Author Archives: Jeffrey Keller MD

Is My Patient Faking?

This article was initially published on MedPageToday, found here.

I remember walking into one of my jails and seeing a patient on the floor of his cell twitching and shaking. “Don’t worry about him,” said the sergeant on duty. “He’s faking it.”
Boy, that spun me up! Nothing will make me more anxious than hearing “he’s faking” or its close cousin, “he’s malingering.” I hate and fear those words. Now, I know that medical personnel, both in my jails and in the emergency departments where I used to work, get upset when they think that they are being deceived or manipulated by a histrionic patient. But charging a patient with “faking it” is almost always a bad and dangerous idea. Continue reading

Sample Guideline: Bottom Bunk Requests

This clinical guideline is intended to be used as a template to help clinicians and administrators create their own policies. This sample guideline must be modified to make it applicable to each unique correctional facility. This guideline is not intended to apply to all patients. Practitioners should use their clinical judgement for individual patients.

Introduction. Occasionally, inmates who have been assigned the top bunk of a bunk bed state that they have a medical condition that requires them to be given the bottom bunk instead. Since medical providers must be fair and consistent, it is important to differentiate medical need for a low bunk from requests made for non-medical reasons such as a desire for convenience or as a sign of increased status.

Medical need. Medical need for a low bunk generally falls into one of two categories: Patients who are unable to safely climb onto the top bunk because of physical limitations and patients who have a medical condition that might lead them to fall off of the top bunk and injure themselves.

Patients who are unable to safely climb onto the top bunk because of physical limitations include:

  • Obesity (BMI >30)
  • Advanced age and/or infirmity
  • Late term pregnancy.
  • Permanent physical disabilities, such as amputations, paralysis, or previous strokes.
  • Temporary physical disabilities such as a broken bone or recent surgery.

Patients who have a medical condition that might lead them to fall off of the top bunk include:

  • Seizure disorders which are current and ongoing.
  • Conditions causing vertigo or dizziness, such as Meniere’s disease.
  • Conditions which impair coordination such as cerebral palsy.

Chronic pain syndromes independent of other conditions such as those listed above generally do not constitute a medical need for a bottom bunk assignment.

Patients who have been successfully using a top bunk generally do not have a medical need for a bottom bunk reassignment unless their medical condition has acutely changed, such as with a traumatic injury. Example. A patient has been using a top bunk for three weeks. Now he comes to medical stating that there are several bottom bunks available in his pod. He would like medical to approve a bunk reassignment for him because of an old leg injury. The fact that he has been using a top bunk for three weeks indicates that this patient does not have a legitimate medical need for a bottom bunk.

Nursing Personnel may address routine patient requests for low bed assignments based on this guideline. If nursing personnel are unsure or have questions, they may refer the patient to a medical practitioner.

Documentation. Security personnel assign bunks, not medical personnel. Medical personnel are being asked if a patient has a medical need for a low bunk assignment. Therefore, medical personnel should document the answer to this question only.

Incorrect: “Bottom bunk request is not approved.” Correct: “This patient does not have a medical need for a bottom bunk assignment.”
Incorrect: “Bottom bunk is approved for medical reasons.” (Security staff may elect to place the patient on a single bed, a cot, or a floor “boat” instead of a bottom bunk.)
Correct: “This patient should not be assigned a top bunk for medical reasons.”

If a patient does have a legitimate medical need for a low bunk assignment, consideration should also be paid to the patient’s other housing needs. For example, a low bunk may not actually meet the patient’s needs; the patient may need a hospital bed. Patients who have a medical need for a low bunk assignment may need to be restricted to a bottom tier so that they will not have to climb stairs. Patients who are inmate workers may need work restrictions. If the medical need for a low bunk assignment is temporary (such as a broken arm), the bottom bunk memo should have a time limit.

Sample guidelines can be found under the “Guidelines” tab (above) as they are published. I view these sample guidelines as a group effort! If you have a suggestion, critique or simply a better way to phrase some concept, say so in comments!

Opioid Withdrawal Not Deadly? Wrong!

One thing I always tell practitioners who are beginning a jail medical practice: you’re going to see a lot of withdrawal cases — study up! In particular, since the opioid epidemic hit, the number of patients I’ve seen in my jails withdrawing from heroin and other opioids of all stripes has skyrocketed. I’ve seen enough patients withdrawing from opioids that I think I am reasonably knowledgeable on the topic. Because of this, I was quite surprised when I ran across this sentence in a recent edition of The Medical Letter:

“Opioid withdrawal is not life-threatening.” — The Medical Letter

The problem is that although this sentence seems quite self-assured, it is flat out wrong. In fact, it is not just wrong; it is also dangerous. People do die from opioid withdrawal. I know of several such cases from my work with jails. Opioid withdrawal needs to be recognized as a potentially life-threatening condition, just like alcohol withdrawal and benzodiazepine withdrawal. Continue reading

Sample Food Allergy Guideline

Today’s post is the second in a series of sample clinical guidelines.  All of these sample guidelines will be placed under the “Guidelines” tab (above) as they are published. I view these sample guidelines as a group effort!  If you have a suggestion, critique or simply a better way to phrase some concept, say so in comments.

I wrote about food allergies previously on JailMedicine in “Food Allergies: Sorting Out Truth from Fiction” (found here). Since then, I have had more email requests for a Food Allergy guideline than all other sample guidelines put together.  It is clearly a BIG issue in corrections. Continue reading

Gabapentin in the News!

2018 has been a remarkable year for news and research into gabapentin, and the year is not even over yet! That is great news for those of us (myself included) who puzzle over the proper role of gabapentin within correctional medicine. On the one hand, if gabapentin is a useful drug for chronic pain, neuropathy, or any other medical condition, I want to use it properly. On the other hand, gabapentin is a ferociously abused drug within jails and prisons. It is both a sedating and euphoric drug that also can be hallucinogenic at high doses. When it is available within a prison, there is inevitably abuse of gabapentin (like snorting it), diversion of gabapentin (because it has large value within the correctional black market and so can be sold to others), and finally, there is inevitably coercion of weaker inmates by stronger inmates to acquire gabapentin prescriptions and give those prescriptions up to the strong.  Those of us in corrections have seen all of this and worse.

So any news of gabapentin, whether good or bad, can change the balance of this deliberation. If gabapentin is proven to be more effective medically, it may be worth tolerating the abuse. If it is found to be ineffective, there is no reason to introduce this stressor into the system.  With this in mind, here is a sample of the 2018 news on gabapentin. Continue reading

My jail Is Safer Than Your ER! from MedPage Today

This article was first published here on MedPage Today.

How safe is correctional medicine?

People naturally assume that working in a jail or prison is dangerous. “Aren’t you nervous about working there?” they ask me. What people have seen of jails on TV looks pretty rough! After all, that’s where they put the violent criminals, right? The problem is, it just isn’t so!

Jails and prisons are not dangerous places to work; to assume so is just one of many misconceptions people have about correctional facilities. In fact, my jail medical clinics have been a much safer work environment than where I worked before.

Continue reading

Sample Clinical Guideline: Medical Approval of Personal Footwear

Today’s post is the first in a series of sample clinical guidelines.  These will be placed under the “Guidelines” tab (above) as they are published.  These guidelines are open access; you may use them in whole or in part as you see fit.  I view these sample guidelines as a group effort!  If you have a suggestion, critique or simply a better way to phrase some concept, say so in comments.

This particular clinical policy addresses a common problem in jails (less so in prisons). I addressed the issue of allowing personal shoes in jail previously in “A Quick-and-Easy Solution to those Pesky ‘Own Shoes’ Requests,” (found here).  As a result of that post, I have had many email requests for a sample “Own Shoes” guideline.

Medical Approval of Personal Footwear in Jails

This clinical guideline is intended to be used as a template to help clinicians and administrators create their own policy on personal footwear. This sample guideline must be modified to make it applicable to each unique correctional facility. This guideline is not intended to apply to all patients. Practitioners should use their clinical judgement for individual patients.

Introduction. Inmates housed in county jails are provided footwear by security personnel. Occasionally, inmates will state that they have a medical condition that requires them to wear their own personal shoes. If an inmate asks medical personnel to authorize him to wear his own personal shoes, medical providers should re-frame the question as “does this patient have a legitimate medical need to wear his own personal shoes?” Inmates may desire to wear their own shoes for many non-medical reasons, such as convenience, as a sign of increased status among other inmates and as a way to smuggle contraband. This guideline addresses the question of when inmates have a medical need to wear their own personal shoes. Continue reading

How Did I End Up in Jail? from MedPage Today

I have begun a new blog that is being published on MedPage Today entitled “Doing Time:  Healthcare Behind Bars.” The difference between that blog and JailMedicine is the audience.  JailMedicine is written for medical professionals already working in a jail or prison (bless us all!). The MedPage Today blog is written for medical professionals who have no idea what Correctional Medicine is all about.  The first post of Doing Time follows: Continue reading

NSAIDs Essentials of Prescribing for Inflammation

In the last JailMedicine post, I discussed the use of NSAIDS for pain. Pain management is probably accounts for 90+% of NSAID prescriptions in primary care. Oftentimes, though, we delude ourselves into thinking that we are also treating inflammation. Usually we are not and that is the subject of today’s post.

To show why, we have to delve into the NSAID inflammatory effect. How NSAIDS act to affect the inflammatory response is well known (unlike their pain effect, which is still a mystery). All practitioners should know the basics of how NSAIDS work. This is essential knowledge for rational prescribing. Continue reading

NSAIDs. The Essentials of Prescribing for Pain

After many years of reviewing prescribing practices of physicians both within correctional systems and outside of the walls, here is something that I strongly believe:

Non-Steroidal Anti-inflammatory Drugs (NSAIDS) just may be THE most misunderstood and overprescribed drugs in clinical medicine. It appears to me that, in general, we practitioners overestimate the benefit NSAIDS give. We underestimate the risks NSAIDS carry. And we prescribe NSAIDS in ways that are not evidence based and not in our patients’ best interest. Continue reading