Monthly Archives: April 2013

Judges Practicing Medicine Continued

With regard to the recent article about judges issuing court orders for medical treatments while in jail, I wanted to get a legal perspective, so asked my friend David Tatarsky, who is General Council for the South Carolina Department of Corrections, for his thoughts.

South Carolina Department of Corrections

South Carolina Department of Corrections (Photo credit: Wikipedia)

Here is his response:

My thoughts   (all of which must be considered in light of the particular judge you are dealing with):

1.         You are exactly right about the major cause of this problem—–no one in the courtroom representing the interests of the jail/prison. The parties just want to get the plea completed and move on to the next case. Your solution is great if you can successfully develop the type of relationship you have created with the prosecutors.

2.         In some states, judges may be expressly prohibited from requiring particular medical treatment in a sentencing order.  Jails/prisons should check with Legal on this.  The analogous situation is when a judge sentences an inmate and requires the DOC to house the inmate in a particular prison.  In South Carolina, there is a state statute that says the DOC has the exclusive authority to determine where an inmate is housed:

(A) A person convicted of an offense against this State and sentenced to imprisonment for more than three months is in the custody of the South Carolina Department of Corrections, and the department shall designate the place of confinement where the sentence must be served.

Here is another one I use in South Carolina:

SECTION 24-1-130. Management and control of prison system.

The director shall be vested with the exclusive management and control of the prison system, and all properties belonging thereto, subject to the limitations of Sections 24-1-20 to 24-1-230 and 24-1-260 and shall be responsible for the management of the affairs of the prison system and for the proper care, treatment, feeding, clothing, and management of the prisoners confined therein. The director shall manage and control the prison system.

This is basically what attorneys call a “separation of powers” argument.  Managing inmates belongs to the DOC, a part of the Executive Branch of government.  A judge who tries to assume this power is going outside the power/authority of the Judicial Branch of government.

3.         Sometimes the problem can be solved via education.  Judges, like lawyers, have continuing education requirements.  See if you can get this issue addressed at a CLE for the judges.  My office does a lot of training for prosecutors, public defenders and (sometimes) judges on sentencing issues.  Maybe ask the legal office for the DOC in your state if they can help.

4.         Tied in with the education issue—many (most??) judges know little or nothing about how jails and prisons operate, because most attorneys, before they become judges, learn little or nothing about the corrections system.

5.         If your agency has in-house counsel, ask him/her to contact the judge when you get one of these orders.  What I sometimes do is write to the prosecutor and defense attorney, letting them know that the order is improper and asking them (nicely) to have it corrected.  If I get an unsatisfactory response, I sometimes contact the judge’s law clerk.  Judges do not want to look stupid.  If someone points out the issue to the judge (without embarrassing him/her), he/she may fix it.

6.         A “split the baby” approach is to have the judge “recommend” rather than order some form of treatment on the sentencing order.  Then you can just look at the medical issue when the inmate arrives and exercise your own professional judgment.

These are all excellent points.  I wonder how many other states have a “separation of powers” statute like South Carolina’s.  Mine does not (sadly).

I also like David’s idea of trying to get on the judge’s required Continuing Education schedule.  I intend to do this, myself.  If I am successful, I will write about the experience here.

Davis County Jail Success Story

Tied in with David’s thoughts, I especially liked James Ondracek’s comment about his experience:

I have been the Nursing Director at Davis County Jail for almost 20 years now. I have the e-mail addresses and phone numbers of every court clerk in Davis County. I contact them every time we have a medical issue that requires assistance from a judge. None of our current Judges will grant medical furloughs without contacting me first. I have inmates tell me all the time that they requested a medical furlough and the judge told them to talk to the jail medical staff first because he will not grant a furlough without receiving a recommendation from the jail. Likewise we do not currently, have a problem with judges ordering medications in the jail. It has taken many years of working with judges and attending judge meetings and getting prosecutors to help reverse court orders in the past, but it has paid off in the long run. I have met with many of the judges in court chambers about specific inmate needs and discussed having the judge grant medical furloughs and releases from jail when appropriate. It is very worth it to build relationships and understanding with prosecutors, judges, and attorneys. You will not win every battle but from my experience, most judges are glad to contact the jail with a concern and glad to tell the inmate that the jail will take care of his medical needs and he is not qualified to make medical decisions as a judge. Incidentally, I have never had any of our doctors come to a meeting with a judge. I will occasionally ask him for a note to take with me to meet with a judge or the prosecutor but we have always been able to handle this with our in-house staff.

The key quote here is this: It has taken many years of working with judges and attending judge meetings and getting prosecutors to help reverse court orders in the past, but it has paid off in the long run. It takes time and effort to cultivate a close relationship with judges and prosecutors.  But it is well worth the effort.  Besides being a medical care issue, it is also a time-management issue.  I believe that if you spend the time and effort to cultivate these relationships now, you will spend much less time in the long run—by a substantial margin. 20031105

What About Defense Attorneys?

Besides prosecutors and judges, it may also be worthwhile to cultivate a relationship with the defense attorneys.  Here in my hometown, one local defense attorney (who happens to be a friend of mine) organized a tour of the jail for the County Bar Association.  It was surprisingly well attended by around 40 attorneys.  The 1 ½ hour program featured short presentations by sheriff and the jail commander who talked about jail procedures  and another by me about jail medical services.  The attorneys then took a tour of the jail.  The attorneys had lots of questions.  Basically, like David Tatarsky said above, the attorneys did not know much about how jails work.  It was quite eye-opening for most of them.

The feedback was overwhelmingly positive. As part of my presentation, I gave each of the attorneys my personal cell phone number and invited them to call me if they had any questions about the medical services their clients were receiving.  (I reminded them that they had to have a Release-of-Information form signed by the inmate before I could talk to them in detail).  As a result of this, I have received several phone calls in the last month.  But as I told the attorneys, inviting them to call me directly is a time management issue for me.  It takes much less of my time to talk to them directly than to answer their letters, requests for records, subpoenas, etc.

Have you ever invited the Bar Association to tour your facility?  Please comment!

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Inmate or Convict? What’s in a Name?

For many years after I came to work in jails, I was confused as to why those incarcerated in my jails were referred to with such varied and stilted names.Old Idaho Pen

 

IDOC (the Idaho Department of Corrections) calls its charges offenders.    The Federal Agencies, both ICE and the Federal Marshals, say detainees. The deputies and administrators of the jails use the word Inmates.

I have always been interested in linguistics and etymology (the study of where words come from).  I had always thought that inmate was the correct term for someone incarcerated in a jail or prison. It turns out that the word inmate dates from the 1500s and originally meant someone who was living in a house rented by another.  It derives simply from inn (an inn, of course, but also inside) and mate (companion).  Over time, inmate came to refer to anyone who lived with many other people in a single dwelling.  By the 1830s, the term inmate carried the connotation of the person being confined to the residence, i.e., housed involuntarily.  You were an inmate if you lived with many other people but were housed there against your will.

Among the places where you could be housed against your will originally included hospitals but I don’t think it does, anymore.  If your grandmother was on the medical floor of the local hospital, you would not refer to her as being an inmate.  I think this is so because even though grandma might not have wanted to be there at the hospital, she could leave anytime she liked.

So this is the meaning of the word inmate as it is understood now:  a person who has been has been remanded by some sort of authority to stay at some facility against their will and which they cannot simply leave.  That would apply to residents of jails, prisons and juvenile facilities but also secure psychiatric hospitals.

Understood in this way, inmate seems to be an appropriate descriptive term for residents of our correctional facilities. It also is without any sort of negative connotations, at least that I was aware of.  So why the use of offender or detainee?  They just seem cumbersome and don’t work as well as the original English word inmate.

But then I ran across this interesting website, Prison News Blog, in which the incarcerated author explains the hostility to the word inmate. Evidently, there are two terms in prison culture for someone incarcerated there:  inmate and convict. One does not want to be an inmate.  Inmate is a derisive term, even an insult, because it is believed to imply that the person is a fawning “good little boy,” so to speak.

In the parlance of the penitentiary, we generally understand an inmate as one who becomes a little bit too closely aligned with the institution and its rules. Inmates are quick to engage in conversation with staff members. It seems as if inmates suffer a bit from the Stockholm Syndrome, where they identify more with their captors than with others who share their captivity.

Instead, those incarcerated in prisons prefer to think of themselves as “convicts.”  A convict, in prison culture, is defiant and his own man.

Convicts differ from inmates. Convicts may abide by the rules, but only because they want to avoid additional aggravations or frustrations. Yet if he believes breaking a rule would be in his interest, he will make his choice and live with the consequences. A convict would never cooperate with a staff member in some kind of diabolical deal to spare himself. Convicts have an air of defiance. He may suppress that defiance, though he feels it coursing through his veins.

After reading this, I wondered who had decided that inmate and convict had these different meanings in prison?  And on what basis?  I understand better where this definition of “convict” came from.  As a convict, you have been convicted of some crime.  By the rules of polite society, you are a bad boy.  By preferring to be called a convict, you are embracing your antisocial nature.   It also has some cool harsh consonants that sound manly!

The term inmate, however, has never implicitly meant that you are a good boy or that you are a sheep.  That meaning has been made up.  Throughout its history, inmate has never meant complicit or cooperative.  Quite the opposite, in fact.  The historical meaning is that you are being held against your will.  The closest synonym is prisoner.

And this inmate vs. convict dichotomy cannot be applied to many correctional institutions.  Most inmates in jails have not been convicted yet, and so cannot properly be called convicts.  They are pretrial detainees.  And also inmates, of course.  It does not even apply to all prisons.  Many of the residents of Guantanamo prison are not convicts; but they are all inmates.

Nevertheless, I understand that the inmate/convict labels, as described in the Prison News Blog, have become well established usage at most of the prisons in the United States to the point that it truly is a grievous insult to refer to someone as an inmate.  Prison officials haven’t wanted to perpetuate the anti-social meaning of the word convict, and so they have come up with the clumsy term offender.  Similarly, federal officials prefer the term detainees. (Although I wonder what would have happened if prison officials instead had adopted the term convict and applied it to everyone, the cooperative and non-cooperative, alike.  Would that eventually have defused the antisocial meaning being given to the word?)

So far, this has not been a problem in my jails, which are off the beaten path in a less populous state.  We still use the term inmate and so far, have not had any objections, even from the IDOC, ICE and Federal Marshal inmates that we house.  If it ever becomes a problem in the future—well, I guess I will be saying “the detainees that we house.”

Do you use the term inmate at your facility?  How about convict?  Please comment!

 

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Involuntary Chemical Sedation–The Right Medications

Let’s start by setting the stage:  Our patient is a 35 year-old man who is angry that he has been arrested in a domestic dispute case.  He cooperated with the booking process, but then, several hours later, began to repeatedly ram his head full force into the wall.  There is blood on his face and on the wall.  The word “uncooperative” does not do him justice.  He is agitated and belligerent and wants to fight.  He is screaming offensive obscenities. 

Of course, he cannot be allowed to continue to hurt himself.  The deputies take him down and strap him to a restraint chair.  A spit mask is required.  Nobody really expected him to calm down after he is placed in the restraint chair and they are not disappointed.  30 minutes later, he is still screaming.Restraint

This patient certainly meets the criteria for chemical sedation.  He is an acute danger to himself.  He is an acute danger to others.  He has refused voluntary sedation.  He is not hypoxic or hypoglycemic (but if there is a suspicion of this, it is easy enough to get a pulse oximetry reading or a finger stick blood sugar).

What medications should be used to sedate this patient? 

Remember that our goal is to sedate the patient so that he can be released from physical restraints.  We would like him to be sedated and drowsy and even go to sleep, but to be easily arousable.  We do not want respiratory depression or other serious side effects.

The two main drug classes that have been traditionally used for this type of chemical sedation are the benzodiazepines and the antipsychotics.  I was taught in my Emergency Medicine residency that the benzos were “minor sedatives” and the antipsychotics were “major sedatives.”  However, there have been several studies comparing the two when sedating agitated patients, including this 2010 Cochrane Review, and, in fact, both work well.  They may work even better when given together.  Each has advantages and disadvantages that should be considered.

 Antipsychotics for Sedation–Haloperidol

The best overall antipsychotic for rapid sedation of agitated patients in a correctional setting, in my opinion, is good, old haloperidol.  Haldol has been safely used for this indication (probably) millions of times world-wide.  It is “tried and true.”  It is Vitamin H.  The Velvet Hammer.

The main advantage of haloperidol is that it is so safe.  It does not cause respiratory depression and so can be given to intoxicated patients.  It has no dose limit for safety reasons.  This means that it can safely be given to patients who are already taking antipsychotics.  The dose is the same whether po or IM, so if a patient changes his mind and accepts oral meds, it is easy to change course.  It can be given IV as well as IM (though we would seldom give haloperidol IV in a correctional facility as is done routinely in ERs).

 “Haloperidol has been evaluated in a large number of clinical trials alone and in combination with benzodiazepines.  These studies demonstrate that intramuscular haloperidol is both safe and effective in the treatment of agitation caused by virtually any etiology” Roberts: Clinical Procedures in Emergency Medicine, 5th ed.

Any other antipsychotic that can be given IM can also be used for rapid sedation.  Possibilities include Inapsine (droperidol), Geodon (ziprasidone), and Zyprexa (olanzapine).  There is nothing wrong with any of these agents, and if you already use them and are comfortable with them, that is great.  They offer no advantages to Haldol, however.  None are more effective and none are safer.

The major potential adverse effects of acute one-time dose Haldol administration are exceedingly rare.  One of these is Q-T prolongation that can, potentially, cause dysrythmias.  Another is Neuroleptic Malignant Syndrome. Both of these are very rare, however, and the risk is far less than the risk of prolonged physical restraint.  Haldol has also been reported to lower the seizure threshold, but this is controversial.

The one reasonably common adverse effect of acute IM Haldol administration is a  dystonic reaction.  Dystonic reactions involve involuntary muscle contractions  usually in the neck, shoulders or face, but also elsewhere.  It can also manifest as akesthesia, which can be thought of as a case of restless legs from hell.  We are not talking here about Tardive Dyskinesia. Tardive Dyskinesia is also involuntary muscle contractions but these occur after years of neuroleptic medication use and are irreversible.  Acute dystonic reactions are easily reversible, using an antihistamine, like Benadryl.  Unlike tardive dyskinesia, dystonic reactions are a nuisance, trivial and easily treated.

Because of the possibility of a dystonic reaction to IM Haldol, some practitioners give Benadryl 50mg IM at the same time as the Haldol.  I do not do this for the following reasons:

  1. The dystonic reactions from Haldol tend to occur the day following the IM injection.  Benadryl is so short acting that it is gone by then.  Theoretically, then, it may not be effective in reducing dystonic reactions.  This has never been studied, as far as I know.
  2. Only 1 in 6 or 7 patients who receive a single Haldol injection will develop dystonia.  If you give Benadryl to everyone, you are treating the majority of patients needlessly.  Benadryl has its own set of ill effects and side effects.
  3. If a patient does develop dystonia the next day, 50mg of Benadryl given orally will solve the problem quickly at that time.  That is when I prefer to treat these nuisance reactions.

The standard adult dose of Haldol for rapid sedation is 5-20 mg IM.DSC01310

Benzodiazepines for Sedation–Lorazepam

Any benzodiazepine that can be given IM can be used for chemical sedation.  I like to use Ativan (lorazepam), myself.  Valium can be used but is not as good because it is not well absorbed from an IM injection.  Versed (midazolam) is an acceptable alternative to Ativan.

The main disadvantage of Ativan as a chemical sedative is that it can cause respiratory depression, especially when combined with other sedating drugs.  For example, it should be used cautiously in the obnoxious drunk.  Haldol alone is a better choice for him.  It also reportedly can cause hypotension, though I have never seen this.

On the other hand, lorazepam is an excellent choice for stimulant overdoses.  It almost can be thought of as an “antidote” to stimulant “poisoning.”  So the patient who is agitated while “tweaking” on meth would do well receiving lorazepam.

The standard dose of lorazepam for chemical sedation is 1-4mg IM.

Combination Therapy

One cool thing about Haldol and Ativan is that they play well together.  The medical term for this is that they are synergistic—they increase each other’s effectiveness.  In practical terms, this means that if they are combined, you can use a smaller total dose of each agent.  Instead of needing 4mg of lorazepam IM to sedate a patient, if you combine it with Haldol, you only may need 1 or 2 mg  and vice versa. The two drugs are so compatible that you can mix them together in the same syringe.

The standard dose of the combination used for chemical sedation of the agitated patient is “ten and two” meaning 10mg of Haldol and 2mg of Ativan.  You can reduce this to “five and one” or increase it depending on the circumstances.  You can also vary the ratio or use just Haldol or just lorazepam depending on a particular case.  For example, what would you use in these cases?

  1.  The Standard Jerk.  This is the patient who is agitated and belligerent not because of drugs or alcohol,  but because of frustration, manipulation or whatever.  Chemical Sedation:  “Ten and Two” (Haldol 10mg and lorazepam 2mg IM).
  2. The “Mean Drunk.” This patient is still intoxicated, so you might not want to use lorazepam since it potentially could cause respiratory depression in combination with the alcohol.  Chemical Sedation:  Haldol 10mg IM.  It will not cause respiratory sedation and can be used safely in an intoxicated patient.
  3. The Acutely Psychotic or Manic Patient.  Chemical Sedation?  “Ten and two.”  Sometimes these patients need a second dose in an hour.  Should we be worried that the patient is already taking antipsychotics (let’s say Abilify, for example)?  The answer is no.  You can still safely give Haldol.
  4. Methamphetamine Intoxication.  Lorazepam is the “antidote” for the patient who is tweaking on meth or cocaine.  Chemical Sedation?  Lorezepam 4mg IM.  You can add 5mg of Haldol, as well if you want.
  5. “Undifferentiated.”  If you just do not know why the patient is agitated and belligerent, remember that “intramuscular haloperidol is both safe and effective in the treatment of agitation caused by virtually any etiologyRoberts: Clinical Procedures in Emergency Medicine, 5th ed.  If you are reasonably sure the patient is not drunk, add the lorazepam, as well.

 Next installment in the series:  Chemical Sedation:  Right Documentation and Right Follow –Up.

What medications do you use for Involuntary Chemical Sedation at your facility?  Please comment!

 

 

 

 

 

Involuntary Chemical Sedation–The Right Patient

In my last blog post, I argued that chemical sedation was safer that prolonged physical restraint for patients who represent an acute threat to themselves or others.  Today, I would like to explore who is an appropriate candidate for involuntary chemical sedation—and who is not.  This is the first part of the Four Rights of Chemical Sedation:  Right Patient, Right Medication,  Right Follow-Up and Right Documentation.

RestraintFirst, let’s define what we are talking about here.  The key concepts in Chemical Sedation-Restraint are:

  1. It is an urgent situation.  Consider again the patient who is running his head into the wall.  We have to stop him now.  There is no time to consult with superiors or obtain a court order.  The patient is harming himself now and we must stop him–now.
  2. It is an alternative to prolonged physical restraint.  We are restraining patient behavior using medication because this is safer for the patient than is prolonged physical restraint.  In fact, we are using chemical sedation precisely so that we can release the patient from physical restraints.
  3. It is involuntary.  The patient does not want it to be done.  Sometimes, when a patient is in a restraint chair and you say, “Would you like something to help you calm down?”  They will say “Yes.”  The sedation there is not involuntary anymore.  We are talking here about someone who is refusing any type of medication.
  4. We are using sedating psychotropic medications.  There are many medications that can be used for sedation but they all have in common that the patient will be sedated at the end.  The end goal is that the patient will be asleep (but arousable) and no longer requires any type of physical restraints.

There are many terms we could use to convey these concepts.  We could say: Urgent or Emergency for the first concept, Restraint or Sedation for the second, Involuntary or Forced  for the third, and Chemical or Psychotropic for the last concept.  This could lead to some cumbersome terms like “Emergency Involuntary Psychotropic Restraint” or “Urgent Forced Chemical Sedation.” The emergency medicine literature tends to use the more concise term “Chemical Sedation” for this procedure.  Since the overall goal is to get the patient out of physical restraints, I prefer the term “Chemical Sedation” instead of “Chemical Restraint.”

Who Is A Candidate for Emergency Involuntary Chemical Sedation?

There are four indications for Chemical Sedation in a correctional facility:

  1. The patient is a danger to himself.  The patient who is running his head forcibly against the wall is an obvious example.  I once had a patient who kept climbing up onto the sink in his cell and doing a swan dive onto the floor.  Head-bangers, I think, would qualify as would those patients who pull out fist-fulls of hair or gouge at their eyes.  I also would include poop-eaters, since as a trained medical professional, I know that eating poop is considered bad for one’s health.  Poop-smearers probably qualify, as well.  On the other hand, screamers may not qualify since screaming obscenities, even for prolonged periods of time does not represent a danger to self.
  2. The patient is a danger to others.  There is an element of a judgment call here in assessing the level of danger involved with those inmates who threaten others with violence. For example, if you happened to have John “Bones” Jones (world champion mixed martial arts fighter) in your facility and he were to say “I will kill anyone who comes into my cell,” you should believe him.  Mr. Jones would represent a true danger to others and probably should be chemically sedated.  On the other hand, a frail 90-year old man who makes the same threat might not be a real danger to others and chemical sedation based on that statement alone might not be warranted.  Other examples of inmates who pose a true threat to others might include poop-throwers, biters, and maybe even spitters.
  3. The inmate represents a threat to the integrity and security of the institution.  For example, an inmate who is tearing apart his cell, damaging the door or plexiglass, might qualify for chemical sedation.  Another example would be an inmate who screams racial taunts at other inmates, inciting them to anger and a potential riot, also could qualify for sedation.
  4. To assist in the medical assessment and management of the patient.  Sometimes, I don’t know for sure why an inmate is being aggressive and threatening.  An example here would be a newly booked inmate who is acting bizarrely.  Let’s say he is not talking coherently.  He will not cooperate even with getting vitals signs.  Is he high on meth?  Delirious?  Drunk?  Psychotic? Sometimes, the only way to be able to assess this patient is to chemically sedate him so that we can examine him..

Two Reversible Medical Conditions Can Cause Agitation

When deciding to chemically sedate someone, we need to keep in mind that there are two easily reversible medical conditions that can cause agitation.  These are

  1. Hypoglycemia
  2. Hypoxia

Fortunately, both can be quickly and easily assessed if there is any question in a particular patient (say the patient described above, who is acting bizarrely in booking and we do not know why).  Once a patient is physically restrained, and before injecting the chemical sedating agents, it is simple to check a blood sugar and an oxygen saturation in appropriate patients.  It is embarrassing to sedate a patient and then find out later that he had a blood sugar of 20.  Oops.

Other medical conditions can potentially cause a patient to be agitated, such as brain tumors, delirium, and being post-ictal after a seizure.  However, these are not easily reversible as are hypoglycemia and hypoxia.  If a patient has one of these, they usually will be sedated and then the underlying medical cause will hopefully be sorted out thereafter.

Chemical Sedation Should Never Be Punitive!

Always remember that the goal of restraining and sedating patients is for their benefit, not ours.  I have found that when jail deputies find out how much better chemical sedation is than prolonged restraint, both for the patient and for them, they sometimes want to chemical sedate everyone who is a management problem.  However, most jail management problems are not candidates for chemical sedation.

Even patients who are appropriate candidates for chemical sedation should always be offered less restrictive means of calming down.  Sometimes, just putting a patient in a restraint chair preparatory to getting chemical sedation is enough for them to settle down.  More often, however, patients facing a cell extraction, or who are already in a restraint chair  will accept oral medications rather than receive an injection.

Summary.  Is This the Right Patient for Chemical Sedation?

1.   Is he a danger to himself?

2.  Is he a danger to others?

3.  Is he a danger to the safety and security of the facility?

4.  Is sedation the only way he can be medically assessed?

5.  Does he have a reversible medical condition?

6.  Will he accept a less restrictive form of sedation?

What is your experience with chemical sedation?  Please comment!