drug-seekers and gunshot victims in Detroit. Because it so often looks to me like she is the last line of defense between these people and the complete inhumanity of the institutions they are trapped in. She is the last human in their lives, because she is the only one who sees their humanity.