When Covid-19 burst onto the scene three months ago, the jail administrators and the medical teams in my jails initiated several common sense practices to reduce the possibility of Covid infiltrating the jails. These included screening and quarantining new inmates before allowing them into the dorms, screening jail employees daily, doing lots of Covid tests and, perhaps most importantly, having deputies wear masks at work. The good news is that, so far, there have been no cases of Covid-19 in any of my jails (knock on wood here).
However, there seems to be growing evidence of “Covid
Fatigue” in my community. When I go out
in public, I am one of the very few still wearing a mask. And this is unfortunately spilling over to
the correctional facilities. I did a
clinic at one of my smaller jails this week and was surprised and dismayed to
see that the deputies were no longer wearing masks. In the meantime, Community Covid cases are
climbing, so the risk of transmitting Covid to the jail is actually greater
than it was, say, a month ago.
I am seeing a 52-year-old male in my jail medical clinic who
was booked yesterday on a felony DUI charge.
He says he drinks “a lot of beer” but denies having a drinking problem. He is cranky and not really cooperative. He does not want to be here. However, the deputies tell me that he did not
sleep much last night and did not eat breakfast. I note that he has a mild hand tremor and a
heart rate of 108. According to the
clinical Institute Withdrawal Assessment for Alcohol–revised version (the most
common tool used in the United States to assess the severity of alcohol
withdrawal since 1989) my patient needs no treatment for alcohol withdrawal. But this is wrong! In actuality, my patient is experiencing
moderate withdrawal and should be treated immediately and aggressively.
Using CIWA is like
using a wrench to pound in a nail. It
can be done, but it is not really efficient or accurate. A different tool (a hammer) could drive the nail
much more quickly and effectively. CIWA is simply not the right tool to assess
alcohol withdrawal. We should be using
I recently published the official position paper of the American College of Correctional Physicians (ACCP) on the treatment of Hepatitis C in incarcerated patients (found here). However, some state legislatures (and others who which authorize funds for inmate medical care), have been reluctant to fully fund Hepatitis C treatment. Because of this, ACCP has formally approved the following Position Paper to encourage full funding of HepC treatment among incarcerated inmates.
“We’ve got another one,” My nurse told me on the phone. “He
says he was exposed to Covid.”
Ever since Covid-19 came to my town, many people being
arrested have begun to say that they have Covid or have been exposed; the
thought being that “If I have Covid, they can’t put me in jail.” Of course, it doesn’t work that way. They go to jail anyway.
Patients are dying in correctional facilities from
benzodiazepine withdrawal! This is not
just a theoretical observation; this really is happening. This fact bothers me since
benzo withdrawal deaths are preventable.
Benzodiazepine withdrawal is easy to treat! It is certainly easier to treat benzo
withdrawal than the other two potentially deadly withdrawal states, alcohol and
opioids. By far, the most common cause of
benzodiazepine deaths is, of course, not treating it!
So, is your facility at risk to have a patient die of
benzodiazepine withdrawal? To find out, compare
your policies to the following Rules for the Treatment of Benzodiazepine Withdrawal.
At one of my recent jail medical clinics, three patients in a row requested prescriptions for gabapentin. One was a patient newly arrived from the Idaho Department of Corrections to be housed at my jail due to prison overcrowding. He had already been prescribed gabapentin at the prison for complaints of low back pain radiating to one leg and wanted me to continue it–forever. The second patient was prescribed gabapentin by his outside practitioner for a boxer’s fracture that had been surgically repaired years ago. The third was prescribed gabapentin at a previous jail due to “nerve damage” from an old gunshot wound to the upper arm (he had a large scar but no functional disability or decreased sensation).
Gabapentin prescriptions for nonspecific musculoskeletal pain have clearly become common in the community and in corrections. These three patients represent only a fraction of the similar cases I see in my jails! I suspect that this gabapentin-mania is being driven by a belief that gabapentin is preferable to prescribing narcotics (though I would not think any of the three patients above would be candidates for narcotics). Gabapentin, in fact, is often prescribed for musculoskeletal pain in my community first line—before NSAIDS and Tylenol, even—and many, like these three patients, subsequently believe that gabapentin is something they will need to take for the rest of their lives.
The problem is that prescribing gabapentin for
musculoskeletal pain is not evidence-based and (in my opinion) bad medicine.
The State Board of Medicine in my home state recently sent out a bulletin about the practice of “friendly prescribing” to people who the practitioner has not examined. For example, a friend might call me and say something like “I have a sore throat. Will you call me in a prescription for antibiotics?” I’m sure that almost everyone who has practiced medicine has received such phone calls! The Board of Medicine was concerned about this. They went so far as to to condemn as unethical the practice of issuing such prescriptions without ever examining the patient or documenting the encounter.
In my opinion, this applies to correctional physicians prescribing to new inmates they have never seen, as well.
When arresting officers arrive with their charges at a certain large urban jail, the first person they see when they come through the doors is a nurse. The nurse quickly evaluates the arrested person to determine whether a medical clearance is needed before the person can be booked. If a clearance is needed, the arresting officer has to transport the prisoner to a local ER and then return with the medical clearance in hand.
One evening (so the story goes), an arresting officer arrives at the jail bodily dragging a prisoner through the pre-book door by the backseat of his pants and coat. “This guy’s an a**hole,” the officer says. “He won’t do anything I ask. He just ignores me.” He then dumps the prisoner on the floor. The nurse kneels down by the prisoner briefly, looks up and says, “That’s because he’s dead!”
Medical clearances are a hugely important and often neglected part of the jail medical process.
Words matter. What we write about our patients in our medical notes to a great degree reflects how we feel about them. Our words also mold our future relationship with our patients. One good example cited by Jayshil Patel, MD in a recent JAMA editorial (found here) is the common phrase “the patient was a poor historian.” There may be many reasons why a patient is not able to answer our questions well, such as dementia, delirium or psychosis. In fact, the inability to present a cogent narrative usually is an important symptom of an underlying condition. “Poor historian” does not reflect this fact. To the contrary, “poor historian” implies that the patient is at fault for my poor documentation, not me! “Poor historian” leaves out that there are other ways for me to get a medical history (medical records, talking to family, etc). “Poor historian” also implies that the patient was deliberately not cooperative—even though perhaps I spent maybe two minutes attempting to get a history.
Many other common medical phrases also subtly disparage patients. Two good examples are the words “denies” and “admits” as in: “The patient denies drinking” or “the patient admits to IV heroin use.” The implication of these words is that we are engaged in something akin to a hostile cross examination where I forced the patient to “admit” (against their will) to drinking and I really don’t believe the patient who “denies drug use.” Words guide how we think about our patients, even if on a subconscious basis. When I use these words, I am saying that my patient and I are not on the same team.
In corrections, perhaps the single best example of a word that negatively influences our relationship with our patients is “inmate.”