CRUEL & UNUSUAL MEDICINE: PRISON DOCTOR'S PRACTICES REVEALED

It was obvious the wound in Ronnie Russell's arm was not healing.
Obvious to Russell, who endured constant pain as it worsened. Obvious
to the nurses who, suspecting an infection, meticulously documented
the appearance and size of the oozing hole.

"It was going on for weeks," says Russell, an inmate patient at the
Dodge Correctional Institution infirmary in Waupun. "My arm was
turning black. There was a real lot of black stuff there and a real
lot of nasty smells."

But to Dr. Thomas Williams, who was in charge of Russell's medical
care, it wasn't obvious. He said it was ugly, but not infected. It
would heal. He was so sure that he stopped the antibiotics ordered by
an on-call doctor, according to medical records obtained by The Capital Times.

Russell's wound was the result of a failed attempt by a surgeon
working at Waupun Memorial Hospital to create a fistula -- the
splicing of a vein and an artery -- in his arm to facilitate dialysis
treatments. Four days after Williams discontinued the antibiotics, a
dialysis physician at the infirmary ordered an appointment "ASAP" to
assess the wound with the surgeon who attempted the fistula. Over the
phone, without seeing Russell, the surgeon said such wounds "look
awful, but there's no danger," according to medical records. Based on
the conversation, Williams canceled the appointment, according to the
records. There is no record showing that Williams examined the wound
himself in the week before or the week after speaking with the surgeon.

The day after Williams canceled the appointment with the surgeon, the
prisoner's wound finally got treated. Russell, a diabetic who has
AIDS and a host of other medical problems, was sent to University
Hospital in Madison for an appointment unrelated to his arm. Doctors
there saw the wound, ordered lab tests and determined that Russell
had an infection. They gave him antibiotics and surgically cleaned
out the wound.

This is a familiar scenario for Williams' patients, several nurses at
the infirmary say. Unable to get Williams to order what they feel is
adequate care, nurses try to find someone who will, often by
arranging expensive trips to the Waupun Memorial Hospital emergency
room or University Hospital in Madison.

"We get medications and start treating them," says veteran nurse
Kathy Bradley. "And, on Monday morning, the doctor stops them without
even seeing the patient, just stops them because somebody messed with
his orders."

But nurses and other critics say the problems with Williams and the
state infirmary extend far beyond poor wound care.

They say Williams routinely denies pain medication to patients who
are in pain. They say that he refuses to see some patients who need
his attention and that he treats patients and infirmary staff with
contempt. And he has ordered prisoner patients into "dry cells" where
their water supply is cut off.

Bradley, who recently found another job, is the only one of about a
half-dozen nurses and other infirmary staffers interviewed who agreed
to be named for this story; the others said they feared retaliation
from supervisors.

Williams and other corrections officials, when confronted with the
allegations by The Capital Times, deny them all. They say their
critics don't fully understand the complexities of their patients'
medical conditions and the challenges of providing health care to
difficult and often conniving inmates.

Asked about the nurses' complaints, Williams says: "I have no answer
for that. I've been in practice since 1978 and I have not had issues
with nursing staff in the past."

But many of the allegations of the nurses are corroborated by
hundreds of pages of medical records obtained by The Capital Times
with the consent of the prisoners or their families.

One prison expert said Williams' pattern of turning off water in
inmates' cells for extended periods might violate constitutional
guarantees against cruel punishment. A public interest lawyer who
specializes in inmate cases is preparing for a possible lawsuit over
the treatment of Russell and is considering filing legal action on
behalf of another inmate.

"I find the same issues keep coming up, being raised by the inmates
who are under (Williams') care, being reported to us through other
channels, and as I've gone through records, appearing time and time
again in those records," says Todd Winstrom, an attorney with
Disability Rights Wisconsin who specializes in prison issues. "Those
concerns are not seeing inmates very often, not responding to what
appear to be significant medical problems that appear to require a
medical response and an ongoing pattern of just plain discourtesy to
the patients."

He attributes much of that to a pervasive suspicion about inmates and
their motives in seeking medical attention.

In addition to a notice of claim, the first step toward a lawsuit
which he has filed on Russell's behalf, Winstrom says he plans to
file a complaint seeking action on Williams' medical license with the
state Medical Examining Board, which has disciplined Williams for two
incidents in the past.

Bradley says it's about time.

"People just trust that the state of Wisconsin would not do these
things," says Bradley, a registered nurse who logged five years at
the infirmary. "If you told me these things, I would not believe you.
But it's consistent and Dr. Williams needs to lose his license."

Mistreatment From Day One

The infirmary Williams oversees is operated within the Dodge
Correctional Institution, a sprawling complex that sits on 57 acres
in Waupun, a city of about 11,000 located 60 miles northeast of
Madison whose most prominent industry is incarceration. In addition
to Dodge, Waupun is also home to the Waupun Correctional Institution
and the John C. Burke Correctional Center for women.

Dodge is the reception center for the entire Wisconsin prison system,
the first stop for inmates after their sentences are imposed in state
court. From there, they are sent to whatever state prison officials
deem appropriate.

Dodge is also home to the infirmary, a 64-bed facility for
Wisconsin's sickest inmates. Many of the patients are chronically
ill, suffering such ailments as kidney, heart and liver failure,
diabetes or AIDS. Others suffer from serious injuries. Like the rest
of the prison, the infirmary is maximum security, and so inmates are
locked in cells 23 hours a day.

It was on Dec. 17, 2005 that Ronnie Russell arrived at the infirmary,
and that's the day that his mistreatment started, according to the
notice of claim that Winstrom has filed on Russell's behalf.

The claim alleges that Williams compelled Russell to accept
"inadequate and inappropriate" medical care without Russell's
informed consent and despite Russell's objections, resulting in an
almost immediate deterioration of Russell's medical condition and
requiring a three-week hospital stay shortly after he was admitted to
the infirmary.

The notice names Williams and other medical personnel involved in
Russell's care, as well as outgoing Corrections Secretary Matthew
Frank and Gov. Jim Doyle. The document alleges negligence in the care
of Russell's wound as well as ongoing pattern of negligence.

Winstrom asked retired Madison-area family physician Linda Farley to
review the treatment of Russell's wound and she says in her review it
"was grossly inadequate and did not meet any acceptable standard of care."

In an interview with The Capital Times, Farley stressed that the
reviews of Russell's case and others cited in this story were based
only on medical records and were done without the benefit of seeing
the patient or speaking with nurses or physicians involved in the
inmates' care.

In her review, Farley says further that: "In my opinion, confirmed by
my conversation with an infectious disease colleague, the infirmary
physician overseeing this patient's care did not exercise good
medical judgment in neglecting to treat the fistula site which showed
clear evidence of infection, adding serious risk in a patient whose
immune system was already compromised by AIDS and diabetes."

But Department of Corrections Medical Director David Burnett says
Williams "performed up to our expectations" in providing care for
Russell and Williams and his immediate boss, Dr. Scott Hoftiezer, say
they are not convinced by the UW doctors' findings.

"I'm not even convinced that there was an active infection that was
the problem," Hoftiezer says. "I've reviewed the notes from UW and
there is a difference of opinion on that."

Nurses, who are licensed, say Russell's case put them in a difficult
position, one in which they often find themselves. Unable to properly
care for the patient, they took measures to ensure they wouldn't be
held accountable for medical negligence.

As Russell's wound festered, they documented its progression as well
as their attempts to get Williams to look at it. They slipped a
sketch and a photograph of Russell's wound into his medical file to
make sure documentation existed to back up their concerns.

"It's very frustrating working for this doctor," one nurse says. "I
do lot of things just to cover my tail."

Staffers say Williams regularly dismisses medical issues noted on the
infirmary's "doctor's list," which nurses use to communicate their
medical concerns to the physician. Nurses have also reported cases of
low-level harassment and scorn, both toward themselves and patients.

In March, one nurse documented a tantrum by Williams as the two were
discussing a patient's care. The nurse noted that Williams stormed
into a cell, ripped off a patient's blood-pressure cuff, shoved the
blood-pressure machine at the patient and commanded the nurse to "get
this out of here."

The medical chart containing this account was obtained by The Capital
Times after the patient, Etienne Guzman, signed a release.

Some nurses say they have complained to higher-ups, including
Hoftiezer, Burnett, Bureau of Health Services Director James Greer,
and Dodge Warden Cathy Jess, to no avail.

"Dr. Hoftiezer covers up for him. David Burnett and Jim Greer are
well aware of the problems with Dr. Williams and they do nothing,"
says Bradley. "They just keep covering up."

Burnett says he's not aware of any complaints, either written or
verbal. Hoftiezer says he's gotten "a couple of verbal complaints
left in the form of voice mails."

"I took those seriously enough to consider that when I did the
routine performance review that I do on all physicians," he says.

'His Care Is Sound And Good'

Williams, 58, joined the department in July 2004. He says he sought
employment with the department because he wanted a change and fewer hours.

His previous employer was Waukesha-based ProHealth and he worked as a
family practice physician at the company's Mukwonago clinic. In the
course of his career, he says he logged 26 years of nursing home
experience, serving a portion of that time as medical director at two of them.

Williams was initially hired as a doctor at Stanley Correctional
Institution, making about $92,400 during his probationary year,
according to personnel records obtained through an open records
request. In March 2005, he began work at the infirmary, where he
oversees medical care for a daily average of nearly 60 inmates.
Williams is the fourth and possibly longest-serving physician to hold
the position since early 2000.

Since joining the Department of Corrections, Williams has seen a
hefty boost in his salary. According to state Department of
Administration records, in 2006 he earned $169,000.

His superiors at the Department of Corrections say they have full
confidence in his abilities.

"He's one of our board certified physicians," says Burnett. "His
medical care is sound and good, and I'll stand behind him."

"Dr. Williams has my full confidence in taking care of sick
patients," says his immediate boss, Hoftiezer, "as much as any
physician I work with would have."

Hoftiezer, Burnett and Williams agreed to an interview, attended by
Department of Corrections spokesman John Dipko, to discuss care
provided to several inmates as well as the nurses' concerns about
Williams' medical practices. Responding to nurses' complaints that
they routinely have to obtain treatment for their patients from
on-call and emergency room physicians, the doctors say the nurses
sometimes are out of line.

"If there's a change in condition that requires something being done,
I have no problem with that," Williams says. "If it's just their
opinion, then there may be an issue."

Burnett says: "The thing you have to remember is the physician
on-site has the whole chart, has been treating that patient for a
longer period of time. And a physician getting called on the phone
isn't going to have that information, is going to have a selected
point of view that's being provided by the nurse. And those decisions
aren't always best informed."

Williams says the nurses are just plain out of their depth.

"Many of our inmates up there, and patients, are very complicated
multiple-symptom issues, multiple system failures -- and many of the
recommendations I may get are very simplistic and inappropriate, and
I don't follow those," he says. "I do what I think is right from a
medical standpoint."

As a counterpoint to the nurses who were contacted by The Capital
Times, Dipko offered an interview with Sandy Sitzman, a former
infirmary manager who worked with Williams for the first eight months
of Williams' tenure there. In a conference call, in which Dipko
participated, Sitzman, who now manages health services at John Burke
Correctional Center, calls Williams "a good doctor, a competent
doctor. He knows what he's doing."

She says she doesn't recall any major complaints about Williams by
the nursing staff during her time there, but adds that the dynamics
of the infirmary can lead to hard feelings.

Some of the nurses who work in the infirmary currently may have come
from jobs where they had more autonomy, then had trouble adjusting to
the infirmary where the doctor tightly manages patient care.

On other issues raised by nurses inadequate pain management, poor
wound care Burnett and Hoftiezer defended Williams, though Burnett
conceded shortcomings with patient relations.

"At times, maybe his communication rapport hasn't been the best," he
says. "That's something we've worked with him on, had some counseling
and talked to him about it."

A Hole In His Leg

Scott Schuetze, the other patient for whom Winstrom is considering
legal action, has had his share of issues with Williams'
"communication rapport" and with his medical care.

Schuetze, 43, came to Dodge last August. After processing he was to
be shipped out to another institution to serve a three-year sentence.

That transfer was put on hold when his leg swelled up with a serious
infection, the origin of which is unknown. In September, Hoftiezer
sent Schuetze to Waupun Memorial Hospital to have the infected area
cleaned surgically.

The surgery left a wound, a half-dollar-size hole, that never healed.
Indeed, it got worse.

Health service requests, forms that allow inmates to request medical
attention, clearly document Schuetze's concern that the leg was still
infected months before anything was done about it.

"I said, well, maybe I should be on some more antibiotics," Schuetze
says. "Nobody would listen."

Records show that at least one doctor shared his concern.

In October an on-call doctor prescribed the antibiotic Cipro,
according to Schuetze's medical records. Once Williams returned to
his office, he discontinued the antibiotic.

For the next several months the wound failed to heal. Schuetze
repeatedly complained of pain, but Williams, according to infirmary
records, didn't believe him.

On March 7, Schuetze filled out a health services request asking
Williams for the phone number of the doctor who performed his surgery
in September. He wanted to tell him that he leg was not healing. He
got a reply from infirmary manager Fred Goetsch, stating, "I spoke
with Dr. Williams and he assured me that as long as you are compliant
with your treatments and with taking your medications your wound
should heal without complications."

Two weeks later, more than five months after his first surgery on the
wound, he went back to Waupun Memorial Hospital for a second surgery.
It was Sunday and Williams was off. The approval for the hospital
care came from an on-call physician.

At the hospital, he was given antibiotics for the infection, and the
wound was surgically cleaned up.

Williams maintains that blame for the wound's inability to heal lies
with Schuetze.

"It would have healed if he had stopped abusing it," he says. "He was
witnessed by several of my nursing staff who reported to me he was
digging at it in the shower. Every day he'd come out of the shower
with bright red blood draining from the wound, which would only occur
in a setting if he was manipulating the wound."

Asked what Schuetze had to gain by digging at his wound, Williams
says, "I kept asking myself that question, too. Why does he want to
stay here? He says he wants to get out. He's the only one who can
answer why he was doing that."

Schuetze denies doing anything to worsen the wound and says Williams
not only didn't treat the infection, but cut back his pain
medications, took away the cane he was using to get around and denied
him use of a wheelchair.

Farley, the doctor who reviewed Russell's care, also took a look at
the care provided to Schuetze, and concluded in her report: "The
standard of care should have dictated a return visit to the
orthopedic physicians at (Waupun Memorial Hospital) many weeks
earlier, thus ensuring a much faster healing of the wound and saving
the patient much pain and misery."

Farley also took Williams to task for ordering treatment without
examining the patient, blaming the slowness of the healing process on
Schuetze's "manipulation of the wound," dismissing Schuetze's
complaints of pain, and not ordering physical therapy or occupational
therapy to a patient who was spending up to 20 hours a day in bed.

Farley also wrote that after Schuetze's most recent release from the
hospital, Williams ignored explicit orders for a follow-up visit with
the surgeon, removed the stitches himself and didn't give sufficient
pain medication.

Throughout his time at Dodge, Schuetze communicated with Williams
primarily via his health service requests, which he would fill out
frequently. The requests were mostly for medical treatment and pain medication.

The requests prompted Williams to shoot back such replies as, "I do
not believe your excess pain," "You have the nerve to ask ... for
pain pills after you have been witnessed to be manipulating your
wound," and Williams telling him to "act like an adult."

During that time, the two rarely spoke face-to-face.

"He'd come in and he'd talk to the nurse and he'd stick something in
(the wound) real quick, and he'd run out the room," Schuetze says.
"He'd never talk to me. You know, you see a doctor, they talk to you,
you know, How you doing, you feeling any pain?' He didn't do that."

A Questionable Death

Nurses also told of a dying patient who developed an infection that
they say Williams didn't treat.

Sepsis -- the spread of an infection into the bloodstream -- was not
mentioned in a Dodge County Medical Examiner's report as contributing
to the Feb. 22, 2006, death of George Lyons, an 81-year-old diabetic.
Lyons' death certificate lists his cause of death as complications
from coronary artery disease.

But infirmary records released to The Capital Times by Lyons' wife
listed sepsis as the cause of death.

Dodge County Medical Examiner P.J. Schoebel could not explain why the
pathologist who performed Lyons' autopsy didn't mention sepsis as a
factor, though Lyons had a high fever in the days before he died. He
said the pathologist found extensive evidence of severe coronary
artery disease, but the autopsy report didn't mention sepsis. He
could not say if the medical records made available to the
pathologist mentioned Lyons' sepsis because those records are
protected by federal confidentiality laws.

Lyons' infirmary medical records show that on Dec. 11, Dr. Timothy
Correll, who often fills in at the infirmary when Williams is off
duty, prescribed the antibiotic Cipro to Lyons after his temperature
reached 99.4 degrees. The next day Williams discontinued the treatment.

Williams says being too quick to use antibiotics just increases the
chance that bacteria will become resistant, and there was not enough
clinical evidence of an infection to continue the antibiotic.

"During my years in practice -- I have extensive nursing home
practice I have dealt with a lot of catheters, a lot of elderly
patients," Williams says. "The standard practice is not to treat a
person with a catheter unless there's a fever. Not all physicians
follow that as strictly as I do."

But Farley says "it's just not true because elderly people frequently
do not show a fever."

She reviewed the laboratory analysis of Lyons urine and she says it
clearly indicated an infection.

"I've had a lot of nursing home experience, and there's no question I
would have treated this based on the lab work," she says.

She adds, "Cipro was appropriate."

Correll again prescribed Cipro a month later, when Lyons' temperature
was near normal at 97.7 degrees. Lyons got the full course, but the
infection persisted. Correll later prescribed Cipro again, but Lyons
died before the seven-day course was completed.

Burnett says like all deaths in the prison system, a mortality review
was performed.

"Our conclusion was that appropriate care was rendered," he says.

Prison officials would not release a copy of the mortality review.
Burnett says such reviews are available only to a mortality review
committee that includes corrections staff as well as medical people
from the private sector. They are off-limits even to the families of
the deceased.

'A Bunch Of Criminals And Complainers'

Winstrom, the attorney, sees Williams as a product of a flawed
system, one that allows negative attitudes about inmates to interfere
with the care they receive.

"There's always a risk in correctional settings, health care, mental
health care, of providers developing a negative attitude," he says.
"Seeing the inmates as malingerers, as manipulators, as people who
are trying to cheat something out of them. And instead of maintaining
the normal attitude -- 'I'm your health care provider, I'm working
with you, we are trying to care for your health' -- there's this
on-guard, negative. 'You're trying to cheat me, you're trying to lie
to me, you're trying to get things out of me.' And that creates a
poisonous atmosphere, an atmosphere which is absolutely antithetical
to good health care."

Winstrom and some nurses say there's a tendency to see patients as
criminals -- for instance, Ronnie Russell, the sex offender or Scott
Schuetze, the substance abusing thief -- rather than as patients.

Medical assessments by Williams and Hoftiezer show that they held off
giving Russell certain pain medications because he had a history of
drug abuse. The notes also peg him as a malingerer.

"You can read those notes time and time again," Winstrom says. "And
it's the heightened suspicion of the patient that keeps coming through."

That kind of suspicion is evident when speaking with prison officials.

"They've committed crimes," says Department of Corrections spokesman
Dipko. "They've been sentenced to serve time in prison. They can be a
very challenging population, not just to manage but to administer care to."

"This is a population that at times gets to be frustrating," Burnett
says. "We've had to work with all our physicians. We bring people in
at times for training on just how to handle people who are
manipulative, don't always tell you the truth, are looking for narcotics."

Barbara Neitman, a nurse who works at the prisoner intake center at
Dodge, says inmates get "excellent, excellent medical care" while
many law-abiding citizens have to do without.

"And they still complain," she says.

"These are individuals who ruined their lives by doing drugs and with
their lifestyles and now we are to save them? That upsets me, to be
honest with you."

Some of the infirmary nurses interviewed for this story say they're
no strangers to manipulative inmates, but the problem patients are a
small minority.

"The infirmary's a hard place to work," says one. "You have a lot of
patients that are there long-term. Some people can be manipulative,
but you can't carry that through with every patient. You know, pain is pain."

Bradley says: "It's only 10 percent or less that make that job
difficult. The rest are trying to do their time, get out and go home
and have a life."