Category Archives: Inmate issues

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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The Art Of Meeting New Patients in a Jail

I will be meeting a new jail patient with multiple medical problems today in my clinic.  I know this much before I even meet him:  He will almost certainly be scared, especially if this is the first time he has ever been to jail.  He will likely be suspicious of me. He may even be downright hostile. I know this because this is the norm for correctional medicine. I can’t be an effective doctor unless I can turn this attitude around.

Consider the situation from my patient’s perspective.  Prior to seeing me, he was arrested, handcuffed and driven to jail in a police car.  Once at the jail, he was thoroughly searched (spread-eagle against the wall), fingerprinted and had his “mug shot” taken.  His clothes were taken away and he was given old jail clothes (including used underwear).  He was placed in a concrete cell.  Now he is summoned by a correctional deputy and told (not asked) to go to the medical clinic.

He did not choose me to be his doctor.  Though he doesn’t know anything about me, he has no choice but to see me for his medical care. Not only did he did not choose me; he cannot fire me or see anyone else.  He may fear that I am not a competent doctor; otherwise why would I be practicing in a jail?

This is the attitude that I have to overcome.  How to do this is an essential skill for correctional practitioners. And, of course, the single most important encounter is the first one. A negative first impression is hard to overcome–and I am already starting out at a disadvantage.  What I have to do in only a few minutes is convince my patient that I am a legitimate medical doctor and that I care about him. I have learned in many years of doing this that these things are essential:

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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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Reader Question: Don’t Be the Decider

I work at a prison and your blog has been such a resource for our unique niche of medicine. There’s nothing like practicing “behind the walls!” . . .
Recently I’ve been incorporating more conversations about functionality and short-term/long-term goals and visits are mostly positive. However, there are the difficult patients . . . wanting to bargain “well if you’re not going to do anything, can I have an extra mat?” Or “Can I have a bottom floor restriction?” “Transfer me then!” “Give me insoles.” …and other requests like this. How do you recommend I come to an agreement with these patients that are difficult to have conversations with? . . . If by the end of the appointment we do not come to some sort of agreement, they end up right back in sick call with the same complaint. Then the cycle repeats. KR

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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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MAT in Jails. Response to Reader Questions

My last post about MAT in jails generated a lot of excellent responses–so many, in fact, that I realized that my discussion of MAT in jails was incomplete. I would like to enlarge the discussion about the proper role of MAT in jails by responding to these comments. Before I do, I want to make sure that we are all looking at the issue from the same perspective. Please consider how MAT should be used in three different jails.

What’s the role of MAT in a small jail?
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Reader Question: How does a KOP Policy Work?

Hi Dr Keller,

I work in the prison system in the UK. I wanted to ask you if the prisoners have in-possession medication in America or is it all supervised? 
If you do have in-possession medication, have you seen or thought of a way for the inmates to keep the medication safe i.e. lock box in their room (this then highlights a security issues as can store contraband etc. in  lock boxes? Is there a feasible and reasonable way that inmates who want to keep their tradable medication to them self and not fear being bullied by peers for them? 
Any ideas would be greatly appreciated!

After doing research in my current jail. The percentage of people who actually pass random meds check is currently 18%. Now obviously not all those that failed had them “pinched” from their possession and most certainly commonly abused meds such as trazadone and mirtazapine have been sold as “sleepers” on the wings. But for those people who genuinely get bullied for their medication or do in fact get them stolen what is the alternative measure to help them apart from to put them not in-possession and supervise them daily? 

If you have any ideas I would greatly appreciate it.

Dez

Thanks for the questions Dez! In the United States, most medications are passed in a supervised setting. “In-possession” medications are referred to as “KOP,” which stands for “Keep on Person.”  I’m going to use this term despite the fact that not all KOP meds are kept on person. Different facilities handle KOP medications in different ways, which I’ll get into. Here are the basics of KOP medications:

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Grievance Responses PLUS Sample Grievance Guideline

Benjamin Franklin once famously quipped “nothing is certain but death and taxes.” However, Franklin did not work in a jail, otherwise he would have said: “Nothing is certain except death, taxes and grievances.”

On the outside, patients do not write grievances—they vote with their feet. If they dislike the medical care they are receiving, they will just go to a different doctor. In a jail, they cannot do this. We have a grievance system in Correctional Medicine because our patients cannot fire us (and we cannot fire them–discussed previously here). If jail patients are unhappy with their medical care, their only recourse is to write a grievance.

Grievances are not necessarily bad things. A medical grievance is sometimes the way by which jail patients alert us to significant problems that we may have not known about or mistakes that we made. I myself have had my butt saved in this manner—more than once! Many grievances are simply about communication errors. We have not yet adequately explained a medical decision to the patient.

Yet jail medical personnel often have a bad attitude about grievances. This is unfortunate, because medical grievances are an important—even essential—part of the jail medical system. I believe that the most important reason for the bad attitude is that people have not been taught how to write a proper grievance response. That, then is the topic of today’s JailMedicine post. 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!