Monthly Archives: February 2012

Insulin Dosing Made Simple

I have found, in my years of practicing correctional medicine, that few practitioners who come to corrections are comfortable with insulin dosing. In my experience, this is especially true for physician assistants and nurse practitioners, but many physicians have problems, too. Insulin dosing can be complicated and tricky at times, but for most patients, 10 simple rules will get you to where you need to be.

We first need to cover some groundwork and some terms. Insulin terminology can be confusing. First, it is very important to remember that this discussion applies to type 1 diabetics only. Type 2 diabetics sometimes use insulin, but that’s a “whole ‘nother ballgame.”

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The Ankle Rules–You Don’t Always Have to Get an X-ray!

Brian, Correctional Mental Health Professional. And his ankle.

Back in the days when I worked in the ER, I ordered a lot of unnecessary x-rays.  Ankle x-rays were a particular problem.  Often I was sure that there was no fracture, but I ordered the x-ray anyway because of habit–patients with injured ankles got an x-ray.  That’s just the way it was.

So I loved the Ottawa Ankle Rules when they came out.  The Ottawa Ankle Rules were developed by a group of doctors in (where else?) Ottawa to determine which ankle injuries did NOT need to be x-rayed.  They have been studied many times and have been found to be  accurate.  When used, Ankle Rules can cut the number of ankle x-rays by a third, easy.

The Ottawa Ankle Rules can be even more important in corrections than in the ER.   There, the only downsides to an unnecessary x-ray were expense and time.  But in corrections, x-rays can be a logistical and security nightmare.  So it is good to know when you don’t have to order an x-ray for the inmate who twisted his ankle attempting to dunk the basketball at rec.

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Since when did antibiotics become the one and only treatment for acne?

Since when did antibiotics become the one and only treatment for acne?  It seems to be a common thing for Continue reading

The Right Way to Deal with Outside Physicians

Those of us who practice medicine in jails frequently (Frequently? Daily!) run into the thorny issue of our relationship to the doctors who care for our patients outside of the jail.

When patients are in our jails, we are responsible for them; they are our patients. But these patients also have doctors outside of the jail that perhaps they have been seeing for years. The inmate considers their outside physician to be their “real” doctor, not us. (Throughout this article, I am going to use the term “doctors” rather than the more generic “practitioners.” I do not mean to slight nurse practitioners or physician assistants. What I say applies to them, as well.)

What brought this topic to mind is a case that occurred in one of my jails recently. A patient came to jail with a prescription pad filled out by his outside physician authorizing him to have a double mattress, an extra blanket and an extra pillow. (There was no note requiring us to feed him pizza every Friday night—he must have forgotten to ask for that.) So I was left in a little dilemma. What should I do about this note? Ignore it? Allow the inmate to have the extra comfort items?

Dealing with inmates’ outside physicians can be tricky, but I have found (mostly through sad experience) that there is definitely a right way and a wrong way to handle these encounters. The right way involves recognizing three important points:

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Tasers and Narcotics

Emergency Medicine News this month had two articles of interest to corrections.

The Physiology of Tasers reviewed research into the safety of Tasers including a US Department of Justice study from 2009.

I think that those of us who evaluate patients who have been Tasered, as well as those correctional officers and deputies who carry Tasers, should have some familiarity with the research into Taser safety.  This is a good, short article on that subject.

The second interesting article in the same issue, Second Opinion: Treating Pain a Little Too Well, is an editorial on the striking rise of prescription narcotic abuse and deaths in the last few years.  The author is an ER physician, but the points he makes about pain scores,  patient “entitlement” to be pain free and people trying to “anesthetize their lives” will strike familiar chords for those of use in correctional medicine.

Beware the Compliance Trap. It will catch the unwary . . .

"I take 6 Dilantin caps a day."

I had yet another patient recently who demonstrated what I call the “Compliance Trap” of corrections.  The Compliance Trap is simply this—on the outside of jail, in the real world, most people do not take their medications perfectly.  They miss doses.  They forget sometimes.  Many studies have demonstrated this.  But when these same people come to jail, they get their medications passed to them every dose—they do not miss doses.  They are compliant with their medication dosing in a way they weren’t on the outside.  And this can sometimes get them into trouble.

Take for example, the patient who came to my jail with a prescription for Dilantin 600mg a day.  This is a huge dose!  But he had a legitimate prescription for it and so it was continued at the same dose in jail.  However, two weeks late, he began to have nausea, vomiting and dizziness.  We checked his dilantin level and it was 32–he was toxic!  Dilantin 600mg a day was, indeed, too big of a dose for this patient.  In fact, after we had adjusted his dose and checked levels a couple of times, we found that the proper dose of Dilantin in this patient was a more modest 400mg a day.

So how did this happen?  I did not interrogate this patient’s outside doctor, but I think I know what happened.  He kept returning to the outside clinic with subtherapeutic blood levels of Dilantin and the doctor kept increasing to dose.  However, the reason the patient had subtherapeutic blood levels was NOT that he was a super-rapid metabolizer of Dilantin; rather he just hadn’t been taking it every day.  He had been missing doses.

But when he came to jail, the jail nurses made sure he did not miss any doses and quickly, he was toxic.

So that is the Compliance Trap.  Outside of jail, many patients do not take their medications regularly or at all.  When they come to jail, they don’t miss doses.  Outside–not compliant.  In jail–compliant.  And sometimes this can make them sick.

The Compliance Trap–Examples

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Interesting References of the Week!

OneTouch Ultra2 is being used by a diabetic pa...

Is this really necessary?

Self Monitoring of Glucose in Type 2 Diabetics Does Not Work

The Cochrane Review did an analysis of 9 studies of self monitoring of blood glucose.  In these studies, There was no beneficial long term effect of self monitoring of blood sugars in Type 2 diabetics not on insulin.  The authors say “We did not find good evidence for an effect on general health-related quality of life, general well-being, patient satisfaction, or on the decrease of the number of hypoglycaemic episodes. “

I had run into this concept before. This study randomized Type 2 diabetics into two groups.  The first group received glucometers and were encouraged to check their  blood sugars as frequently as they wanted.  The second group had no glucometer and could not check their own blood sugars.  At one year, there was no significant benefit to self-monitoring of blood sugars.  In fact, the only significant difference between the groups was that the self-monitoring group had more depression!

Of course, all patients on insulin, whether Type 1 or Type 2, need to have their blood sugars checked at least every time they get insulin.

However, the take home message from these studies for me is that doing a lot of glucometer checks in Type 2 diabetics who are not on insulin is probably a waste of time, despite the fact that it is heavily marketed on TV.  The proper way to follow diabetic control in these patients is by using the HbA1C every 3-6 months.

If you do frequent blood sugar checks in these patients at your facility, bring up the Cochrane Study at your utilization review committee meetings and talk about it!

I know that this can be a controversial topic.  Any feedback?

Fun Reads of the Week

Can Statistics Predict Recidivism Rates?

The Incredible Flying 91 Year Old

“Merely having an open mind is nothing. The object of opening the mind, as of opening the mouth, is to shut it again on something solid.”
– G.K. Chesterton

What’s the most cost-effective way to treat scabies? The answer might surprise you . .

Tiny, itchy red dots! Yowser!

All correctional medical people should be able to recognize scabies by sight. 

Just to review, scabies is a tiny mite that burrows beneath the skin and causes intensely itchy lesions. Since the mite wanders (as little animals will do), scabies tends to spread with time, and can be passed from individual to individual.  Weirdly, scabies does not cause lesions above the neck, probably because of the increased blood supply there. If you are interested, you can find more detailed information on scabies in Wikipedia.

Scabies is found commonly in correctional facilities.  Both nurses and practitioners need to be able to spot scabies, hopefully before it spreads throughout a housing dorm! Continue reading

Is this patient psychotic? Or Delirious?

Delirious or psychotic? Sid Hamberlin, Jail Commander, Bonneville County Jail

In my career in corrections, I have seen 4 or 5 cases in which a patient was thought to be acutely psychotic, but actually was suffering from delirium.  A typical case would present like this:  Deputies report that Mr. Jones is acting strangely.  He is talking to the wall of his cell and seems to be attempting to turn on a TV that isn’t there.  He has been in jail for 5 days and was acting normally yesterday.  Mr. Jones has a vague history of mental illness (he is on citalopram for depression) and so the deputies call mental health.  Mr. Jones is not thought to be a danger to self or others, so is seen by the jail psychiatrist the next day.  The psychiatrist notes a heart rate of 150, sweating and disorientation and diagnoses not psychosis but acute alcoholic Delirium Tremens (DTs).

Just to review, the term “delirium” refers to a syndrome of disorientation, confusion and often hallucinations caused by a specific disease process.  For example, people who become septic from serious infections can become delirious.  Pesticide exposure and overdose of many street drugs like “meth” and Ecstasy can cause delirium.  Probably the most common cause of delirium in jails is the delirium of alcohol withdrawal, called “Delirium Tremens” or DTs.

Missing this diagnosis is very important since  alcoholic Delirium Tremens is a life threatening condition.  Some references put the mortality of untreated DTs as high as 30%.  Were this patient to die because we missed his Delirium Tremens, well, it doesn’t look good on a resume.

So how did it happen that this life threatening condition was not recognized?  As is often the case, several things went wrong here.   First, Mr. Jones adamantly denied any history of alcohol abuse or previous withdrawal at booking and so was not placed under observation for withdrawal.  He probably showed the typical early signs of withdrawal like hand tremors and sleeplessness but since he was in the dorm with a lot of other inmates, nobody noticed.  Finally, and most critically, when he did begin showing signs of delirium, it was mistaken for psychosis.  Nobody thought of alcohol withdrawal because Mr. Jones just didn’t fit the pattern we normally think of for alcohol withdrawal.  He was acting crazy, so was thought to be crazy, not sick.

How To Tell Delirium from Psychosis (It’s Usually Easy)

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An Unusual Case of Cheeking

Idaho Sunset

Like everyone in corrections, I have seen my share of cheeking.  For those who may not know what this is, “cheeking” is the slang term for when inmates pretend to swallow their medications but really secrete the pills in their cheek (hence the name) or elsewhere in their mouth.  Some cheekers are really good at sleight of hand, and palm the pills as they pretend to pop them in their mouth.  Some spit the pills into the cup that holds their water.  A good correctional nurse will usually catch such attempts.

Some inmates, however, will get really creative.  We had one inmate who was missing a tooth and he would slide the white pill into the empty socket so that when he showed his mouth, the pill would look like a tooth in a row of teeth.  Another inmate put denture adhesive on the roof of his mouth and then stuck his pills onto the Fix-o-dent, so they weren’t visible when the nurse would check his mouth.  But I recently ran into a method of cheeking that was new to me.

This was discovered when a certain inmate had a dystonic reaction of the type that occurs sometimes with phenothiazines like Haldol.  Only he was not taking Haldol and the only inmate who possibly could have cheeked the Haldol and given it to this inmate was his roommate, a guy I will call Fred.

Fred had a long history of cheeking medications.  He had tried many creative methods and had been caught on numerous occasions.  Most recently, Fred’s medications were being crushed on the assumption that that the powder could not be manipulated and hidden.  However, Fred found a way around this.  He would pretend to swallow the powder, but would leave it on the back of his tongue.  Then, when the nurse had gone, he would scrape the powder off of his tongue and mix the powder with saliva to make a paste.  He then would dry the saliva-wad and sell this concoction to other inmates.  By the way, the spit wad pill contained all of Fred’s medications, not just Haldol.  He was on several.

Apart from the initial aesthetic response to such a thing (Ewww!), there are some lessons to be learned from this.  First, some inmates are so desperate for psychoactive drugs to substitute for their preferred drugs of abuse outside of jail, that they will do near anything to get them, including eating a spit wad with who knows what in it.  This is especially true for medications with very high value in correctional sttings, such as Seroquel and Trazodone.  But anything that will alter consciousness will work.

Second, the effort we put into preventing cheeking is part of “the good fight.”  We cannot prevent all cheeking—inmates are too creative.  But inmates who purchase and consume someone else’s medications may have serious adverse reactions.  The inmate consumer in this case only had a nuisance reaction (dystonia) that we easily treated with Benadryl.  But it was still quite unpleasant and could be worse next time.  I believe that our efforts to prevent cheeking are part of our overall “due diligence” efforts to keep our patients safe.