Opinion ID: 4548568
Heading Depth: 2
Heading Rank: 2

Heading: Medical Requests

Text: Over the course of his day and a half in general population, Pulera submitted three inmate medical requests relating to his prescription medications—clonazepam and tramadol. Clonazepam is a benzodiazepine that Pulera was apparently prescribed for anti-anxiety purposes. Tramadol is an opioid pain-reliever that he used to treat chronic pain from a back injury. Pulera submitted his ﬁrst request a few hours after booking, around noon on Saturday. Cleaned of spelling errors, it said “I need my clonazepam and tramadol. My family is dropping them oﬀ. For my pain, anxiety, and depression.” At around 4:30, Nurse Erica Rea responded, telling Pulera that he was under the care of the jail doctor and that she would notify the doctor after his family dropped oﬀ the medications. As it turns out, Pulera’s brother, William, had brought the prescriptions earlier that afternoon, and Rea reviewed them minutes after responding to the request. She saw that Pulera had reﬁlled his prescription the day before, so he should have used just a couple of doses. Instead, the bottles contained only 34 out of the expected 60 clonazepam tablets, and 81 out of 120 tramadol tablets. She never asked, and no one ever discovered, where the missing pills went. A half hour later, Rea called Dr. Karen Butler, the facility’s medical director, who worked remotely except on Tuesdays. Rea reported the missing pills and asked whether she should distribute Pulera’s prescriptions while he was in the jail. Dr. Butler declined to set up a regimen at that time and Rea noted that order in Pulera’s chart. Testifying at her deposition, Dr. Butler explained that she made this decision based on the 6 No. 19-2291 missing pills, which she believed might be a sign of abuse and could have made further dosages dangerous. Neither Dr. Butler nor Rea recorded these thoughts in the medical record. Nevertheless, the jail’s written policy supported her decision; it states, as a default rule, that non-compliant medications would not be continued while in custody. That evening, at around 8 PM, Pulera sent his second request. Clariﬁed, it read “My heart hurts. I can’t breathe. I need my meds or I can die. My heart is pounding. They are here, I need you to please bring me my meds ASAP. Thank you.” Rea’s shift had ended, so Nurse Denise Gilanyi received this request instead. She called a correctional oﬃcer to check on Pulera around 9 PM, and the oﬃcer said that Pulera was in no distress: he just wanted his medications. Gilanyi knew that Dr. Butler had decided not to set up the medications just hours before, and that neither prescription was “lifesaving,” so she did nothing further. Near the end of her shift, at 5:55 AM, she wrote back to Pulera that the doctor had not set up any medications. Pulera sent the third and ﬁnal request on Sunday afternoon. This one—again cleaned up—said, “I can’t eat, sleep. I am throwing up and I am dizzy. I can’t breathe. I need my blood pressure taken. Please see me. My brother and mother just died. I need my clonazepam. I am sick.” Within minutes, the nurse on duty, Markella Reed, responded, telling Pulera someone would check his blood pressure. Reed testiﬁed that she based this immediate response on her guess that Dr. Butler would order a blood pressure check, once they talked. Reed further testiﬁed that between receiving the request and responding, she, like Gilanyi, had called a correctional No. 19-2291 7 oﬃcer. This oﬃcer reported that Pulera was complaining he had a cold, walking around, making phone calls, and asking for a TV remote. Unlike Gilanyi, though, Reed did not add this conversation to the chart when it happened. Instead, she wrote it in a late entry the next day, after Pulera’s suicide attempt. When Reed called Dr. Butler, a few hours later, her prediction proved accurate. Dr. Butler ordered a vitals check, both to conﬁrm Pulera’s health and to get him face-to-face with a nurse. She asked that the nurse call her if anything abnormal came up. Reed added the doctor’s new order to the chart. At 6 PM, Reed left, and Nurse Sylvia Summers-Sgroi started her night shift. On reviewing the chart, SummersSgroi saw the order to take Pulera's vitals and to call Dr. Butler if anything was wrong. Around 8 PM, she met Pulera in a small room outside his cell block. She tested and recorded his blood pressure, pulse, respiration rate, blood oxygen level, and temperature. His results were not abnormal, indeed, they were excellent, and she saw nothing else concerning, so she did not call Dr. Butler. Although they disagree on the length of their meeting (Pulera said it lasted only a minute), both Pulera and Summers-Sgroi agree that he did not mention any concerns he had, let alone suicidal thoughts.