Monthly Archives: March 2012

Constipation: Straight Talk on the Last Taboo Subject

I have decided after many years of dealing with complaints of constipation both in the ER and in correctional facilities that bowel health is the last taboo subject.  We all received “The Talk” (about sex and reproductive health) when we were adolescents.  But nobody seems to talk about how to have a proper bowel movement.  It is a subject that inevitably causes giggling and uncomfortable laughter.  It is not spoken of in polite society.  As a result many people do not understand how their bowels work.  I have found this to be a big problem in the jails I work in.  Inmates complain of constipation when they are not really constipated.  They are bowel-fixated when there is no reason for them to be.  Often, they need education more than they need laxatives. To this end, I want to discuss several essential factors relating to understanding and treating constipation that may help make your correctional medicine practice a little easier. Continue reading

Is It Possible to Withdraw From both Alcohol and Opiates at the Same Time?

Medicine in the Future.

I recently participated in a Webinar entitled “Managing Alcohol Withdrawal in the Correctional Setting.” During the question and answer section of the Webinar, a question was posed about how to manage the patient withdrawing from both alcohol and heroin at the same time.  I have been thinking about this question since.  In all my years of practice in correctional settings, I personally have never seen a patient who was simultaneously withdrawing from both alcohol and narcotics.  Is such a thing even possible?

After thinking about it, I have decided that this question this question has two answers:  a theoretical answer and a practical answer.  The theoretical answer first:

Theoretically, if a patient was truly suffering from both alcohol withdrawal and heroin withdrawal at the same time, our primary concern would be alcohol withdrawal rather than heroin withdrawal.  The reason for this is that patients die from alcohol withdrawal; it is a potentially lethal problem.  Heroin withdrawal, on the other hand, can be a serious medical problem, but does not tend to be lethal.  I was an emergency physician before I came to corrections, and this principle was drilled into us over and over–you deal with the life threatening concern first. Continue reading

Rethinking Bedtime Snacks for Type 2 Diabetics

I had an obese Type 2 diabetic patient at one of my jails recently who wrote a long grievance about not receiving a bedtime snack.  He argued in the grievance that he had received a bedtime snack at previous facilities where he was incarcerated (which was true) and a bedtime snack was “the standard of care” for Type 2 diabetics.  I thought that this argument was ridiculous, especially since this patient routinely purchases lots of candy bars and Ramen Noodles from the commissary (think 30-40 candy bars a week).

However, despite the fact that bedtime snacks are routine at many correctional facilities, I believe that bedtime snacks for Type 2 diabetics in a correctional setting is, in most instances, a bad idea and bad medical care.   I would like to discuss why this is so by discussing what our overall goals for Type 2 diabetic management are, where the whole idea of diabetic snacks came from in the first place, and then present three cases. Continue reading

Pop Quiz: Medication and Lab Prices

One thing that has long bugged me about how medicine is practiced in the United States is that medical professionals for the most part have no idea how much stuff costs.   Doctors prescribe medications that their patients cannot afford to buy—even when cheaper alternatives are available.  We order tests not knowing what the patient is going to be charged.

This phenomenon occurs nowhere else in American culture.  It is kind of odd when you think about it.  It would be like going to the grocery store and having no prices on any of the food.  You could only get the meat that the butcher recommended, but he wouldn’t know the price of anything, either.   The first inkling you would have about costs would be when you got your bill in the mail a month later:  “Wow—that chuck roast was $200.00 a pound!” Continue reading

Food Allergies: Sorting out Truth From Fiction

In my previous incarnation as an emergency physician (before I discovered “The Way” of correctional medicine), I saw a lot of cases of acute allergic reactions. It is a very common emergency complaint; I have probably seen hundreds in my career. But when I began my jail medicine career, I was still unprepared for the sheer volume of food allergies claimed by inmates. Who knew so many inmates had so many food allergies?

Of course, most of them don’t. Most just don’t want to eat something on the jail menu. Inmates believe that if they claim an allergy to a food they dislike, you cannot serve it to them. They will claim allergies to tomatoes, onions, mayo, etc., when really, they just don’t like these foods. Tuna casserole doesn’t seem very popular, for some reason. Continue reading

Diabetic Case Studies–The Insulin Rules in Action!

People come to jail taking the weirdest insulin regimens.  Often times, I don’t know whether these insulin schems are the result of a practitioner who does not understand insulin dosing well, or whether the patient “tinker” with their insulin dosing, themselves.  Here is a case from one my jails  (I have changed some of the data and patient characteristics to protect patient privacy).

English: C. H. Best and F. G. Banting ca. 1924

Banting and Best, Discoverers of insulin

A type 1 diabetic comes to jail taking Lantus 15 units in the morning and 40 units in the evening.  He says he takes his Humalog on a sliding scale, but when asked to define exactly what the parameters of his sliding scale are, it becomes apparent that he basically decides his Humalog dose based on gut-feeling.  He may take nothing; he may take up to 15 units.  He certainly has no concept of counting carbs.  He thinks his average Humalog dose is 6 units.  His admission HbA1C is 12.8, or an average blood sugar of over 300.  In other words, he is not doing a very good job of controlling his blood sugars on the outside.

Anyway, let’s apply the rules of insulin dosing to this patient: Continue reading

A Quick-and-Easy Solution to those Pesky “Own Shoes” Requests

Sgt. Tracy Cox has permission to wear her own shoes in the jail.

Everyone who works in corrections is familiar with inmates wanting medical authorization to wear their own shoes.  A typical case would go something like this:  “I have chronic back pain and walking on these hard concrete floors makes it worse.  Will you authorize me to wear my own shoes?  You did last time I was in here and it really helped.”

We need to keep in mind, however, that allowing an inmate to wear his own shoes gives that inmate secondary gain.  Shoes from home are, indeed, more comfortable than the typical jail sandals.  Also, any inmate who is granted a special privilege, like wearing his own comfy shoes, gains status among the other inmates.  When we approve inappropriate requests for “own shoes,” we are bestowing prestige upon that inmate.  And we are denying that prestige to those who we refuse.  The unfairness of this is not lost on inmates.  Finally, “own shoes” are occasionally used to smuggle contraband into the facility.  I remember one pair that had an ingenious hollow space carved out of the sole that was not easy to find on a typical security examination.  If you routinely grant requests for “own shoes,” you will inevitably get burned in this way. Continue reading

Should the Flu Vaccine be Mandatory?

Recovering at home with Ed the dog.

So I caught the flu last week and I have been pretty miserably sick for going on 7 days; fever, achy, cough.  Also cranky, peevish, and insufferable.  My hair hurts!  Is that even possible?

I usually get a flu shot, but I didn’t get one this year.  Why not?  I just didn’t get around to it.  It would have been easy.  All I had to do is ask one of the nurses to give me one back in the fall when we were doing them.  Duh.

The CDC announced the official onset of influenza season a couple of weeks ago.  Flu season is extraordinarily late, probably due to the mild winter most of us (me included) have experienced this year.

Coincidentally, around the same time as this announcement (and before I myself caught the dreaded bug), I ran across a couple of thought-provoking articles dealing with the flu that are relevant to our institutionalized patients. Continue reading

Patient Weight is a Powerful Diagnostic Tool!

Patient weight is a powerful diagnostic tool that is underutilized in corrections. 

The reason for this, probably, is that not much attention is paid to weights in outside medicine.  In a general medical clinic, say, a patient’s weight could be compared to their last routine visit and some general conclusions might be reached–such as “You have gained 10 pounds since last year.  This is not good for your general health.”

However, things are different in corrections.  Our patients are with us all the time–they never go home.  Many are “frequent fliers” in the medical clinic, either due to their medical problems or because they complain a lot.  I have found that patient weights in correctional clinics are a gold mine of useful information.  So much so, that I think a patient weight should be the Fifth Vital Sign.

Let me give you several situations where weights will help you.  Often, the patient weight is the only objective evidence you have to assess a patient complaint!

Continue reading