When someone in jail needs surgery, it’s no simple operation

In October, Darrell Palmer, Jr., wrote on a grievance form to Allegheny County Jail administrators: “I need to know the procedure for if I was to die in here?”

He was suffering from a large ventral hernia that had become unbearably painful while incarcerated from March 2021 to November 2022 and then again from August to October 2023. The hernia looked like “a baby arm sticking out of his stomach,” according to Brian Englert, the correctional officers’ union president.

Palmer recalled the intense pain.

“Imagine your intestines coming out of your abdominal wall with the only thing holding it in is this much skin … So the pain never goes away, it’s a constant thing. Sometimes more, sometimes less,” he said in an interview.

Darrell Palmer, Jr., stands for a portrait to display the large ventral hernia in his abdomen on March 11, two days before his surgery, in Wilkinsburg. (Photo by Stephanie Strasburg/PublicSource)

The only solution was hernia repair surgery, which Palmer expected the jail would be able to provide. Incarcerated people are the only American population with a constitutional right to health care, owing to a 1976 Supreme Court ruling. But there’s nothing simple about how that’s administered.

“The Constitution doesn’t require that [incarcerated] people get the best care, it just requires that they get some care,” said Alexandra Morgan-Kurtz, an attorney and deputy director of the Pennsylvania Institutional Law Project who litigates cases related to conditions at the county jail and other state lockups.

In Allegheny County, the procedures, logistics and funding for surgery for incarcerated people are complex and opaque. A new county administration is just beginning to wrap its arms around those challenges.

Obstacles related to a lack of staff, overwhelming medical need and organizational difficulties limit incarcerated individuals’ access to medically necessary surgery, according to former jail employees. Correctional health care experts say most of those challenges aren’t unique.

Allegheny County Jail spokesperson Jesse Geleynse said ACJ is providing appropriate medical care and facilitating surgery when warranted.

“There have been approximately 100 surgeries performed on incarcerated patients in the past three years, which indicates ample access to surgical procedures,” Geleynse wrote in a statement. “There are also numerous off-site appointments that incarcerated patients attend daily. The ACJ continues to provide appropriate medical care to its incarcerated population, despite assertions to the contrary.”

Critics of the county jail are hopeful that new leadership, including the first permanent medical director in more than a year, a new county administration and significant turnover at the Jail Oversight Board will provide opportunities to expand and improve access to surgery.

A multimillion-dollar obligation

In addition to staffing a roster of in-house health workers, Allegheny County has contracted with Allegheny Health Network since 2015 to provide medical care for people incarcerated in the jail. The current contract caps medical expenses at $13.5 million over two years, and during the 2023 fiscal year the jail paid AHN $5.5 million for on-site and outpatient medical care. The spending cap has steadily increased since the first AHN contract was inked in 2015 with a $4 million annual limit.

The county gets a fiscal break when the person is hospitalized for more than 24 hours. Federal law says that Medicaid can then be billed, and pays based on its reimbursement caps. Last year, Allegheny County was billed more than $8 million for inpatient care for incarcerated people. Thanks to the federal regulations, 2011 Pennsylvania legislation and the state Prison Inmate Medical Cost Containment program , the county only had to pay around $250,000 of that.

The jail’s health care staff includes a mix of county employees and workers sourced through staffing agencies. Nurses at the jail deliver on-site medical care and determine when an individual may need to see an off-site specialist.

Most health care is delivered on site, jail reports show, but those needing more complex medical care are transported to community hospitals, usually those operated by AHN, for both planned and unplanned visits. Since mid-March 2023, a typical month has involved 49 off-site specialist referrals and 46 emergency room runs, during a time when the jail population hovered around 1,750.

Brain surgery and lots of fractures

Surgical procedures make up a relatively small share of the jail’s overall health care provision. According to jail records, 132 surgeries were performed on incarcerated individuals between July 2018 and March of this year.

These surgeries represent a wide variety of procedures, including:

• Removal of a brain tumor accessed through the nasal passage
• Skin grafts
• Two amputations, one below the knee and one of a toe
• Reduction of kidney stones with a laser
• Spinal fusion, an operation that permanently fuses together two or more bones in the spine
• C-section.

Rebecca Maine, a general surgeon in Seattle who studies the acute care surgical needs of incarcerated individuals, said in an interview that there are no national data describing the frequency or types of surgeries given to incarcerated individuals.

However, the distribution of injuries and surgeries outlined in Allegheny County
Jail records bears some similarity to findings of a 2022 study Maine co-authored in the Journal of Trauma and Acute Care Surgery. That study followed 943 incarcerated people who presented at 12 emergency rooms across the eastern U.S. over a year-long period.

The study found that bone fracture repair was among the most common surgeries performed, accounting for almost 10% of patients who required surgery.

Fracture repair made up 23% of the Allegheny County Jail surgeries during the past five years. Related procedures to take out pins, screws, plates or wires that hold broken bones together bring the share of surgeries involving broken or fractured bones to a third of all those performed on people in the custody of the county jail since July 2018.

A waiting game

In March 2021, Palmer had a hernia repair surgery scheduled, but he was arrested before his scheduled appointment. During two periods of incarceration between then and October 2023, Palmer said jail medical staff had told him he had been scheduled three separate times for hernia surgery that never occurred.

His medical records from the jail detail three appointments in 2021 and 2022 with two different Allegheny Health Network surgeons specializing in hernia repair. After an emergency room visit in September 2023, he was not taken to the recommended Sept. 26 follow-up appointment with one of those surgeons. The following day, a physician’s assistant at the jail wrote in his progress notes that the appointment would have to be rescheduled.

Reflecting on this period, Palmer recalled brief encounters with jail medical providers, two CT scans and three surgical consults punctuating months of waiting with no word about when he would get the surgery the off-site specialists agreed he needed. He said he was twice told that so much time had passed since his last surgical consult that he would have to start the process over with a new consult. Jail records show five other hernia repair surgeries involving people in custody while Palmer waited for his.

Path to surgery

With the exception of care prompted by an emergency room trip, if an incarcerated individual at Allegheny County Jail has a medical condition that requires surgery, they need to:

• Get the attention of a jail health care provider
• Obtain the provider’s sign-off on a surgical consult
• Receive the consult and a recommendation of surgery
• Have the surgery scheduled
• Be transported to and from the surgery.

Correctional health care experts and former medical workers at Allegheny County Jail said during interviews that at each step of the process various factors limit incarcerated individuals’ access to necessary surgical care.

Getting seen

Before getting evaluated and referred for needed surgeries, incarcerated people at the county jail must first attract the attention of a medical provider. According to incarcerated individuals and former employees, a workforce insufficient for the scale of the facility’s medical needs can lead to delays at this first juncture.

There’s “no telling how long” you have to wait after putting in a request to see medical, Palmer said. “It could be three days … or it could be two weeks or you could just get put in the shuffle over and over and [have to] start over again.”

People come to the county jail with a variety of preexisting health conditions, including substance use disorders, that put them at risk, Geleynse has told reporters in response to inquiries regarding deaths at the facility . Allegheny County is not unique in this regard. Across the country, research has found that jail populations carry a higher proportion of most chronic medical conditions than the general population.

Compounding this difficulty, the jail has at times admitted people with medical issues too complex for its health care team to manage, according to former medical employees. Geleynse declined to comment on that allegation.

Sandra Simms, a critical care nurse practitioner who worked at ACJ for about three and a half years beginning in June 2020, said admitting people who should not have been medically cleared for incarceration was a recurring problem during her employment there. She recounted an individual with a heart implant for late-stage heart failure and someone who was recently paralyzed by a gunshot wound who were admitted to the jail, which she left in April 2023.

Simms said much of this could have been averted by making sure the intake department was adequately staffed with medical providers who could decide when incoming people should be diverted to hospitals. “Many, many times” during her employment, Simms said, “there was not even a medical assistant” at intake.

Roughly half of county medical positions at the jail were vacant at the end of 2022, according to a staffing audit by the county controller’s office.

Experts in correctional medicine say understaffing is a widespread and longstanding barrier to providing quality health care to incarcerated people. Charles Lee, the immediate past president of the American College of Correctional Physicians, currently conducts accreditation surveys for the National Commission on Correctional Health Care. Lee said he has surveyed roughly 200 institutions in 46 U.S. states and that at least 90% of them struggle to maintain adequate staffing levels. Lee said staffing is the “No. 1 challenge” in correctional health care and one he’s observed for 20 years.

At the May Jail Oversight Board meeting, County Executive Sara Innamorato said nursing shortages represent the county’s primary staffing challenge and are the focus of an active recruitment campaign. The jail has recently hired a talent acquisition specialist and is instituting $6,000 hiring bonuses for nurses, social workers, case managers and therapists.

On top of staffing shortages, the jail didn’t efficiently connect incarcerated people to medical professionals, according to former jail employees.

“We didn’t have the organization to take the medical people that we had and put them where they needed to be,” Simms said, noting that many of her colleagues, including former medical director Donald Stetschulte, were dedicated and skilled. Overall disorganization, though, made it difficult to identify those with the most urgent medical needs, she said.

“[Incarcerated people] could be there for months, and we weren’t seeing them,” Simms said. “And then … a corrections officer would say, ‘Hey, I’m really worried about this guy.’ And then, you know, we would look into it and we’re like, ‘Dear God,’ you know, ‘how has this person not been seen?’”

Trips out historically ‘frowned upon’

Former jail medical employees said that over the years, they and their colleagues have sometimes had difficulty getting permission to send patients out for treatment.

Lori Deaderick, who worked at the jail as a substance abuse counselor between March 2018 and November 2019, said that during her time there it was “frowned upon” to send an incarcerated individual to an off-site doctor.

Charles Timbers, another former jail nurse practitioner, who worked there for almost 10 years spanning three different periods between 1999 and 2020, confirmed this difficulty.

“You’d have to go through this red tape and a sea of people that weren’t trained medically… [who] would hesitate on sending the individual out,” if it wasn’t an emergency situation, Timbers said, recalling that he sometimes had to fight to get an incarcerated individual sent out to a specialist.

Getting to the hospital

An emergency room referral form in Palmer’s jail medical record stated, “It is necessary that the patient is not made aware of any appointment scheduling information.”

Per jail policy, incarcerated people are not informed of the date or time of their off-site medical appointments, for security reasons. Simms recalled that in her time at the jail, medical staff sometimes “had to reschedule surgeries whenever somebody accidentally let [a patient] know that their surgery was the next day,” in part for fear that family members or people with ill intent might come to the hospital

The lack of transparency regarding scheduling makes it difficult for incarcerated individuals or their loved ones to keep tabs on their care.

Earlier this year, the spouse of a person incarcerated at the jail emailed oversight board Liaison Karen Duffola about her concern that her husband wasn’t making it to his off-site medical appointments for serious injuries he sustained prior to his arrest.

“As of 2/27 he has had zero external appointments, yet every time I speak with scheduler as of late January he has appointments in the ‘next month to month and a half,” the concerned spouse wrote.

Transporting an incarcerated person to an off-site medical appointment, accompanying them to the appointment and bringing them back to the jail requires careful coordination on the part of custodial staff. For this reason, the county jail’s documented shortage of correctional officers hamstrings the availability of more advanced health care.

The county controller’s staffing audit found that in 2021 and 2022 the jail was short an average of 30 correctional officers before any call-offs occurred. After call-offs, the shortage rose to an average of 53. Recent county employment data show modest gains in correctional officer employment in 2023.

Simms, Timbers and Deaderick confirmed that they frequently saw external medical appointments get canceled because of staffing limitations whenever those appointments weren’t seen as a priority.

Geleynse said that the jail “triages appointments based on patient acuity and the ability to safely facilitate the transportation,” noting that there are security considerations for the patient, staff and community any time an incarcerated individual leaves the jail and a finite number of appointments available each day.

Getting scheduled

Once a specialist recommends surgery for an incarcerated patient, their office contacts the jail directly to arrange the scheduling. “If surgery is scheduled by an outside provider, it isn’t an issue of if it will occur, but rather when it can be performed,” Geleynse wrote in an email.

Both Timbers and Simms said that in their experience, approval wasn’t automatic. The jail’s medical director and perhaps other members of jail administration would have to sign off on an outside specialist’s recommendation in order for it to be implemented. Simms added that jail staff tended to strongly consider specialist recommendations.

Palmer had to wait to be released from the jail before he could get the surgery he needed. After a late-February consult at West Penn Hospital, Palmer’s hernia surgery was performed two weeks later, on March 13. As he heals, several months on, he said his pain is lessening.

Since January, he has tried, unsuccessfully, to get answers from the jail administration via the oversight board about why he never got the surgery he needed. He said it was a frustrating experience yielding no answers.

“I’m always hopeful for change, but I don’t see any change,” he said. “I still have family in jail, and they still complain about the same things as when I was in there, sometimes even worse. So, it’s like, I’m hopeful because I have faith in God, but I don’t have faith in them.”

Jordana Rosenfeld is a freelance writer in Pittsburgh and former PublicSource intern who covers carceral issues and can be reached at jordanarosenfeld@gmail.com.

This story was fact-checked by Lucas Dufalla.

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