Category Archives: Editorial

The Root Cause of Jeffrey Epstein’s Suicide

The recent suicide of Jeffrey Epstein while in custody at a Manhattan detention facility has focused intense media scrutiny into jail suicide prevention procedures. Suicide is the biggest cause of death in jails in the United States—by far.  Because of this, all jails (including the facility where Mr. Epstein was housed) have a suicide prevention policy.   Since the suicide prevention process was an epic failure at the facility where Mr. Epstein was housed, it might be useful to discuss how a jail suicide prevention program is supposed to work.

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Comfort Items: Why Not?

Perhaps the strangest aspect of practicing medicine in a jail or prison is “comfort requests.”  This is when an inmate comes to the medical practitioner asking for something like a second mattress, the right to wear their own shoes, a second pillow, a second blanket, etc.  This, of course, never happens in an outside medical practice.  When was the last time you heard of a patient asking for a prescription for a pillow?  Yet such requests are extremely common in correctional medicine.  You might think, “Well, just give them the second pillow—what harm can it cause?” But it is not that simple. Like every medical issue, there is a right way and a wrong way to handle these requests. To understand why, let’s consider the single most commonly requested comfort item in a correctional medical clinic:  a second mattress.

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Why Correctional Medicine is often Driven by Lawsuits

Imagine, if you will, a nurse who is assigned to take care of 50 patients on a medical floor—by herself. Clearly, this is an impossible task.  There are just too many patients for one nurse to adequately monitor.  But this nurse gamely does her best.  Now let’s say that there is a bad outcome and an investigation.  Even if the understaffing problem is recognized, it would be easy—and tempting–to scapegoat the nurse, especially if there was no intention of fixing the staffing problem (“We can’t afford to hire more nurses!”)  Instead, the scapegoated nurse would be replaced by a new nurse, who, once again, would be expected to care for 50 patients.

Such were my thoughts when I read this article about the problems with the medical care for inmates in the Illinois prison system (found here):  https://www.chicagotribune.com/news/local/breaking/ct-met-illinois-prison-health-lawsuit-20190103-story.html. The article says that there have been so many problems with medical care in the Illinois prison system that a class action lawsuit has successfully forced Illinois to make sweeping changes to the prison medical system.  What is not mentioned in the article is that similar lawsuits have happened before in other states and will happen again. 

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Transforming Our Approach to Chronic Pain

One of the most fearful and frustrating events in my correctional medicine world used to be when a new chronic pain patient would arrive in my clinic.  A typical patient would be a “Ralph,” a middle-aged man who has had chronic back pain for many years.  Ralph has had a couple of back surgeries, steroid injections and more than one kind of stimulator, none of which has been effective.  He arrived at the jail taking a long list of sedating medications such as muscle relaxers, gabapentin, and sleeping aids plus, of course, big opioids.  In addition, Ralph has alcohol abuse issues.  The reason he is in jail is a felony DUI charge.  Now he is in my medical clinic, looking expectantly at me.  How am I going to fix his pain problem? 

The answer, of course, is that I am not.  I am not that smart.  He has already seen lots of doctors, including pain specialists and surgeons, who have tried almost everything that can be tried and they have not fixed his chronic pain problem.  I’m not going to be able to, either.  In my opinion, the most common and serious mistake made in the treatment of chronic pain in corrections is when we imply that we can eliminate chronic pain. 

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Can the Oakland Raiders Be Saved Using the Principles of Medical Research?

One of my good friends is a die-hard Oakland Raiders fan.  Those of you who follow pro football know that Oakland has fallen on hard times recently.  They went from being one of the best teams in the league two years ago to one of the worst teams in 2018 with a dismal 4-12 record.  As a result, my friend has had to suffer taunts from fans of better teams—like me!  He has become despondent.

But it doesn’t have to be this way!  The Raiders can quickly and easily turn their season around by using the tried-and-true techniques of medical research.  If a pharmaceutical company did 16 clinical trials of their new potential blockbuster, Drug X, they would never let a 4-12 outcome get them down.  When published, I guarantee those trial results would look a lot better than 4-12.  The Oakland Raiders can use the same techniques to improve their own season record.

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Is a Concrete Cell Really the Best We Have To Offer Our Mentally Ill?

Consider the case of a 60-year-old patient I will call “Library Man.” While at the public library, Library Man took off most of his clothes and was talking loudly to no one in particular. The police were called, of course. He was charged with disturbing the peace and brought to my jail.

Jails basically have three types of housing areas. First are dormitory-style rooms with 60-100 residents. Library Man cannot be housed there—the young aggressive inmates would prey on him. Second are smaller cells that hold two to four inmates. The problem with these cells is that even if the jail could guarantee gentle cell mates, it would be hard to monitor Library Man in such cells. Such cells tend to be in out-of-the-way places and have small windows on the doors. The only place that Library Man can be reasonably housed in most jails is “Special Housing,” which refers in this case to a single-man isolation cell with lots of plexiglass to allow easy observation. Such rooms are designed to have nothing that someone could use to harm themselves, so they are made entirely of concrete and steel—even the bed. This is where Library man ends up—basically in a large concrete box.

Unfortunately, this is not a good place for Library Man to be. You may have guessed that Library Man is a homeless schizophrenic who had gone off of his meds. He is harmless–certainly not a danger to himself or to others. In his psychotic state, he does not understand why he was arrested and jailed. Library Man would benefit from familiar surroundings and normal social interaction with people. He will get neither of these in the alien and sterile environment of his concrete isolation cell. Continue reading