The following story is one of my husband’s war stories. He worked for the Michigan Department of Corrections from 1990-1998.
Almost a decade ago now, in the late spring of 1996, was the timeline of this incident. My husband had been very satisfied with his career initially, but as time went on things had seemed to change both on the job and how it was impacting him and our family.
He had been injured in an incident in December 1994 and continued to work in spite of his injuries. Near the end of 1995, I left him and moved into my own place because of the stress that he carried home with him and the unrelenting tension he seemed to be under.
This is his report:
An inmate died in the spring of 1996 of severe medical neglect in what any reasonable person would consider “cruel and unusual punishment”, the inmate died of kidney failure and laid on the floor of his cell for an extended period of time, days not hours, in a fetal position.
He would occasionally go into convulsions and after a few minutes of violent shaking would once again lay motionless until the next round of convulsions. These convulsions were found to have been caused by the build up of electrolytes in his body because his kidneys were no longer working and he would convulse involuntarily until the lactic acid built up in his muscles and severe cramping stopped the convulsions.
After a time the cycle would begin again and repeated itself many times until he finally died. This happened in the Aspen Segregation Unit at the Alger Maximum Security Prison in Munising, MI.
I was on duty on the yard as a Corrections Officer and escorted the ambulance that hauled his dead body out of the institution and to the hospital for autopsy the day he died.
For several days before and after the death, I had been hearing out the concerns of my co-workers regarding the decision of the administration not to intervene. This event had not gone unnoticed, that’s not the way things work in a modern maximum security prison.
The prisoner and his deteriorating condition had been under regular observation of the staff on duty in Aspen Unit as well as Health Services Staff. These reports were being taken directly to the Administration by Ruby Cheatham, the RN who at that time was in charge of Health Services at Alger Max.
The Administration was fully aware of the fact that this man was down on the floor and was exhibiting this behavior. This was not the first time this prisoner had episodes like this, the inmate was at times paranoid and had refused his meds before and similar episodes required staff to enter his cell and assist his recovery.
The decision was made by the Administration that they would adopt the position that the inmate was faking his illness and manipulating staff for extra attention and that no intervention would be ordered; they would call his “bluff”.
It was obvious and known to the staff assigned to observe him on a regular basis (hourly minimum) and responsible for his care, that it wasn’t a manipulation and that this man would eventually die on the floor of his cell if no intervention was made. Despite the protests and better judgment of the officers on duty in Aspen Unit, aid was withheld and the prisoner was left to die.
Afterward, logbook entries and reports disappeared and the investigation was focused on a single RN from the Health Services who had the misfortune of being on duty and called to Aspen Unit when it was decided to remove the inmate from his cell. The inmate was then in the early stages of riga mortus and CPR was pointless.
The RN was familiar with the circumstances and had properly reported them and had simply followed the standing orders not to intervene. When the cover-up began she was trying to defend herself and actions and get copies of the documentation she had submitted beforehand.
A stop order was placed against her and she was barred from working and entry into the facility pending the outcome of the investigation. I know this first hand; I was assigned to entry control duty and personally was ordered to deny her access.
She happened to be a friend of mine and we were small town schoolmates. I’d also come to have a deep respect for her and the way she handled the very difficult job she was asked to do at the prison. She’s rather attractive and it’s a difficult environment for anybody to work in, especially an attractive female.
We’d graduated in 1976 from the same High School Class and were a short time away from our 20th class reunion when these events unfolded. She was devastated, her career was in limbo and she was concerned that she’d lose her nursing license altogether.
I’d like to tell you that what had happened to the inmate was my chief concern at the time. That would be a lie. Other than the extreme suffering he must have endured waiting for death, both physical and mental, I personally regarded him to be better off dead. He was doing life with no chance of parole and had been doing it the hard way.
It was for the trauma that the experience caused for the staff involved and the fact that all questions of culpability were directed at the RN who had done her job as she understood it. I also didn’t like the pressure and heavy handed tactics that were used upon me to try to get me to clam up.
I saw it as a slippery slope situation and the only way to prevent recurrence was for staff to take the attitude that this type of negligence would not be tolerated or engaged in by the line level staff, no matter the position of the Administration or State Government in general.
No criminal investigation was ever undertaken and though the inmate’s family did eventually sue the MDOC, I believe the death was ruled to have been caused by natural causes and I don’t know the details of the settlement.
Within six months of the incident, as the pressure continued and the threats continued, I finally went to a different physician with my ongoing complaints and pain from the undiagnosed spinal injury from that was then almost two years old.
Once the disk herniation was imaged and I’d seen a specialist he immediately advised that I was to have no more inmate contact, since another incident could result in paralysis. My spinal cord was already severely compromised.
I was accommodated with light duty positions to for several weeks while the Administration helped to make the arrangements for me to be seen at the Mayo Clinic in Rochester, MN. I was supposed to be rotated working entry control, alert vehicle and gun post. They kept me on gun post. That way I was out of the loop and having only limited contact with the rest of the staff and only by phone, my conversations could then be monitored.
When I was initially evaluated at Mayo, I was offered surgery the next day. I decided to wait and consider all that I’d been told, since I now had two opinions and they were recommending different surgeries. The Mayo recommendation was for a single level diskectomy and fusion with no plate and the Marquette neurosurgeon had recommended two levels with a plate.
When I returned the without having the surgery, I was called in and ordered to report to the shift commander Captain Dave Place when I was home and off duty. This was almost unheard of. When I reported to work for regular duty afterward, I was called to the personnel office with my union steward.
The Administration refused to allow me to continue to work in a light duty or non-contact position because they wanted me out of the institution and out of circulation, and away from the staff at the facility.
The Michigan Department of Corrections was under heavy scrutiny during this period by the Human Rights Watch for the sexual exploitation and reprisals against female prisoners for reporting these abuses downstate.
Everybody has heard of the “blue line” regarding the code of secrecy amongst the ranks of the nation’s police forces. The prisons are even tighter and exploit the latest technologies to enforce this code.
Citizen’s today complain of the lack of privacy due to the “Patriot Act” but the State of Michigan has exploited the “electronic emissions” from the homes of individuals for years before the “Patriot Act” was ever drafted.
They counted on this technology to suppress dissent and monitor who is communicating with whom for the sake of “institutional security”. This unseen control allows for the manipulation of individuals and their circumstances.
Anyway, I was forced off the job completely until I had a release that would allow me to work without restriction. There would be no retraining for another assignment and I was told they didn’t even want me to come on property. I might slip and fall. That was the thanks for struggling to remain on the job for over two years trying to work through a serious injury.
They put me out on a one year unpaid medical leave of absence. After being off for 6 months I rescheduled to be seen again at the Mayo Clinic.
I finally opted for the less invasive of the two procedures and returned to the Mayo Clinic for treatment in November, 1997.
What happened to me at the Mayo Clinic is a horror story in and of itself. You’d think my tale to be straight out of Nazi Germany, certainly not something that would happen to somebody in Rochester, MN in 1997.
I was supposed to have a single level diskectomy and auto graft fusion at the C6-C7 level. A fairly simple operation performed frequently by the staff at the clinic. The graft was to come from my iliac crest (hip) and be shaped to fit the interspace between the vertebras after the disk was removed. Though the disk was removed as planned, as was the bone from the donor site on my hip, no graft was placed in the interspace between the vertebras.
This was not a mistake or an oversight. It was a deliberate act. When I became conscious after the surgery I was surrounded by four men. The three I saw, I have no recollection of seeing prior or since. On my right side was a Caucasian male, at the foot of the table was a large African American male and on the left side of the table was an oriental man. The fourth person was at the head of the table and out of sight. They had taken a bag of fluid and filled my bladder and removed the catheter. The Caucasian male on my right and the oriental on the left side were both pressing down on my abdomen and the African American had my penis clamped in his hand so that no fluid would be expelled. The Caucasian male was saying to me you must really have to pee, don’t you. The protective Aspen collar had already been placed on me and when I tried to sit up to object to what was going on, the man behind me grabbed my head and attempted to twist my head towards my right. Almost immediately I laid flat again and reached with my hands to brace my own head and began to yell quite loudly asking them what were they trying to do and bitching about how the man behind me had the collar all twisted around on my neck. The black man re-inserted the catheter and this relieved the pressure on my bladder and they all backed off and left the room while others came to take their place and bring me back to my room.
I tried to calm myself down and felt very much at risk in the condition I was in and didn’t say anything more to anybody until I was taken back to my room and reunited with my wife.
I was afraid to even tell her what had happened for fear of being overheard and didn’t really explain to her about it until I was checked out of the hospital.
I told my parents of the experience afterward and they couldn’t believe it was a deliberate act, but thought it was a misinterpretation of what actually happened because of the anesthetic.
I had then and still have vivid and precise memories of those moments and they were/are etched in my mind like a slow motion video. I described the characters involved and was only this year able to find their identities by blowing up some of the pages of my medical records and then doing some searches on the Internet till I was able to find pictures of the men involved. They are as I described them at the time to my wife and parents.
These are the men directly responsible for what was supposed to have been an anterior approach diskectomy and auto graft fusion of the C6-C7 levels of my cervical spine done 11/12/97. Bone was removed from my right hip, however no graft was placed as is apparent in the follow up x-rays.
John L. D. Atkinson, upper left, Robert J. Spinner, upper right. Lower left, Yoshihiro Yamamoto, and lower right Geoffrey R. Dixon, all practicing neurosurgeons today.
Robert J. Spinner, M. D. was an assistant to Dr. Atkinson in the surgery and the other two were interns at the time and this was part of their learning experience at the Mayo Clinic. They are all practicing surgeons today though only Atkinson and Spinner remain at the Mayo Clinic in Rochester, MN.
The following day I was looked in on by another doctor who came to check on the small bottle that was attached to the drain tube that was stitched into the wound in my neck. He asked if any one else had changed the bottle. I told him I didn’t think it had been emptied or changed that the contents in it were all that had come out of the tube; he looked pissed and removed the bottle which was taped to me and yanked the tube from my neck as he spun out of the room. My wife was with me at the time and couldn’t believe her eyes. I got dressed and we proceeded to get me packed and checked out of the St. Mary’s Hospital in Rochester, MN.
I believe this man was Jay Smith, M.D.
who had examined me originally when I was first appraised for surgery at the Mayo Clinic earlier that year in February.
Now this might lead one to wonder what the motive to have been for the actions of these men in the post surgical escapade. Dr. Atkinson had been spoken of a “life worse than death” several times to me when describing the potential for paralysis which though was extremely low. They had also seemed to be somewhat upset by the fact that I had no advance directives regarding organ donation had something gone seriously amiss and wasn’t interested in drafting one. I believe that the intent was to have me awaken with the memory of pain in my abdomen caused by the pressure on my bladder and when I sat up to resist to break my spinal cord at the point of C6 and C7 where the disk had been freshly removed. During surgery they had done a great job removing the edges where the vertebra would meet and without a graft in place the bleeding bone surfaces would slide easily against one another. If the unseen man whom I believe to have been Atkinson had been able to give my head the right spin, it should have resulted in paralysis.
Of course it would have been described as some sort of accident with me falling off the table in my embittered and coming out of the anesthetic word against the 4 of them. I imagine they would have taken me back into the OR and tried to repair whatever damage had been done and place the graft for the purpose of later examination or autopsy.
It seemed at that point I was deemed a major liability to the system and worth less alive, whole and speaking than muted, maimed or parted out.
Even if I’d been left to live paralyzed, it’d definitely have kept me in a situation where I’d be unlikely to say anything or pursue any legal recourse for the ill treatment I’d been subjected to by the Administration and their pet staff at Alger Max. I certainly wouldn’t be speaking of that which they were so concerned with keeping quiet regarding the dead inmate and the hassle to which they subjected my friend the RN.