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Escape artist with MDR-TB is back in the san’
A fractious patient with multidrug-resistant (MDR) tuberculosis and a history of multiple escapes is back in the state TB sanatorium for the fourth time, to the frustration of Florida state TB controllers. The 46-year-old man, who is also infected with HIV, has escaped three times from A.G. Holley Hospital in Lantana. During a three-week trial, attorneys for state TB control argued that the man was a public health risk, while hospital staff members testified the patient had been verbally and physically abusive.
Even so, the judge hearing the case declined to send the patient to jail to finish out his treatment. Instead, he suspended a jail sentence and ordered the patient back to the state sanatorium — adding that if he caused any trouble this time, he’d wind up behind bars for certain.
So far, the patient reportedly has been cooperative. Accreditation standards prohibit the facility from installing the bars and locks the judge had asked to be added; but the hospital has assigned employees to keep watch over the patient 24 hours a day, a measure that may cost over $100,000 by the time treatment is completed.
"We’re not a forensic unit here," says David Ashkin, MD, medical director of the state TB control program. "We do have a locked ward, but we have no bars on our doors and no correctional guards. This is unique for us in Florida; we’ve traditionally handled such situations as civil cases."
About half the patients who wind up at Holley are remanded there on court order, Ashkin adds. The vast majority complete treatment without any problems. "Over the nine years I’ve been here, we’ve treated 900 patients," he says. "This is the first time we’ve ever had to bring criminal contempt charges against one of them."
Ironically, Lake County Judge Richard Boylston suggested the strategy that attorneys for the state used. After first ruling that Florida’s civil detention law could not be used to keep a noncompliant TB patient in jail, Boylston suggested to state attorneys that they bring criminal charges against the patient by filing a contempt-of-court charge. That strategy made good legal sense, says Kimberly Tendrich, chief attorney for the TB control program, because the patient had already violated court orders to complete treatment at Holley.
Jail sentence matched treatment time
Next, the defendant entered a guilty plea to the contempt charges, which carry a sentence of no more than 179 days in jail. The judge handed down a 179-day sentence — which would have carried the patient through to the end of treatment — but then, to the surprise of state attorneys, the judge suspended the sentence and ordered the patient back to the state "san."
"I’m shocked at the decision," says Tendrich. "I don’t understand the judge’s motive for putting him back [at Holley]." Especially frustrating to TB controllers is the fact that the county jail (where the patient had been held during the trial) is well-equipped to care for TB patients, with several jail cells under negative pressure, Tendrich says. Confining the patient to jail for the remainder of treatment would have posed only a "nominal cost" to the county, she adds.
But jail officials had strongly resisted housing the patient for the remainder of his treatment and wanted him returned to Holley. "It’s ironic," Tendrich says. "He’d been in jail before, and since he hadn’t told anyone about his TB, they hadn’t been treating him. Now he’s no longer infectious, and they don’t want him."
Florida’s statute on civil detention directs the use of "the least restrictive possible" means for treatment of noncompliant patients, Tendrich explains. Treatment settings listed include "hospitalization, placement in another healthcare facility or treatment facility, or isolation at home" but the list of options doesn’t explicitly include jail, she adds.
Law not to blame: Attorney
Even so, Tendrich says she doesn’t believe the wording of the statute is to blame for what happened; nor do lawyers for the state plan to try to have the statute amended. "Having [jail listed as a possible setting] would have made our life easier at certain points during the trial," says Tendrich. "But we do have the ability, if someone violates a court order, to bring them to jail on criminal contempt charges. Truly, the judge had the authority to do this."
Counsel for the patient argued that because the patient had committed no crime, he didn’t belong in jail and should be permitted to post bond. The patient, who has two grown sons in his so-called "county of origin," wanted to return home and complete treatment there. After Boylston ruled the patient couldn’t bond out of jail, the patient threatened to stop taking his medications. (The following day, his attorney explained his client was "just venting.")
The patient had begun treatment for drug-sensitive TB almost 10 years ago. After outreach workers supervising his therapy lost track of him, he was sent to Holley for the first of three times. He escaped in 1992, 1993, and 1995 — once by lowering himself out the window on a bed sheet. By that time, cultures showed the patient had become resistant to three first-line agents.
The patient was then convicted on a burglary charge and spent 18 months in prison, where he received anti-TB therapy. Once his prison sentence ended, TB controllers petitioned to have him kept in jail while he finished the remainder of his treatment.
"The worst thing about all this is that [between 1995 and the present time] this man was on the loose for five years," says Tendrich. "How many people has he infected with [MDR-TB] during that time?"
If the state TB control program and A.G. Holley Hospital decide they can’t foot the bill for the patient’s 24 hour-a-day watch, they will seek reimbursement from the patient’s county of origin, notes Tendrich.