WALLA WALLA - It is arguably one of the most private of taxpayer-funded hospitals. And despite offering free medical care, the price of admission would be considered inordinately high by most.
The exterior perimeter of the patient-waiting area is just one tip-off - there are no "welcome" signs, only a high chain link fence topped by coil after coil of razor-sharp wire.
This facility is the newest hospital at Washington State Penitentiary and no one receives care here unless they are behind bars.
Nonetheless, on this day, Trevor Roberts is happy to get the attention his hepatitis C demands, he said. "I started doing IV drugs when I was way young. I shot meth starting at 16."
Now 21, the inmate is serving time for arson and possession of a stolen vehicle, he said from his hospital bed - just some consequences of his drug addiction. Once released, the health effects will haunt him far longer than his prison sentence, he conceded.
But for today, there is a clean, if sterile, room, with nurses attending his needs. Which is nice, Roberts said - his mother died when he was a preschooler and his dad has been out of his life for a long time. "It's better here than in my cell. I get some privacy I don't normally get."
Nurses do end up taking the place of family in some cases, said Julie Mason, inpatient services manager and 20-year nursing veteran of the penitentiary.
Primarily that happens when patients are approaching death and their family of origin has lost all contact. Penitentiary staff works with Walla Walla Community Hospice to help give dying inmates the support of kin,
"We're the buffer," noted Kathy Jackson, a nurse in the infirmary, adding if families are involved, the penitentiary staff works with them. "Now we communicate with the families. Ten years ago we didn't."
When an offender has been in prison a long time, his peers behind bars become family. In those cases, inmates may be allowed supervised visits to dying friends, staff said.
In Roberts' case, effective treatment can delay some of the worst effects of his illness, Mason said. "We do everything we can here. We will do a liver biopsy and treat it with medication."
If this offender is luckier than history indicates, he will get a liver transplant in the future if needed, she added.
Hepatitis and diabetes are two of the most common issues staff at the hospital treat, but it's like any community hospital, Mason noted. "Other than the OB stuff, we have a little bit of everything."
Unlike other hospitals, however, patients get searched, locked into rooms and sometimes restrained. The waiting rooms - separated into a quadrant system by walls and windows to avoid agitation and potential assaults between patients - are overseen by men and women in blue shirts and pants, the uniform of penitentiary correctional officers.
"All the safety and security measures are not just for the staff, but for the patients," explained spokeswoman Shari Hall as she stood in front of a control booth with windows overlooking nursing stations and hallways.
A few steps to one side is the dental clinic. Through a locking metal door, the space looks much like any high-volume practice. Dental stations are separated by short walls and each of the five chairs are filled.
One separate room is used to confine high-risk offenders. Rubberized paint covers the walls and floor.
Some offenders - the prison's official term for inmates, Hall said - enter the corrections system having had regular dental care. "But I think the majority is probably to a lesser degree."
Dentist Herbert Edwards agrees. The providers at the penitentiary treat lots of bad teeth in inmates in general, as a result of poor oral hygiene and poor nutrition, he added.
And then there's "meth mouth" and lots of it, Edwards said. "The men are in their 20s and 30s and they're losing most, if not all, their teeth."
The Walla Walla College graduate has worked at the penitentiary just over a year, landing back in Walla Walla after a stint in the United States Air Force. In his current practice, Edwards is somewhat restricted how he can use his education and experience, he noted. While the Washington Legislature has granted some latitude to save prisoners' chewing molars, every other situation must meet strict criteria, he said.
For example, except for dental emergencies, inmates are not eligible to receive elective oral care until they've been in the Department of Corrections system for two years.
"The state tried to bring (dental care) into the standard like people living in poverty," Edwards said. "The key emphasis is medical necessity. No caps or crowns. We use a lot of composite on teeth. It can be built up and look very realistic."
The dental clinic is just one component of the health care "on the hill," as the Washington State Penitentiary is often referred to.
Built in 2009 at a cost of $25,060,441, the Health Services Building boasts 14 exam rooms in the outpatient area and many typical hospital functions, including imaging capability, emergency medicine, chemotherapy and vision services, thanks in part to excellent relationships with area service providers, Hall pointed out.
Inmates continue to be sent to Walla Walla's two hospitals - it averages 120 a month for events such as major dental and other surgeries, radiations treatment and some emergency matters - but having the on-site hospital saves the state a "lot of money," said Richard Cross, acting health-care manager. When an inmate is "taken downtown," it means dedicating two or more officers to go along, plus the cost of transportation, he said.
Staffed by 50 nurses of varying degrees, three physicians and six mid-level practitioners to serve 1,900 inmates, the hospital has an annual budget of more than $17 million. However, it operated at nearly $1 million under budget this last year, Hall noted. "We work hard to save money."
The inpatient section of the hospital has 46 beds on its five halls, with average occupancy ranging 28-33 patients, Cross said. As well, the mental health wing can house 15 offenders at once and is staffed with a psychologist, counselors, psychiatric nurse and correctional officers.
"It's been running pretty much full since it opened," Cross said. Estimates put the population of inmates who with live with mental illness at almost 500. "There are very limited resources within the community and they end up committing crimes because of their mental illness. They end up here and then they start receiving services," he said.
"We've seen it really go up since the resources in the community went down."
On this day, one inmate was not happy to be counted among those on the unit. "Hey, man! My stomach is killing me," he screamed out from his locked room.
"Medical is aware of it," a correctional officer calmly replied from his post.
Suddenly taking note of the group in the hall, the patient sensed an audience. "They treat you like dogs in here," he yelled. "You see how they have us sleeping on the floor."
The typical stay in the mental health unit is less than a week, Cross said. "It depends on how they respond to treatment."
Here offenders have an outside "yard" to use, consisting of a room with an opening into the fresh air and the rubberized paint, plus one wall-mounted telephone. While not technically outside, it does offer fresh air and a change of environment for a short time, Cross said.
The view from within is more prison buildings and razor wire.
The Walla Walla prison, which stays about 75 percent full on average, also serves inmates from Coyote Ridge Corrections Center in Connell, Wash., adding to a mix of diverse medical needs.
"We have more challenging patients" than the typical hospital treats, said Dan Delp, a physician's assistant. "Because of their lifestyles, biologically a lot of them are older than their stated age."
On a daily basis, the penitentiary hospital is about 75 percent full, Cross said. This section of the health services building offers inmates a true outside yard, with benches to sit and scan the horizon. In this case, more wire and a guard tower in the distance. "We're not known for our views," Cross said.
Jesse Dollison sees it all, the inmate said, pushing a mop along the concrete floor at the center of five hallways. The 34 year old cleans the area seven days a week and was a patient himself, when he broke an ankle a few months ago.
Dollison brought his incarceration on himself, he said. "I've been doing time since 1998, this time since December for possession of a firearm. I like my toys," he said with a grin. "I need to give that up sometime soon."
Seriously, however, staff here does a good job, he said. "They put up with a lot, actually."
It goes with the territory, Mason said recently. "We work with murderers, rapers robbers, child molesters. My expectation is that the care we provide for our patient doesn't look any different than what anyone else gets at a private care facility."
There is no denying her staff nurses a population that is more challenging, she added. "But that's the nature of working in a prison that we agreed to when we accepted our job here. It's a good job."