When Nevada death row inmate Charles Randolph asked for a specific medicine to address his heart condition earlier this year, Max Carter, the prison's physician assistant, sent a curt reply: The medication was the wrong kind and potentially lethal, but he would be happy to prescribe it "so that your chances of expiring sooner are increased."
When another prisoner, John O. Snow, asked for pills in July to ease the pain from his deteriorating joints, Carter's denial came with another stinging missive, stating that he was "gonna let you suffer."
To many prison observers, Carter's responses exemplify the callous indifference custody officials at the maximum-security Ely State Prison have for sick prisoners. There has been no staff doctor to handle the medical needs of any the 1,000 inmates here for more than 18 months. Carter is the highest-ranking medical worker at the men's prison; the last staff doctor was a gynecologist.
According to interviews and records obtained by The Times, prisoners at Ely have been denied care for heart problems, diabetes and other serious medical conditions. Earlier this year, a nurse was fired after complaining about substandard care at the facility, which she said led to one inmate needlessly dying of gangrene.
Attorneys for some Ely inmates say they believe the lack of medical care has played a role in a high percentage of death row inmates giving up their appeals and "volunteering" to be executed. All but two of 12 inmates executed in the state in the last 30 years have been volunteers. No other state in the country has had close to that percentage of volunteers, records show.
Recently, the American Civil Liberties Union's National Prison Project has taken up the cause at Ely. ACLU attorneys Amy Fettig and Margaret Winter have met with corrections officials and pressed for reforms to improve inmate care.
A doctor working with the ACLU was granted access to 35 inmates and their medical records in October, and he came to a stark conclusion.
"The medical care provided at Ely State Prison amounts to the grossest possible medical malpractice, and the most shocking and callous disregard for human life and human suffering that I have ever encountered in my 35 years of practice," Dr. William K. Noel said in a report sent Wednesday to Howard Skolnik, director of the Nevada Department of Corrections.
"It is highly unlikely that these 35 cases are aberrations," Noel wrote. "These cases show a system that is so broken and dysfunctional that, in my opinion, every one of the prisoners at Ely . . . who has serious medical needs, or who may develop serious medical needs, is at enormous risk."
Skolnik said Wednesday he had not seen Noel's report and could not comment on any specific allegations. However, he added: "I do know that I have recently been informed through some other auditing that the access to medical care and the quality of care provided by the department meets or exceeds community standards."
An attorney who represents the corrections department said she could not comment, as did an assistant to prison warden E.K. McDaniel.
Max Carter did not respond to messages left for him at the prison's medical department.
Dr. Steven MacArthur, the obstetrician-gynecologist who was the prison's last staff doctor, said it was difficult to treat inmates with severe psychological problems and who cursed and spat at staff. Some prisoners refused to visit the infirmary simply because they couldn't smoke there, he said. Nonetheless, he said, they were well cared for.
"Most inmates age in dog years. They beat the hell out of themselves," he said. "They have lots of aches and pains."
In his report, Noel said he found instances of prisoners being denied medical attention despite suffering from seizures, syphilis, deep vein thrombosis and rheumatoid arthritis. He acknowledged that many Ely prisoners "have committed horrible crimes" but said physicians took an oath to make "no judgments as to character or morality" when treating a patient.
Under a 1976 Supreme Court decision, based on the 8th Amendment's prohibition against cruel and unusual punishment, government officials are obliged "to provide medical care for those whom it is punishing by incarceration."
In a letter accompanying Noel's report, ACLU attorneys Fettig and Winter asked the director of corrections to set up a meeting with Gov. Jim Gibbons because the "medical crisis" at the prison goes far beyond the lack of a doctor and it "seems unrealistic to expect" the department "to summon the resources to resolve the problems without the assistance of the governor and the Legislature."
The facility, which opened in 1989, is more than 250 miles from the state's population and power centers: Reno, Las Vegas and capital Carson City, where executions take place. It handles the day-to-day medical needs of prisoners, but if inmates experience serious ailments, like chest pains, they are sent to a local hospital; life-threatening cases, such as stabbing victims, are airlifted to a larger city.
The prison sits about a dozen miles outside its namesake's downtown.
The prison's desolation -- a source of frustration to inmate families and defense attorneys -- is part of its appeal to the 4,000-person town, said Mayor Jon Hickman The facility is easy to ignore, he said. It also provides hundreds of secure jobs to a city whose economy is tied to the tumultuous mining industry.
In this setting, inmate advocates say, corrections officials have denied prisoners needed antibiotics, pain pills and surgeries with little outcry because no local groups exist to do so. When a nurse who had worked at the prison for nearly a decade spoke out, she was forced to scrub the infirmary floor with a toothbrush, court papers say.
That nurse, Lorraine Memory, said in an interview that the prison's dozen or so medical staffers lacked equipment, including an IV pump and a blood pressure monitoring machine, that were particularly helpful during a medical trauma. Little training is provided to the staff, some of whom struggle to use a defibrillator, said Memory, who was eventually fired.
Jewel Jacques, a nurse who has worked at Ely since 1993, and two other prison staffers have signed declarations backing up Memory's account of prison conditions.
Most inmates complaining of pain are given only a handful of Tylenol a week, Jacques said.
Relatives of some inmates say prisoners with minor ailments often avoid the infirmary, convinced that Ely's medical staff would either ignore or harm them.
Inmate Snow, who is on death row for the 1983 contract killing of a Las Vegas nightclub owner, has no cartilage in his hips, but was given no painkillers to cope with bones that scrape against one another, Noel's report said. Instead, the prisoner was prescribed Indocin, whose side effects are so severe that the anti-inflammatory medication is mainly used on horses.
At Noel's suggestion, Dr. Robert Bannister, medical director of the state corrections department, changed Snow's medication. But the doctor is still balking at allowing Snow to have hip surgery, Noel wrote. Without it, the inmate will eventually be unable to move, Noel said.
Bannister did not return calls seeking comment.
Such cases frustrate medical staff who said their superiors had long shrugged at inmate suffering because they were concerned about the costs of treatment, according to court papers.
In a complaint to the federal Equal Employment Opportunity Commission, Memory alleged that two diabetic prisoners were denied insulin because MacArthur "wanted to hasten the demise of these two inmates in order to save money or cause them more pain and suffering."
MacArthur denied the allegations.
One of the diabetics, Patrick Cavanaugh, likely suffered from dementia after three years without insulin, according to Noel's report.
Cavanaugh, a former manager for the rock group the Coasters, was on death row for shooting to death one of the group's singers, mutilating his body and dumping it in a canyon.
In prison, Cavanaugh developed gangrene, Memory wrote, and his "toes and feet turned black and this gradually progressed up the legs until it had turned into a stinking, rotting, oozing mess of dead flesh which had reached clear up the level of his knees."
Cavanaugh's medical records, however, described his condition as cellulitis, which Noel said was akin to calling "9/11 a high-rise fire."
MacArthur said Cavanaugh refused oxygen and was never denied insulin. If he was not given it, it was because Cavanaugh declined it, the doctor said.
Cavanaugh died in April 2006; his death certificate was signed by a doctor who had not seen the body and lists "natural causes" as the reason, Memory said.
A month later, state officials fired MacArthur -- but not because nurses and other prison employees charged that he provided poor or negligent care. Rather, corrections officials said, it was because MacArthur refused to give up his full-time job at the local hospital, though there was no evidence that it caused him to neglect his prison duties.
MacArthur said the dismissal was unmerited. In a letter to his private practice patients he said that he "was responsible for saving the taxpayers of this state $1 million per year."
In an interview with The Times this week, MacArthur said he was proud of care he provided to prisoners, but acknowledged limits on what the medical staff would treat.
"We didn't cater to every rash and boo-boo that you'd run to your mommy and get kissed," he said.
Powers reported from Ely and Weinstein from Los Angeles.