Douglas M. Milligan went into the Erie County Correctional Facility with two healthy feet.
Eight days later, he had one good foot and one lopped in half.
That's where Milligan begins his story about Sheriff Timothy B. Howard's medical team at the county-run lockup.
In the 14 years Howard has run the Correctional Facility in Alden and the Holding Center in Buffalo, 30 inmates have died. The public record features numerous complaints, lawsuits and state investigations about poor or indifferent medical care. Now, the record contains at least one amputation.
Surgeons cut off the front of Milligan's foot because, Milligan says, the sheriff's medical staff waited for days as swelling from a suspected spider bite on July 27 spread from foot to ankle to shin, stopping just short of the knee.
Records from Erie County Medical Center bolster his claim. While doctors never confirmed a spider bit Milligan, they found dead tissue around the wound. Infections had set in, including MRSA, which can pave the way for a flesh-eating disease. The doctors drained a puffy abscess and after a round of antibiotics prepared to operate.
Before the anesthesia took hold, Milligan knew surgeons might remove a toe or two.
He woke to learn that under all the bandages, his forefoot was gone.
Spider bite or not?
Because of health privacy laws, Howard's team usually refuses to comment for articles about the problems individual inmates have with health care in the county jail system. But with Milligan, the sheriff's top aides blame the former inmate for any delay that opened the door to dead tissue or methicillin-resistant Staphylococcus aureus – MRSA.
Milligan initially told a nurse only that he had popped a blister on his foot, not that the wound and resulting infection came from a spider bite, said John W. Greenan, the sheriff's chief of administration. Milligan was immediately given an antibiotic, Greenan said.
Two days later, Milligan first mentioned the likelihood of a bite, Greenan said. He immediately received a second antibiotic, Greenan said, and two days after that – on Aug. 1 – he was bound for ECMC.
Researchers have long warned that MRSA infections can follow spider bites, especially in prisons and other close quarters. One study urged doctors to begin "early aggressive treatment" for soft-tissue infections following a spider bite.
But while MRSA can follow spider bites, they are not the only cause or indicator. Sometimes MRSA infections masquerade as spider bites early on. The Mayo Clinic says staph skin infections, including MRSA, generally start as swollen, painful red bumps that might resemble pimples or spider bites.
When questioned by ECMC doctors and The Buffalo News, Milligan said he never saw a spider bite him. He surmised the wound came from a spider because they were in his dormitory and other inmates complained about them.
Erie County's jail system has been urged to do a better job recognizing MRSA. When the U.S. Justice Department sued Erie County a decade ago to force more humane jail conditions, it said Howard's medical teams were failing to diagnose MRSA even after seeing the symptoms of "red bumps, rashes, and the 'spider bite.' "
Whatever the infection that the prison's medical team thought it was treating, first with a topical antibiotic and then an oral antibiotic, the medicines did not work. Hospital records show that not only was Milligan's foot discolored, swollen and painful, he met two of the four criteria for sepsis, the body's sometimes fatal reaction to infection.
Milligan, 51, had been jailed on a felony robbery charge and lesser charges. In a News interview, he admitted taking cash from a West Seneca hotel. A town judge later placed him on probation.
He has a complicated medical history. The record reveals numerous concussions from hockey, football and boxing. He has chronic back pain from a motor vehicle accident in 2016, when he suffered a traumatic brain injury. Anxiety, depression and post-traumatic stress disorder have led to "multiple medications," a passage in his record says. He has had skin infections before, he told the doctors.
Milligan offered The News papers to show he served in the National Guard and the Army Reserves.
He says he has a gambling problem and at least a few arrests. He does not portray himself as a model citizen.
Still, he believes he deserved better attention than he got in the county correctional facility. Here's his story:
When he woke up on the morning of July 27, his foot felt hot, and he saw a red mark on the middle toe of his left foot. He had heard other inmates talk about the many spiders in the large dormitory known as the kilo unit and would later see them himself. He figured it was a spider bite.
A nurse would arrive at the unit each morning and night to deliver medications. Milligan said he approached her that morning to tell her about the bite.
"Put in a slip," she said, according to Milligan. The slip is the written request for medical attention.
While Milligan did so immediately, he said, he was not sent to the medical unit that day.
Greenan, of the Sheriff's Office, said Milligan's initial complaint was only about his ability to buy items from the commissary, the prison store. "There was no indication of any problem with his foot," Greenan said.
By the next morning, the swelling was worse, Milligan said. While his foot and lower shin were red, a distinct triangle of redness flared from the bite mark to the base of his toes.
According to Greenan, Milligan was treated that day, July 28, with an antibiotic. Milligan says he received no treatment. He said the medical staff told him an oral antibiotic – Bactrim – would be ordered. He was returned to his unit.
That night, the pain was unbearable. "If anything touched my leg it felt like broken glass," he said. He said he approached two prison officers and showed them his foot. It was about 2:30 in the morning.
"Oh my God," one said, according to Milligan. The officer asked what would help.
"An ice pack," Milligan told him.
He said he watched one of the officers phone the medical unit. All he wants is an ice pack, he heard the officer say. The officer hung up and assured the inmate an ice pack was on the way, Milligan said.
The ice pack never came, he said. In the medical unit the next day, a nurse told him to never again have a corrections officer call at 2:30 a.m. for an ice pack, he said.
Milligan said on another occasion he pleaded with the nursing staff to do more for his swelling and the pain traveling up his leg.
A nurse cut him off.
"She said, 'you've picked the wrong hotel,' " Milligan recalled.
"That was the knife to the throat," he said.
Greenan said the Sheriff's Office disputes both of those statements. He said the Howard team would release the prison's medical record on Milligan if he signed a form allowing it, and then the truth would be revealed. But a lawyer who filed a notice of claim against the county on Milligan's behalf blocked The News from asking Milligan to sign the form or from interviewing the former inmate a second time. Attorney James Morris said he wants to limit Milligan's public statements before any depositions or trial testimony.
While the ice pack was a no-show, so was the Bactrim, according to Milligan. For two more days he was told the antibiotic had been ordered but was yet to arrive, he said.
Nurses would measure the swelling and bathe his foot with a sterile rinse, he said. But no one seemed willing to send him to a hospital.
"I could tell, someone was afraid to make a decision on me," Milligan said.
ECMC records indicate that on July 31 – four days after he noticed the mark on his toe – prison nurses gave Milligan his first doses of Bactrim. But the antibiotic was slow to work.
Finally, the status quo changed. Milligan said he doesn't know the medical practitioner's name. But the woman said it was time to get him to the hospital, he said. He went to ECMC the morning of Aug. 1.
An emergency room doctor noted cellulitis, the infection making Milligan's skin swollen, red and painful. Also worrisome: Draining the foot had produced "serosinguineous fluid" – fluid tinged with blood that could indicate capillary damage. Then there was the "necrosis," or the dead tissue around the toes.
The physician had Milligan admitted and ordered antibiotics to be given intravenously, the record says. The doctor then expected to consult with surgeons because, his notes said, they might need to do more than remove dead or damaged tissue.
Two days later, Milligan was prepared for surgery. The antibiotics had not helped. In fact, the wound had worsened, according to the surgeons' summary of the case. They told their patient that as they removed dead tissue they might have to take part of his foot – a "transmetarsal amputation," they called it.
That's what they did.
They cut through the skin and "transected the metatarsals," the tubular bones that connect to the toes, the surgeons' report said. They folded healthy skin from the sole over the incision, creating a flap. Then they stitched the flap shut but left a partial opening for the area to drain.
'Head and shoulders above'
On Oct. 31, the sheriff and a top aide, Michael Reardon, assured a County Legislature committee that health care practices at both the Correctional Facility and the Holding Center have greatly improved in recent years. County lawmakers were asking questions because four Erie County inmates had died over a recent three-month period.
But because of lawsuits and health-privacy laws, neither Reardon nor Howard talked specifically about any of those inmates. Not mentioned, for example, was Joseph E. Bialaszewski. He died after a Holding Center nurse thought he was detoxing when he actually was bleeding internally, doctors told his family. Connell Burrell, a diabetic, died after the jail staff gave him a dose of insulin that sent his blood sugar plummeting. The staff then fed him a peanut butter sandwich to raise his glucose – exactly what they should not have done, one medical expert said. When Burrell's heart stopped, the sandwich hampered efforts to insert a breathing tube. A jail nurse was fired.
The Legislature convened a similar hearing in July 2018, after the state Commission of Correction found that the medical and mental health care offered to Holding Center inmate India Cummings before her death was "so grossly incompetent and inadequate as to shock the conscience." At that hearing, Howard told lawmakers the state report was merely an opinion.
When the Justice Department sued in 2009 to force more humane conditions, Howard fought back, saying county taxpayers shouldn't have to provide hotel-like conditions for inmates. But 10 years later, he sat silent as Reardon credited the Justice Department for the dramatic improvement in the health care provided to inmates.
"It took the Department of Justice coming in here and forcing the county to spend money where it was needed," Reardon told lawmakers. Now, Erie County's policies and procedures are "head and shoulders over any jail in the state," Reardon said.
Milligan said that during his troubles at the Correctional Facility, he never saw a doctor. Greenan does not dispute this. "He saw a nurse and a nurse practitioner," Greenan said.
To walk these days, Milligan stuffs socks into the front of his left sneaker, to help him keep his balance and fill out the shoe. When he revealed the foot to a reporter and photographer days ago, he remarked about how well it was healing. For the longest time, the shortened foot had the color of a ham, he said.
"I went into jail with two feet," Milligan said. "I came out with a foot and a half."