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Side Effects

Whenever someone handed Pharmacist Bob a prescription for thirty pills, he filled the order for thirty pills. "Not 29. Not 31," he says. "Thirty. That's how I see the world." So when he started seeing nurses fudging the rules at the Colorado prison where he worked, Bob Gusich didn't like...
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Whenever someone handed Pharmacist Bob a prescription for thirty pills, he filled the order for thirty pills.

"Not 29. Not 31," he says. "Thirty. That's how I see the world."

So when he started seeing nurses fudging the rules at the Colorado prison where he worked, Bob Gusich didn't like it. In fact, he voiced his objections to the management. And then, suddenly, he was fired.

In his 32-month tenure as the lone pharmacist for the Denver Reception and Diagnostic Center, or DRDC, Gusich says he complained about pills being given to prisoners they weren't intended for. He protested the haphazard storage of narcotics and opposed the department's hiring of a recovering substance abuser to help him fill prescriptions. During a stint at a different Colorado Department of Corrections pharmacy in Cañon City, Gusich was appalled to find an unsupervised inmate cleaning the well-stocked pharmacy, expired drugs on the shelves, and razor blades and sharp scissors left within prisoners' reach.

He also saw a lot of money going down the drain.

A 1996 look at the DOC's inmate health-care system by the state auditor's office revealed that while Colorado spent about $25 million on inmate medical services that year, it had no idea exactly how inmates use -- or abuse -- the system. "Colorado inmates, on average, use health-care services about five times as often as the general public," the auditor's report concluded. Yet the DOC had no records about when and why inmates seek treatment and had not analyzed the appropriateness and necessity of its 285 clinical staff positions. The state's aging and burgeoning male prison population and the growing number of incarcerated females, who tend to have more expensive medical needs than males, could make inmate health-care costs rise even higher in coming years.

Which is why Gusich didn't mind raising a stink about how nurses were letting hemophiliac drugs that cost hundreds of dollars a bottle expire on the shelves; or about doctors who were writing huge prescriptions for painkillers to inmates who'd strained themselves while weightlifting or playing testosterone-soaked basketball games during prison rec time. The reforms he suggested, Gusich insists, could save the DOC more than half a million dollars a year. If someone would listen.

Fired in July 1997, Gusich later sued the Department of Corrections under the state's whistleblower protection statute. His lengthy hearing ended last month, and administrative law judge Mary McClatchey is expected to make a ruling soon. Now the guy nicknamed "Pharmacist Bob" by his co-workers wants his old job back. He wants his back pay. And, he says, he wants the Colorado Department of Corrections to stop breaking the law.

Set just east of the Denver County Jail and ringed by spirals of barbed wire, the DRDC is the first stop on an inmate's journey into the state prison system. Each morning, buses and vans from county jails across Colorado pull up to the intake dock and unload their human cargo: men or women dressed in street clothes, red prison jumpsuits, or even the old black-and-white-striped convict's suits. Some of the men arrive wearing county-issued white socks and girlish red plastic sandals on their feet.

They are killers, car thieves, child abusers, corporate embezzlers -- all convicted criminals with varied backgrounds and shady pasts. Some of the inmates are passing into DOC custody for only a few months. Others will not leave until they die.

Over the next nine days, the newcomers will have their teeth examined, their education levels measured and their IQs tested. (Certain intake days are reserved for females and youth offenders.) A bevy of "programmers" -- trained to weigh an inmate's criminal and mental history, the severity of his offense and the length of his conviction -- will decide where in Colorado he will do his time. "This is probably the closest look we take at them," says DOC spokeswoman Liz McDonough.

With its multi-colored brick exterior, the DRDC is considered a DOC showcase. The thick courtyard lawn and lush flower beds are tended by women from the Denver Women's Correctional Facility (DWCF), located just south of the complex. Inside, the DRDC is immaculate: The concrete floors gleam; the hallways smell of floor wax; soothing pastel paints cover the spartan interior walls. But the cells are harsh: Each bed is a hard slab covered with a thin plastic mattress. Life here is on 23-hour lockdown.

"We treat everybody as a maximum-security inmate," says Michael Evans, administrative services manager of the 480-bed DRDC, "because we don't know who they are."

Every morning, up to 35 new inmates trudge into the medical clinic at the DRDC, where they wait in one of three holding cells until they're called for a workup: a tuberculosis test, hearing and eye checks, a physical and a dental exam -- at the cost of $206.14 per person. Once the daily intake checkups are finished, the clinic also sees sick inmates from other area prisons. The inmates must make either a 50-cent copayment to see a nurse or physician's assistant or $3 to see a doctor.

Upstairs from the clinic is a 36-bed infirmary, which houses equipment for dialysis and cancer treatment, as well as a "negative air-flow" room for patients with TB. Emergency and critical cases are sent, along with a security officer, to an area hospital such as Aurora Presbyterian, Denver Health Medical Center or University Hospital. (Three inmates were taken to the hospital on July 4 this year for chest pains, a common occurrence around the holidays.) Inmates who are close to death but have not had their sentences commuted can go to a hospice program at the Colorado Territorial Correctional Facility (CTCF) in Cañon City.

Some of the criminals who have to strip in front of the nurses are "macho, gangbangers, dangerous," says one nurse, who, like her colleagues, has been told by the DOC not to talk to the press. "Some are just scared."

But despite their tough demeanor, most inmates treat the 68-member medical staff with politeness and respect. "We're the gatekeepers of what they want," explains a physician who used to work at the DRDC, "whether it be a lower bunk or a trip to the hospital -- which is kind of fun because it breaks up the routine. They know if they piss us off, they're out of luck."

Next to mealtime, an appointment at the clinic is one of the few escapes from cell-induced boredom. When a prisoner isn't feeling well, he or she can slip a "kite," or message, into a box mounted on a wall of the DRDC dining hall. A nurse checks the box after the twenty-minute meal shifts and, if someone has an urgent concern, pays a house call to the inmate's cell. Inmates can call on any DOC staffer (they are all trained in first aid and CPR) in case of an emergency. Patients with less urgent problems sometimes have to wait one or two weeks for an afternoon appointment.

Most of the 6,000 new prisoners expected to come through the DRDC this year don't have a history of good health care -- to say the least. Three out of four are alcohol-dependent, chemical-dependent or both. Because of the wear and tear of the streets, the typical forty-year-old prisoner has the body of a fifty-year-old, according to health workers in the prison system.

Thanks to the precedent-setting 1979 Colorado case Ramos vs. Lamm, prisoners across the country are entitled to a "standard of community care," or the same standard of treatment available to other Americans. Ironically, "it's because they're incarcerated that these guys are getting medical care," points out a doctor who used to work at the clinic. "A lot of them weren't when they were out on the street."

Unlike many prisons around the country, the Colorado system is not faced with a disproportionately large population of AIDS or TB patients. Here, hepatitis -- especially hep C -- is the major concern. At the Denver women's prison -- a dreaded assignment for most medical staff because of its reputation for belligerent or uncooperative inmates -- many women enter the system pregnant; they deliver at a local hospital, and the infant is immediately placed with family members or social services.

With its thick steel doors, bare floors and an intercom system paging inmates for their exams, the DRDC clinic on most mornings is busy, loud and chaotic. "It's like being in a giant bathroom," staff nurse Van Wiliford testified during Bob Gusich's hearing. Sometimes the small area is packed with up to fifty inmates. "These people," Wiliford noted, "are not always the type who listen to directions."

"They're not nice people," adds a nurse. "There's one who's a real dirtball -- and I mean a real dirtball -- but that doesn't mean he doesn't deserve good medical care. We realize that if these people had impulse control and could think things through, they probably wouldn't be here. The reason we take care of them is because they're human beings and we've taken an oath to do so."

About twenty nurses -- both male and female -- work at the DRDC, and there are open slots for a half-dozen more. Like hospitals and clinics throughout the West, the DOC is feeling the effects of a regional nursing shortage. But longtime veterans of the job say they've stuck around for the stability and good state benefits -- and some of the unique challenges of treating tough operators.

"In a prison, you have more autonomy than in a hospital," explains a nurse. "You have different medical problems and different kinds of people. If a medical person is worth their salt, they want to be right in the action." But a little attitude doesn't hurt. "A professional criminal has all the time in the world to watch you -- and if he sees one crack, he can attack you, whether verbally or physically," says one nurse. "It would take an inmate two seconds to rape you or cut your throat. It's not an everyday job. You could go to work and all hell could break loose."

Under the best scenario, a clinic's staff works like a tight, practiced team: Doctors give orders, nurses carry them out, pharmacists provide the right doses of medicines. If one team member inadvertently drops the ball, the others should be ready to catch it to save the play.

But sometimes mistakes don't get intercepted. Instead, they become embarrassing -- or dangerous. In a well-publicized gaffe last November, three nurses at the DWCF injected fourteen female inmates with a tetanus vaccine instead of a TB test. A few years earlier, according to testimony in the Gusich hearing, a prisoner missed getting a prescribed medication 38 times. Staff members were baffled when the blood pressure of yet another inmate -- who had been prescribed blood-pressure medicine -- kept rising, until they found out that several nurses had not given the patient his medicine but had lied and said they had.

The DOC's McDonough declines to comment on any specific incidents or the general management of the department's medical clinics because of the pending Gusich decision.

But during testimony and in interviews, workers in the clinic described a top-heavy administration with one nurse supervisor for every five nurses. Often the supervisors are not around, so lower-level nurses have to make critical health decisions on their own. Recently, most of the nursing staff abandoned their posts for a ninety-minute "meeting" that was actually a baby shower on company time. ("We can't even have union meetings on company time," complains one nurse.)

In charge of the clinic is Joan Shoemaker, a registered nurse who rose to her current job in 1995. As clinical team leader for the DRDC, the DWCF and the Colorado Correctional Center in Golden, Shoemaker directs the doctors, psychologists, dentists and other full-time and contracted staff below her. The daughter of Bob Shoemaker, a former state legislator who was appointed by Governor Bill Owens to the Colorado Wildlife Commission earlier this year, Shoemaker is married to the associate warden of the state prison in Limon. She is also vice president of the influential Colorado Nurses Association.

A clotheshorse with an admitted weakness for footwear, Shoemaker sat through every day of Gusich's lengthy trial, once filing a snag off a perfectly manicured fingernail during testimony. She admits she is prone to tears in the workplace, a trait that sometimes throws staff members off guard.

Both on the record and off, staffers describe Shoemaker as generally personable but unresponsive to suggestions about making the clinic run better. "She'd listen to you," former DRDC nurse Earlene Anderson testified at Gusich's hearing. "She wouldn't do anything about it, but she'd listen to you." Make too many complaints, though, and one of Shoemaker's employees can run into trouble. "I knew that once he [Gusich] started speaking out, it would only be a matter of time" before he would feel some repercussions, Anderson said. "Bob was speaking out against things that were wrong -- and he was right."

Some nurses would take offense when Gusich refused to fill prescriptions they brought to him without a doctor's signature, as required by law, Anderson said. Gusich's by-the-book approach also made him unpopular with several supervisors. "Because of his squareness," says a DRDC nurse, "he got sideswiped."

The Department of Corrections is no stranger to personnel disputes. In fact, the agency faces "a disproportionate number of cases," says Charles Robertson, director of the State Personnel Board, which handles employee suits against state agencies. From July 1, 1998, through June 30, 1999, DOC workers generated nearly 16 percent of state employee cases regarding pay status or tenure and filed 21 percent of all grievances dealing with working conditions at state-run sites. Robertson attributes the high numbers to two factors: The DOC is in constant recruitment mode, bringing new employees onto the state payroll to work in new prisons, and the agency's "quasi-paramilitary structure" means there is generally "less negotiation between employers and employees," he says.

"The DOC dispute-resolution process is not very effective," adds Katie Kaufmanis of the Colorado Association for Public Employees, an advocacy group for government workers. "It's definitely a concern that CAPE has."

At least two DRDC veterans who testified at Gusich's hearing had already been involved in personnel cases against the DOC. Staffers are blunt about their paranoia over tenure. Wiliford, a male nurse who was subpoenaed to appear in Gusich's case, insisted that after testifying about the clinic's working conditions, "I'll be a marked man in the DOC."

"People are scared to speak out," says another nurse, who didn't want to be named. "They [the management] look for scapegoats. Taxpayers are funding this type of mentality."

At the corner pharmacy, law-abiding citizens receive their pills in little plastic bottles with childproof caps. At the DRDC, prisoners get their prescriptions in the med line.

Three times a day, scores of inmates line up outside a bullet-proof window set into a door made from three-inch-thick steel. Through a small opening in the window, a nurse hands out painkillers, psychotropics and other drugs, one dose at a time. Inmates are required to take their medication right there, and guards are on hand to make sure the patients aren't "lipping it," or holding the pills inside their cheeks so they can smuggle out the goods and sell them later.

The pills are kept in heat-sealed "cards," similar to the foil-backed pop-out packets that decongestant capsules come in. Each card is labeled with an inmate's name. But when a patient arrives and the nurse can't find a card for him, she might borrow from another inmate's card. And when that card runs empty, she'll borrow from yet another.

Gusich spoke out against this "borrowing," saying it made it impossible to figure out which meds were going where. His protests were largely ignored. However, recently the practice of borrowing has decreased "dramatically," Shoemaker explained during the hearing, "largely because of Mr. Gusich's issues."

Today more nurses seem concerned about the med line schedule. The first line runs from 6:30 to 8 a.m., the second from 2 to 3:30 p.m., and the third -- or "bedtime" med line -- from 6:30 to 8 p.m.

"Lights aren't out until 9 p.m.," says a nurse who sees sleeping medication and nighttime meds given out as early as 6:30 p.m. Patients who are supposed to take pills three times a day -- every eight hours -- sometimes have to go more than twelve hours between doses.

Shoemaker has promoted a "self-med" program that would allow inmates to keep quantities of medications in their cells and avoid the med line altogether -- a practice that was halted by a doctor during his tenure at the DRDC, a nurse explains. Now the practice has started up again, the nurse says -- even after staffers discovered a dialysis patient had mixed all his costly pills together in an unlabeled coffee can.

Nurses report a dearth of even the most basic supplies in the clinic. "The EKG machine breaks down just about every week," reports one exasperated staffer. "There have been days there hasn't been a thermometer around," adds another. The clinic suffers an acute shortage of blood-pressure cuffs and has none that can fit around the bulging biceps of the DOC's burlier residents.

Every year, the Colorado Board of Pharmacy makes a surprise visit to inspect each of the state's 800 retail drug outlets, including the handful of prison pharmacies. During visits to the DRDC and CTCF pharmacies over the past three years, inspectors primarily found that paperwork from the U.S. Drug Enforcement Administration, designed to trace the flow of legal narcotics, wasn't being filed properly. That type of error is not uncommon or particularly alarming, inspectors say. Likewise, finding expired drugs on a pharmacist's shelf, as Gusich did in Cañon City, "is an omnipresent problem," they say. They also dismiss Gusich's concerns about DOC staffers tossing expired meds down the toilet or into the sink; the state's health department doesn't object, either. As for "borrowing" medications in a public institution, as in the DRDC med line, "Is it okay? No. But in a practical sense, it happens," says the board's program administrator, W. Kent Mount. "It's not a good practice."

Transactions in the med line are recorded by hand. The DRDC doesn't use a computer to track drugs and their use, although a state audit report urged the implementation of "an integrated medical information system" for the DOC's clinical services back in 1996.

Meanwhile, the DOC spent $60,000 on a telemedicine system so that doctors at Colorado prisons could consult with their colleagues at regular hospitals on a video monitor without having to transport an inmate to the hospital. "The nurses were furious," says one, who claims the video system is hardly ever used. "With this new toy, we could have paid for another full-time employee."

Gusich had his own complaints -- often with the nurses. Some were taking more than a week to get inmates' prescriptions to the pharmacy, which meant patients weren't receiving the drugs that doctors had prescribed. He also grumbled about how quickly syringes were vanishing from the nurses' stations. He claimed that the DOC had spent up to $100,000 on Ultram, an expensive painkiller that doctors liberally prescribed for inmates who hurt themselves during body-building sessions in prison weight rooms. Instead, he says, they should have ordered the prisoners simply to lay off the weights.

While working at the DOC's flagship pharmacy in Cañon City, Gusich says he was shocked to find unlicensed pharmacy technicians working alone on Saturdays without a pharmacist present. Doctors were handing over drug samples to be casually mixed with the pharmacy's general stock. Patients were receiving expired psychotropics -- used to treat ailments like depression and schizophrenia -- such as Serzone and Risperdal. "So they were giving them outdated mind drugs," Gusich says.

During her testimony in his case, Shoemaker said she wished Gusich had shown more concern for the nurses' heavy workload. Sometimes he meddled outside his jurisdiction. "The accountability of the syringes by the nurses," she explained, "is their responsibility."

The DRDC pharmacy frequently sends out "care packages" filled with over-the-counter medications such as Tylenol, aspirin and Mylanta for prisoner use at outlying DOC facilities. But the high demand for the packages made Gusich wonder whether their contents were being taken home by staffers. "We didn't monitor how much went out," says nurse Anderson, "and the officers could use them at their leisure."

Staff members at the DRDC liberally swipe from the pharmacy stock, too. Medical workers and guards alike regularly help themselves to Motrin, Chap Stick, hand lotion, contact lens solution, decongestants, Tylenol and the like. Director Shoemaker even had Gusich order special eyedrops for her to use on the job, according to court testimony. "We were considered essential personnel, and these meds could help you stay on the job and finish your shift," Anderson explained at the hearing. Casual use of state resources is taken for granted; for example, Tony Schenk, the DOC's head pharmacist based in Cañon City, sent out copies of his daughter's job resumé and fliers for a theater production on his office fax machine.

Bob Gusich took from pharmacy stock, too: a $1.99 can of Sweet Breath spray that he used on the job. It became the DOC's grounds for firing him.

At 6'4", with a long, ruddy face and a full head of silver hair, the 59-year-old Gusich was born on the South Side of Chicago -- and has a burly accent that makes it obvious. A pharmacist for 35 years who owned his own drugstores in the Denver area from 1978 to 1988, Gusich liked to consider himself the "captain of a ship" in his pharmacy at the DRDC.

Hired first as a contract employee, Gusich took a full-time job with the DOC in March 1995. The following summer, the clinic hired a new pharmacy technician, Mynette Moulton, the daughter of a retired pharmacist who now does contract work for the DOC. Moulton's first application for the job was rejected because of her history of alcohol abuse and marijuana use. But after a letter admitting her past mistakes and requesting a fresh start, Moulton got the job.

Pharmacy "techs" are unlicensed in Colorado; pharmacists bear the ultimate responsibility for their work. Gusich protested Moulton's hiring because he felt she might "be put in harm's way" working around drugs all day, he says. When Moulton later claimed Gusich had created a hostile workplace (Gusich and his lawyers would not be allowed to see her written complaint until months later), the pharmacist was put on paid leave.

Three weeks later, Gusich was transferred to the CTCF pharmacy in Cañon City. He spent the next three months commuting home to southwest Denver on weekends and spending long weeknights in a rented motel room. The father of four grown daughters, Gusich estimates that his temporary transfer cost the state close to $50,000 in travel expenses and wages for a fill-in at the DRDC pharmacy.

But it was about to cost him more: his job.

After an investigation by the Inspector General's Office, an independent DOC division charged with ferreting out abuses by DOC staff, Gusich was charged with harassment and misappropriation of goods worth $67.45 -- including the Sweet Breath, a package of two Dr. Scholl's gel shoe insoles and three pairs of in-shoe "warmies." Gusich admits to using the breath spray but says he never even unwrapped the shoe liners; besides, they were designed for a man's 7-12 shoe size, and he wears a 13 or 14. Even at retail prices, the items wouldn't add up to $67.45, a figure he claims Shoemaker plucked from the air.

"I think Joanie concocted all these things when she wasn't doing her job," he says, "and she was abusing her authority and her responsibility." But Shoemaker's boss, Donald Lawson, stands by the charges against Gusich. "The amount of misappropriation is not as significant as the act," Lawson testified.

Rose Hedgeman, a child psychologist and DOC supervisor whom Lawson assigned to review the paperwork in Gusich's case, concluded that he should be fired. "If I had put Mr. Gusich back in the workplace, that would be detrimental to the DOC," she testified. In a particularly bizarre moment during Gusich's hearing, Hedgeman also noted that after making her decision, "I had nightmares that Mr. Gusich was going to harm me."

Hedgeman's fears surfaced "only in the dream. I did not know him personally," she said. "I felt hunted in those nightmares."

"Is Mr. Gusich responsible for your dreams?" Gusich's lawyer, Bruce Pederson, asked her.

"Of course not," she replied.

(Gusich is an avid hunter, but, his wife says, he has killed only one trophy animal in his life -- a mule deer whose mounted, antlered head hangs on the family's living room wall.)

Before coming to the DOC, Gusich had worked as a pharmacist for Kaiser Permanente. He'd been fired there, too. In surprise rebuttal testimony, DOC defense attorney Lee Hegner brought in Bruce Emeson, Gusich's former supervisor at Kaiser, who said Gusich had been canned in 1993 for putting false arrival times on his time card and "creating a hostile work environment" by loudly drumming his fingers behind other employees' workstations and bringing in photos from the hunting trip where he bagged the mule deer. "Many of the staff in the pharmacy felt those pictures were veiled threats...that he may come into the pharmacy and shoot them," said Emeson, who nearly broke into tears when he said he feared Gusich would come after him and his family. Gusich finds the idea ludicrous and says he hasn't had the slightest contact with Emeson since he left Kaiser.

After he lost his $60,000-a-year job at the DOC, Gusich was denied unemployment benefits from the state. His lawyers challenged the decision, and a judge decided in Gusich's favor -- finding that the pharmacist may have been discharged in retaliation for disclosing information about shoddy practices at the clinic. Gusich decided to fight the harassment and misappropriation charges, too, and to claim protection as a whistleblower.

Within the next few weeks, the administrative law judge will decide if he deserves it.

In the meantime, Gusich and his wife, Bonnie, are living without income and health insurance; his unemployment benefits expired after six months. He has looked for a job at drugstore and grocery store chains, but with no luck. "I'm facing accusations that I'm a thief and a harasser," he says. "I have no references. I have no recommendations. How can I get a job?"

Gusich finds it odd that he was fired shortly before a scheduled June 1997 inspection of the DRDC by the American Correctional Association -- the self-proclaimed watchdog group of the prison industry. When the facility -- and its clinic -- passed the test, it was granted ACA accreditation for the first time, a plush feather in its cap and a credential that can protect the DOC in lawsuits. The DRDC will be up for reaccreditation next year by the ACA, which held its annual congress in Denver last week. (The DOC rolled out the red carpet for the ACA, inviting members for a tour of several Colorado prisons, including the DRDC.)

Gusich hopes he'll be back on the job the next time the ACA comes asking questions. He'd also like to be in line for the post of head DOC pharmacist when Schenk, now in that position, retires. "That's what I still want," he says. "So I can clean up this mess."

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