Monthly Archives: May 2013

Beware the Fecal Veneer

Over the weekend, my family and I went to see the “Mummies” exhibition at the local museum. One display invited participants to feel squares of leather that were said to feel like mummy skin. As I watched the family of six ahead of me all caress the leather, I wondered how many hundreds of people had fondled this exhibit. I wondered if it ever was cleaned. I wondered how many viruses were lurking there. It reminded me that the world is a dirty place. I remembered that one of my professors in medical school had referred to the dirtiness of the world as “The Fecal Veneer.”HiRes

The theory of the Fecal Veneer states that the whole world is covered with a thin layer of, well, shit (Sorry! I will use that crude term only once). When I say ‘the whole world,” I mean every place and every surface, including floors, chairs, desk tops, clothes . .  and even swimming pools, according to this report! In some places, the fecal veneer is thick—like the gas station public restroom I was in recently that must have last been cleaned when it was built. In other places, the fecal veneer is quite thin, like in a hospital surgical suite. But it is still there! Most places are someplace in between. How thick the fecal veneer is depends on how often it is cleaned.

agar ecoliThe theory of the Fecal Veneer is scientifically demonstrable! All you have to do is to wipe down any surface and plate the residue onto agar. You will inevitably grow fecal bacteria, like E. coli. Even the wall of the surgical suite will grow an occasional E. coli. Since the Fecal Veneer does not just include feces, but any and all human secretions, you can also find viruses, MRSA and all sorts of other nasty things.

People interact with their environment and hence with the Fecal Veneer mainly with their hands. That is how we transfer the Fecal Veneer to our own persons. In other words, like every other surface, we people are covered with a fecal veneer–but it is thickest on our hands. Our hands are the vectors that transfer the fecal veneer from place to place.

Many diseases, of course, are transmitted from person to person via the Fecal Veneer. Sick people excrete the virus infecting them into one or another of their secretions. They deposit these secretions on their hands, which in turn deposit the infectious secretions on something they touch, like a doorknob. Someone else touches the doorknob, gets the infected goobers on their hands and then transfers the virus into their mouths, say, when they eat.

Yes, some diseases like TB are transmitted by aerosolized droplets . . . but this is uncommon. The flu and the common cold, for example, are mostly transmitted via the fecal veneer.  I guess they can be transmitted via the air—but not in the same way as TB, where the micro-droplets can float in the air for a long time and for long distances. Instead, if influenza is transmitted through the air, it occurs like this: an infected person coughs or sneezes and launches a mucous goober through the air. This arcs across the room and lands directly in someone’s face or into their food. This can and does occur (which is why you should cough and sneeze into your elbow), but it is more likely that the mucous bomb will land on some surface, like a desk top. However, even more likely than this aerial bombardment would be that the ill person coughs or sneezes infected mucous onto his hands, which touch something (like a doorknob), which you then touch with your hand, and those dirty hands then transfer the virus to your mouth when you eat.

The bottom line here is that hands contaminated by the Fecal Veneer are the source of many common illnesses. Think back to the last time you got sick with a bad cold or the flu. That is likely how you got it—via dirty hands

The solution, of course, is to wash our hands a lot. We tend to underestimate how contaminated our hands get by contacting the items around us. By cleaning our hands, we accomplish two ends—we make it less likely that we ourselves will become infected by pathogens in the Fecal Veneer and we also will be less likely to transmit pathogens to others.

Of course, it is possible to go overboard and wash our hands too often. I was taught to wash my hands after each and every contact with a patient—up to 40-50 times a day sometimes. This much washing can cause skin breakdown in the form of rashes and cracked skin that I used to get especially on my knuckles. The problem is that bacteria counts on damaged skin actually go up. The solution is to use hand sanitizers in addition to washing.

What if you wear gloves? They keep your hands free of contamination, don’t they? Well, not entirely. Here is a study that showed that significant hand contamination occurred 13% of the time despite surgical gloves.  Gloves help, but sometimes the Fecal Veneer can creep even through surgical gloves.

I suspect that most of us remember to clean our hands often when we are working around patients.  However, often, we forget the presence and danger of the Fecal Veneer in the wide world. And we often mistake where the greatest danger of contamination lies.  Remember that dirty public bathroom I spoke of earlier?  As bad as it was, that bathroom was probably not the greatest threat I faced that day, partly because I recognized that it was dirty.  In the news recently was a report that said that Women’s Handbags May Contain More Germs Than the Average Toilet Flush .

It is clear that the more insidious dangers to our cleanliness are those surfaces that we do not recognize as being really, really “fecal veneered.”  So, along those lines, here is an extra-credit quiz for you:

What is the dirtiest surface that people touch all of the time without cleaning their hands afterward (including you, probably)?

Hint: this surface is handled by hundreds, maybe thousands, of people and usually is never cleaned. Answer: Continue reading

Essentials Of Correctional Medicine, February 2014

I am pleased to announce the Essentials of Correctional Medicine Conference 2014!

Cool city shotIt will be held February 18-21, 2014 in the Downtown Hilton Hotel in Salt Lake City, Utah.

Last year’s conference was a great success.  We had much greater participation than we had anticipated and the comments we received from the conference participants were almost all positive.  However, we did get some suggestions for improvements that we are using to make Essentials 2014 even better!

Much like last year’s conference, here is what you can expect:

  1. This is a working conference.  Do not expect a lot of free time.  Do expect to learn a lot.
  2. This is a conference for Correctional Medicine Professionals.  Each and every lecture will specifically pertain to medicine practiced in jails, prisons and juvenile facilities.
  3. Excellent, engaging speakers.  We have three requirements of our speakers.  First, that they teach up-to-date, useful material.  Second, that they are enthusiastic and engaging.  Useful information does no good if the presentation is so boring that you slept through it.  Finally, they must relate their presentations to correctional medicine. We in correctional medicine must always keep safety, security, and the possibility of symptom magnification for gain in the back of our minds in a way that outside physicians find foreign. 

We have made several changes and improvements to the conference format based on the suggestions and critique of last year’s participants:

  1. Fewer speakers speaking on more topics.
  2. More time for questions.  Each speaker will devote time to answering questions.  Also, each day we will bring all of the speakers together with the conference participants and have a question and answer and discussion session.  Expect debates!
  3. Protocols.  Each clinical lecture will come with a sample protocol.  Whether you call them Policy and Procedures, Standard Operating Guidelines or simply Protocols, writing these suckers is hard work.  So besides lecture notes, conference participants will leave with a good number of clinical policies that they can easily adapt to their particular institution.
  4. More vendors.  We especially are looking for vendors with new products that can make our lives better.
  5. More “working on a full stomach.”  Since this is a working conference, continental breakfast and lunch will be provided most days so we can keep on learning! 

2014 Conference Topics.

  1. Infectious diseases.  Our Keynote Speaker, Dr. Joseph Bick, is an expert in infectious diseases and a great speaker.  He is currently on sabbatical working as a correctional physician at a prison in Malaysia, of all places.   Dr. Bick will share those experiences with us in the Keynote Address, and then will address many of the infectious disease conundrums we face in Correctional Medicine.
  2. 032Dermatology.  Every correctional physician needs a dermatology consultant to send grody rash pictures to.  Mine is Neelie Berlin, enthusiastic rash expert who also happens to also be a wonderfully entertaining speaker.
  3. Medico-legal matters.  I personally always enjoy legal discussions and case analysis.  Hearing about bad-outcome legal cases is like driving by a bad wreck on the freeway—you just can’t look away.
  4. Symptom magnification and malingering.  Does any medical profession have to deal as much with this issue as we in corrections do, day after day after day?  Answer:  Ah, no.  Essentials will have presentations about detecting deception, properly documenting these encounters in a medico-legal friendly way and dealing effectively with these inmates without confrontation.  Forensic Psychiatrist Dr. Noel Gardner will discuss symptom magnification and malingering in the psychiatric realm.  Wonderfully entertaining as well as essential information.
  5. Formulary development and maintenance.  It is easier than you think!
  6. Chest Pain and Abdominal Pain.  Simplified approaches to assessing these complaints.
  7. And More! 

More conference information is found under the “Essentials Conference” tab at the top of the page!

Do you have questions?  Suggestions about how to make this and future conferences better?  Contact Us information is found at the conference website:  Essentials of Correctional Medicine.

A Low Salt Diet. Do You Really Need One?

So here is a report that actually can have immediate impact on correctional medicine: NYTimes: No Benefit Seen in Sharp Limits of Sodium in Diet

SaltFor many years, the American Heart Association and other Big Hitters in medicine have extolled the health benefits of a very low salt diet. Patients who have known heart disease were commonly counseled to eat a very low salt diet of less than 1,500 mg a day (compared to the average U.S. daily salt consumption of 3,400 mg a day).

I experienced this myself. When I was growing up, my father had three separate heart attacks and, among other things, was told to eat low salt. So, for several years, that is what my mother cooked for all of us.

Very Low Salt Diets as a treatment and preventative for heart disease has become the prevailing wisdom. Since these less-than-1,500 mg-of-salt-a- day-diets were so commonly prescribed in the community, most jails and prisons had to have such a Very Low Sodium Diet among the various medical diets that could be ordered by a practitioner.

However, I personally have never been a big fan of these Low Salt Diets in general and especially in Corrections.

There are two reasons for this. The first, as I can tell you from my own experience as I was growing up, is that very low salt diets are not very palatable. Most people find the food quite bland and will not eat it long term. Correctional inmates experience this, too, and commonly sabotage the diet by liberally salting the Low Salt Diet at the table (as I myself used to do) and by ordering lots of salty commissary foods like Ramen, and chips.

We practitioners commonly sabotage the Low Sodium Diets as well, by ordering medications with lots of attached sodium, such as naproxen sodium or omeprazole sodium.

So I challenge you to check the commissary purchases and prescriptions of the inmates at your facility who are prescribed a Low Salt Diet and find out how many truly ingest less than, say, 2,300 mg of salt a day. I guarantee, it won’t be many.

The second problem with the Very Low Salt Diet hypothesis is that the science for its efficacy has been pretty tenuous. Basically, eating less salt lowers blood pressure slightly in some individuals. Since people with lower blood pressures tend to have fewer heart attacks and strokes, then, the theory goes, eating less salt will lower blood pressure which will thereby decrease heart attacks and strokes. The Magic Number for salt consumption was pegged at less than 1,500-2,300 mg a day, compared with the average U.S. daily salt intake of 3,400 mg. But until 2006, no one had studied salt consumption directly.

Now comes this report, Sodium Intake in Populations: Assessment of Evidence,
from The Centers for Disease Control and Prevention’s Institute of Medicine, which analyzed the data directly linking salt consumption to death, heart attacks and strokes—no blood pressure middle-man. It turns out, according to the CDC, that all of these bad things (death, heart attacks, strokes, congestive heart failure) did increase with salt intake greater than 7,000 mg a day—but also (and who would have guessed this) for salt intake of less than 3,000 mg a day.

The report has already come under criticism. Most of the criticism I have read so far has been of the “I don’t believe it” variety. But one good observation, in my mind, is that the most common source of big-time salt in American diets is fast food and processed food, rather than overly salted prepared foods. I think we all will agree that most fast foods and processed foods are not the best health-wise, and for more than just their excessive salt content.

This is true in jails and prisons, as well. The biggest source of excess salt in most inmate diets is the junk food found in the commissary, not the food prepared in the kitchen. That is certainly the case at my jails. The prepared meals in my jails do not have a huge amount of salt.

So what is the take home message from the CDC report?

1. It may be OK to get rid of your Very-Low Salt Medical Diet (1,800 mg a day) as long as the standard diet served to your inmates has reasonably low salt content, like less than 3,400 mg a day. It probably does, unless you are serving lots of processed foods.

2. If you do order Very-Low Salt Medical Diets anyway, perhaps it would be prudent to check commissary purchases and NSAID prescriptions to make sure that the patient is really ingesting low amounts of sodium. If, despite the Very-Low Salt Diet, your patients are still ingesting over 3,400 mg a day, what is the point of the diet? It is a lot of time and effort that is not accomplishing anything.

How many Low Sodium Diets do you prescribe? What do you think of the CDC report? Please comment!

Price Check! Estrogens.

I don’t have a lot of women in my jails who take estrogen.  The post-menopausal women I see usually are not prescribed replacement hormones by their outside doctors very often.  mareThe main reason for this is the momentum generated by the landmark study Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial published ten years ago in JAMA which said that the risks of hormone therapy following menopause outweighed the benefits.  Most of the major women’s groups  (here is one example) have backed off a little from this, saying now that for some women, post-menopausal hormones are OK, but should be done for as short of a time as possible.

Nevertheless, most of the women who are taking replacement estrogen are younger women who have had a total hysterectomy.  Since these women are young, it is appropriate for them to take replacement estrogen.  Since they do not have a uterus (for the most part), they do not need to take progestin.  But which estrogen should be on our “Preferred Drug List” (otherwise known as a Formulary)?

In many drug categories, ACE inhibitors, say, there are several options that are equally effective and equally priced.  I don’t care if a patient is taking lisinopril or enalopril.  They are equivalent.

That is not the case with estrogens.  It turns out that in the estrogen department, there is a clear winner.

Here is the price-per-pill breakdown.  The doses listed are the typical standard doses for adult women.

Estrogen Dose Price Per Tablet
Esterified Estrogen (Menest) 0.625mg $1.11
Estradiol (Estrace) 1 mg $0.04
Synthetic conjugated estrogens (Cenestin, Enjuvia) 0.625mg $3.27
Conjugated equine estrogen (Premarin) 0.625mg $3.09
Estropipate (Ogen) 1.5mg $0.24

Premarin has been around since 1942 and for many years, was the only available estrogen product, to the point that  “Premarin” became almost synonymous for all estrogens in the same way that people say “Kleenex” for all nose-blowing tissues.  Premarin continues to be the most prescribed replacement estrogen.

In fact, however, all of the estrogens are therapeutically equivalent.  The only differences are these:

1.  Premarin (conjugated equine estrogen or CEE) is derived from pregnant horse urine.  That is the only thing (except price) that sets it apart from the others.

2.  All the others, including synthetic conjugated estrogen, are made from plant proteins.

3.  17-beta-estradiol (usually just called estradiol, brand name Estrace) is the only formulation that is “bio-identical” to human estrogen.

So there you have it.  By curious happenstance, the one estrogen that is bio-equivalent to human estrogen happens to be the one that costs 4 cents a tablet.

Estradiol should be the preferred estrogen in your facility.

Do you still use Premarin in your facility?  Why or why not?  Please comment!

 

 

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Case Study: “I Fell and Hurt My Hand”

An inmate presents to the medical clinic with a laceration on his hand overlying the knuckle of his small finger.  Hand injury He insists that he fell getting off of his bunk.  He has no other injuries on examination.  What do you think happened?  How would you treat this? Continue reading

Chemical Sedation–Right Follow Up

Remember our patient?  He was the guy who repeatedly ran his head into the wall.  Probably everyone in corrections (if you have worked in the field long enough) has seen someone like this guy , who is working hard to harm himself.

I have argued that chemical sedation is safer than prolonged physical restraint in managing this patient.  We reviewed which patients are appropriate candidates for involuntary chemical sedation and which drugs are best used for this indication.  By now, in our series on chemical sedation, we have reached the point where the patient has actually been injected with the sedating agents.

DSC01324

Of course, once the patient has been given Haldol and Ativan IM, we cannot just walk away.  Most of the time, chemical sedation occurs without incident.  Well within an hour, most patients are asleep and can be removed from physical restraints.  But as with everything in medicine, problems sometimes occur.  Therefore, following the administration of involuntary chemical sedation, the medical team must ensure and document the safe and effective onset of sedation.  Then, there must be appropriate follow-up.  Chemical sedation is an unusual occurrence that has both medical and legal implications.  Follow up visits investigate why the patient became so unmanageable as to need chemical sedation and make sure that the sedation was administered correctly.

Safe Onset of Sedation

Generally, most patients who have received an IM injection of Haldol and Ativan will be asleep well within an hour.  In the normal course of events, the nurse caring for this patient should observe him long enough to document that the patient has become sedated and has been removed from physical restraints.  Once the patient is out of restraints, the nurse should take vitals signs and document that the patient is sedated but arousable and is in good shape.150

Problems sometimes occur, however.  The single most common problem is that the first shot was not enough and the patient is still awake, thrashing and agitated, an hour after the IM injection.  When this happens, the proper course is to start over from the beginning.  Does the patient have an unrecognized medical cause of the agitation, like hypoglycemia or hypoxia or delirium?  Have the vitals signs improved or deteriorated?  Is the patient just as agitated as before or is he (more likely) partially, but incompletely, sedated?  After this re-evaluation, most patients in this situation just need a second dose of Haldol and Ativan to complete the sedation process.  Rarely, though, the appropriate call is to send them to the ER.

Appropriate Follow-Up

All patients who have received involuntary chemical sedation should have two follow-up check ups, preferably within 24 hours.  The reason for these visits is twofold:

  1. To investigate the question of why the patient was so agitated in the first place, and
  2. Whether the patient needs further interventions, like further work up (labs, say), changes in his maintenance medication regimen, or commitment.

The first of these visits should be in the medical clinic with a medical practitioner.  The practitioner should document absence of harm from the procedure and, if possible, pinpoint a medical reason for the agitation, if there was one.  The two most common medical reasons for agitation of this severity are amphetamine or alcohol intoxication.  Confusional states, like dementia and delirium, are also possible.154

The patient should also normally be seen by the mental health.  The purpose of this visit is to determine if there was a psychiatric reason for the agitation.  The three most likely possibilities are:

  1. Acute psychosis.
  2.  Acute mania.
  3.  Misbehavior as a manifestation of a personality disorder, especially the “Big Three:  Borderline, Antisocial and Narcissistic Personality Disorder.

Questions that should be specifically addressed in the mental health visit are whether the threat of aggressive behavior is over (usually it is), whether the patient is a candidate for commitment to a psychiatric facility (usually not) and whether changes should be made in the ongoing psychiatric medication regimen.

Finally, each and every case of involuntary sedation should be reviewed in a quality assurance capacity.  This can be done by the facility medical director or within a CQI committee.  Chemical sedation can be misused and overused.  Once the medical and security staff see how much easier and better involuntary chemical sedation is than physical restraint, there is a tendency to want to use it all the time—in patients who really are not a danger to self or others–just for the convenience of the staff.  The purpose of the CQI review of all instances of involuntary chemical sedation is to ensure that this extraordinary therapy is not misused or overused.

Involuntary Chemical Sedation Checklist

Involuntary chemical sedation tends to be a high adrenaline affair.  When you are in a situation involving a yelling, agitated patient and correctional staff amped up on adrenaline, it is hard to remember everything you are supposed to document.  The charting of these incidents often contains important omissions, at least in my experience.

The solution to this problem is to borrow a procedure from airline pilots, who have a written checklist of everything they must remember to do before they take off.  Without the checklist, something will be missed eventually.  The documentation of involuntary chemical sedation is likewise made easier by using a checklist that contains the following sections:

  1. Appropriate candidate.
  2. Reversible medical causes.
  3. Appropriate agents.
  4. Safe and effective onset of sedation.
  5. Appropriate follow-up.

I have attached below a PDF file of a Sample Involuntary Chemical Sedation Form.  You are welcome to download it and use it to develop one for your own facility!

Click here for the Sample Involuntary Chemical Sedation Form

How often do you have to use involuntary chemical sedation at your facility?  Please comment!