Category Archives: Language

Correctional Medicine is Different: We Can’t Fire Our Patients—and They Can’t Fire Us!

This post is the third in a series exploring how Correctional Medicine is different than medicine practiced outside of jails and prisons.  The previous two differences were The Principle of Fairness and All Clinical Encounters are Discussed Back in the Dorms.

There is a controversy in pediatrics that I have been following recently. Some pediatricians have been dismissing children from their practice if their parents will not allow them to be vaccinated. This practice has been criticized as punishing innocent children for the actions of their parents but the pediatricians defend it by saying they are just trying to protect their other patients from being exposed to pertussis, measles and other transmittable diseases in the waiting room.

unknown-1This story illustrates an extreme example of something that we all know: that the practice of “firing” patients is commonplace in outside medicine. Many of my jail patients have been dismissed from medical practices, some more than once! Patients can be fired for variety of offenses. Some violate the contracts of their pain clinics. Some are dismissed for simply not following the doctor’s advice—like to get their children vaccinated. Many are no longer welcome when they cannot pay their bills or have lost insurance coverage. (One orthopedist that I know routinely sends a dismissal letter to his patients on their 65th birthday since he refuses to participate in Medicare). Finally, patients can be fired for just being too difficult to deal with. One jail patient in particular I remember screamed drunkenly at his doctor’s secretary to the point that she called the police. He received his official dismissal letter while he was in jail.

Well! Things are different in Correctional Medicine! We can’t fire our patients. Our patients remain our patients no matter what. It doesn’t matter if they violate the terms of a pain contract by, say, diverting medications. It doesn’t matter if they refuse to follow our advice. It doesn’t matter if they are difficult to deal with. Continue reading

The M-Word–Malingering

I went to the always excellent NCCHC spring convention in Nashville last month. One of the many outstanding presentations was done by frequent lecturer Deana Johnson. Deana talked about the risks of using the word “malingering.” Her basic message was to be very careful about saying that an inmate is malingering—in fact, perhaps we should never use that word.

I was surprised by the degree of spirited disagreement from several members of the audience. They pointed out that “malingering” has a specific medical meaning and sometimes—even often—it is an appropriate medical diagnosis. They pointed out that malingering is listed as an official diagnosis in DSM-5 and that outside medical agencies, like mental hospitals, use the term malingering. If we can’t say that an inmate who is clearly faking is malingering, what are we supposed to say?

Today in Jail Medicine, I am going to tackle the term malingering. It turns out that there is indeed a correct and proper way to use the term malingering in correctional medical practice—but it is tricky and most often (in my experience) done incorrectly, with resultant bad consequences.

There are three important reasons for this. First, most people have an inaccurate idea of what malingering actually means in a medical sense and so use the term inaccurately. Second, the use of the term “malingering” also carries with it an emotional definition that MUST be taken into account when it is used in a medical document. Finally, use of the term “malingering” has important consequences for patient relations, patient behavior and time management.

The bottom line, in my opinion, is that “malingering” is a term that should very rarely be used in correctional medicine. There are better and more precise ways to convey medical information. But if you do absolutely want to use the term “malingering,” you need to know how to use the term correctly. Continue reading

Pseudoseizures—the Right Approach

I recently had to mediate a complaint from a jail deputy about a jail nurse. The jail deputy had called the nurse in to evaluate an inmate who was having seizures. The nurse said that they were pseudoseizures. The deputy was upset because “You’re accusing this inmate of faking. These weren’t faked. I was there and saw them.” He also was upset that “nothing was done” meaning that the patient was not sent to the ER and was not given any anti-seizure medications (the patient had requested Xanax to help control her seizures).

This little vignette has all of the elements of a good seizure/pseudoseizure case: a diagnostic dilemma (are these real seizures or not?), the potential for medical mismanagement if you get the diagnosis wrong, the possibility that the inmate is manipulating the situation, and, above all, a LOT of emotion. Everybody was upset here: The deputy was upset with the nurse for doing nothing about the patient’s medical problem. The nurse was disgusted and irritated with the patient for “faking.” The patient was upset—and filed a grievance– that she had not been given her “seizure medication” (Xanax).

The issue of seizures/pseudoseizures is a common occurrence in correctional institutions. Little has been written about this phenomenon. So today I’m going to begin to tackle the topic of pseudoseizures. It is a big enough subject that I am going to break it up into discrete segments, each of which (I hope) will have at least one pearl of wisdom to help guide the correctional care provider through this potential mine field.  We need to start by defining what I mean by a “real” epileptic seizure and what I mean when I say “pseudoseizure.”

Today’s Take Home Message: The word “pseudoseizure” does NOT equal “fake seizure.” Assuming this is a medical mistake and will get you into trouble. Continue reading

Verbal Aikido: A Guest Column by Dr. Bill Wright

Dr. Bill Wright

Dr. Bill Wright

Today on JailMedicine, I am happy to present a guest post by Dr. Bill Wright.  As you may remember, Dr. Wright is the author of Maximum Insecurity: A Doctor in the Supermax, which I reviewed here and which you can purchase here.

VERBAL AIKIDO

Correctional medicine attracts more than its share of argumentative and demanding patients. We all feel the tightening in our stomachs when finding certain names on the clinic schedule, anticipating the disputes that are almost certain to follow. It doesn’t need to be that way. Continue reading

Should Inmates Bring Their Own Prescriptions to the Jail?

In response to my last post, one reader wrote to tell me that the jail where she works does not accept medications brought in by inmates or their families. They consider this a security risk.  All medications are ordered and supplied by the jail.  She asks if I will comment on this. Before I do, I need to define a couple of terms that come up over and over in any discussion of newly booked inmates’ medications.

Verification

UnknownThe first term is “Verification.”  Verification refers to the process of verifying what medications an inmate is currently prescribed and is taking.  There are three ways to verify medications.  The first is to call the prescribing doctor’s office to get a list of currently prescribed medications.  The second is to call the dispensing pharmacy to get a list of all prescriptions they have recently filled for the patient.  Finally, the inmate could bring the medications they are taking into the jail with them in the original pill bottles.  On the label is everything we need to know—who prescribed the medication, when it was filled, dosages–everything.

One problem with calling the doctor’s office to verify medications is that the patient often is not taking all of the prescribed medications.  If I remember right, studies show that only around half of all prescriptions are filled.  So you will get a list of prescribed medications, but that may not be what the patient is actually taking.  Another problem with calling the doctor’s office for a current medication list is that doctor’s offices are often closed.  If a patient is booked Friday afternoon of a holiday weekend, you may not be able to get a current medication list until Tuesday.  Finally, many inmates get medications from multiple prescribers.  For example, the patient may have a family physician, but a psychiatrist prescribes their mental health medications and they also use a pain specialist.  And get prescriptions also from ERs and “Doc-in-the-Box” clinics.

Calling the pharmacy may get you more information than calling the doctor’s office.  After all, the pharmacy will only tell you about prescriptions that were filled and can also tell you when the prescription was filled.  If you do call a pharmacy to verify meds, don’t just ask for an “active medication list!”  The pharmacy considers any prescription that they would fill for the patient active, and refills are generally good for one year.  So if a patient may not have taken a certain medication for many, many months, but the pharmacy still considers it “active.”

And like doctors’ offices, pharmacies may be closed when you want to call them.  And inmates often use more than one pharmacy.  Some inmates use mail order pharmacies that are hard to get any information out of.  Or an inmate may not use a pharmacy at all—for example, their medications might be supplied by a psychosocial rehab group.  Finally, it is not uncommon for an inmate not to remember what pharmacy they use, at all!

Authorization

The second term to define is “Authorization.”  I discussed medication authorization in my last post.  Authorization refers to the process of reviewing and inmate’s (verified) medication list and deciding which of those medications will be dispensed at the jail—and which will not.

All incoming inmates taking medications should have their prescription list verified and authorized.  These two processes take quite a lot of nursing time and effort at most jails.

So now we return to the original question.  Which is better, to allow inmates to bring their outside medications into the jail with them or not to allow this and instead verify their medication list and re-prescribe the approved medications ourselves?  The answer is that there is no “right” answer.  Each system has its advantages and disadvantages.  Which you choose to use at your jail depends on several factors, such as the size of your jail, your staffing levels and the sophistication and efficiency of your pharmacy system.

With that in mind, let’s compare each system as to its relative advantages and disadvantages with regard to some of our goals in jail.20130619

Continuity of Care

We want medical care to continue seamlessly from the outside to the inside of the jail.  We want there to be no lapses in ongoing medical care for newly booked inmates.  This means that, ideally, there will be no missed doses of important medications.  This is, of course, easiest to accomplish if inmates brings their medications to the jail in the original containers.  This makes verification, authorization and dispensing to the inmate a simple process.

Contrast this with what usually happens if the inmate does not bring the meds with them.  The current medication list must be verified with phone calls to the doctor’s office and pharmacy.  Even if this goes well (no offices are closed), the medications then must be ordered from the jail’s pharmacy.  Best-case scenario:  the process takes 24 hours.  More commonly, it takes 48-72 hours and the patient has been without medications for 2-3 days.

If the inmate does not bring meds into the jail with them, the only solution for timely administration of most medications is to have an extensive collection of “stock” meds on hand, so that most medications can be continued quickly from stock.  In order to be able to fill the majority of outside medication prescriptions, there must be a lot of stock meds plus protocols for automatic “therapeutic substitution”  (mentioned here).  http://www.jailmedicine.com/the-f-word-formulary/ That is a pretty sophisticated system.

However, even then, no “stock” med collection is going to contain all of the various HIV meds, say.  Or cancer chemotherapy agents.  And these are precisely the medications that we most want to continue without missing a dose!

Clearly, from a “continuity of care” perspective, it is better to encourage inmates to bring in their own, outside medications.

Advantage:  Allowing outside prescriptions.

Information Gathering

There is no question that having the original pill bottles sometimes gives you medically important information.  As one example, consider the patient who takes combination lisinopril/HCTZ for blood pressure.  He brings in a bottle that was filled 45 days ago for a one month supply (30 pills).  There are 29 left in the bottle.  His blood pressure is 128/78.  Would you continue the prescription?  I probably would not.  I would, instead, monitor his blood pressure to see if he really needed the medication.

Or say instead, his blood pressure is 180/120.  If I know that he has not been taking his hypertension medication, I would simply restart it in the jail.  But if he had been taking it faithfully, I might consider adding or changing the prescription.

I could give many more examples of similar situation.  Knowing that the patient has (or has not) been taking their prescribed meds is often very helpful clinically.

Advantage: Allowing meds to be brought in to the jail.

Time Management

The issue here is how long it takes nursing staff to verify and approve a newly booked inmate’s medications.  If the inmate brought meds to the jail in the original pill bottles, verification consists of noting the information on the prescription label, verifying that the medications in the bottle match the label and counting them.  Authorization is easy as a phone call to the provider.  And then the medications can be immediately dispensed to the inmate.

If the inmate did not bring meds to the jail, verification will take much more time.  It consists of interviewing the inmate (Who is your doctor?  Which pharmacy do you use?), then calling the doctor’s office, the pharmacy or both (hopefully, there is only one of each!).  If there is a discrepancy between what the inmate says they take and what the pharmacy says they filled, a second interview with the inmate may be required.  Then, after the approval process, the medications must be ordered from the jail pharmacy, delivered, processed and then, finally, they can be dispensed.

Advantage:  Allow meds to be brought in.

Cost Considerations

Consider the case of the inmate who is only going to be in jail for 30 days.  He is willing to supply his own medications for the month long stay.  Among other things, he takes Abilify, which costs approximately $25.00 a pill.  If your jail will not allow him to bring in his own Abilify, then you must either supply it at a cost of many hundreds of dollars for that medication alone, or substitute something else.  Even if patients are on inexpensive medications, these med costs and fill fees add up.

In addition, if your jail charges a fee to fill prescriptions, inmates will complain, because often they get their outside medications for “free” (meaning Medicaid, most often).  I have even had inmates go so far as to call this extortion and refuse to take jail prescriptions because they do not want to pay any money for meds that they are willing to supply “for free.”

Advantage:  Allowing meds to be brought in at booking.

Medico-Legal Considerations

The main medico-legal risk in these situations is disruption of the continuity of care, in this case, patients missing doses of important medications.  If (Heaven forbid!) something bad happens after the patient has missed a dose of medication—like the patient has a heart attack or commits suicide—it will inevitably be blamed on the missed meds by the patient, his family and their attorney.  I have seen this many, many times.

Advantage:  allowing meds to be brought in.

Security Considerations

This is the one aspect of the problem where there is a decided advantage not to allow outside medications into the facility.  Anytime you allow stuff from the outside to come into the jail, there is a potential for a security breech.

One possibility is that inmates might adulterate capsules by pulling them apart, pouring out the real medication and then filling them with cocaine, heroin or whatever.  However, this is not as easy to do as it sounds.  Adulterated capsules don’t look right and, in my experience, are quickly suspected and discarded.  Besides, if you want to smuggle illicit substances into a jail, there are easier methods than trying to pour powder into tiny capsules.

A more legitimate security concern is what to do with medications that were brought in to the jail but then were rejected during the authorization phase and so never dispensed to the patient.  Non-controlled substances can be placed in the patients’ property, but things can go wrong.  For example, the meds, somehow, are not there when the inmate is discharged from the jail six months later.  Where did they go?  The inmate, of course, may demand compensation for his lost property.  Maybe there should be an investigation?

Controlled substances are even worse, especially DEA schedule 2 drugs like methadone and amphetamines.  Like all schedule 2 controlled substances, these properly should be kept under double-lock (i.e., a locked box in a locked room) and should be counted every day with two people witnessing and signing off.  That is a lot of work should the patient stay in jail for a significant amount of time.   And when the inmate is released, you have this dilemma:  should you return these addictive controlled substances to him? What if he overdoses?  What is your risk exposure?

Advantage: not allowing out-of-jail medications in the facility.

In the end, which system you eventually put into place for incoming inmate medications depends on how important the security angle is to you and how well you can create and use a stock medication system.  To some degree, this depends on jail size.  The smaller the jail, the more important continuity of outside care becomes because the small jail’s medical staff may not be there all the time.  Large jails are better able to develop sophisticated stock medication systems where most incoming prescriptions can be quickly and easily filled from stock.  But even big jails should have exceptions in place for expensive specialty medicines, like chemotherapy agents, immune-modulators and HIV meds.

Does your jail allow incoming inmates to bring their medications to booking?  Do you like the system your jail uses?  Please comment!

Inmate or Convict? What’s in a Name?

For many years after I came to work in jails, I was confused as to why those incarcerated in my jails were referred to with such varied and stilted names.Old Idaho Pen

 

IDOC (the Idaho Department of Corrections) calls its charges offenders.    The Federal Agencies, both ICE and the Federal Marshals, say detainees. The deputies and administrators of the jails use the word Inmates.

I have always been interested in linguistics and etymology (the study of where words come from).  I had always thought that inmate was the correct term for someone incarcerated in a jail or prison. It turns out that the word inmate dates from the 1500s and originally meant someone who was living in a house rented by another.  It derives simply from inn (an inn, of course, but also inside) and mate (companion).  Over time, inmate came to refer to anyone who lived with many other people in a single dwelling.  By the 1830s, the term inmate carried the connotation of the person being confined to the residence, i.e., housed involuntarily.  You were an inmate if you lived with many other people but were housed there against your will.

Among the places where you could be housed against your will originally included hospitals but I don’t think it does, anymore.  If your grandmother was on the medical floor of the local hospital, you would not refer to her as being an inmate.  I think this is so because even though grandma might not have wanted to be there at the hospital, she could leave anytime she liked.

So this is the meaning of the word inmate as it is understood now:  a person who has been has been remanded by some sort of authority to stay at some facility against their will and which they cannot simply leave.  That would apply to residents of jails, prisons and juvenile facilities but also secure psychiatric hospitals.

Understood in this way, inmate seems to be an appropriate descriptive term for residents of our correctional facilities. It also is without any sort of negative connotations, at least that I was aware of.  So why the use of offender or detainee?  They just seem cumbersome and don’t work as well as the original English word inmate.

But then I ran across this interesting website, Prison News Blog, in which the incarcerated author explains the hostility to the word inmate. Evidently, there are two terms in prison culture for someone incarcerated there:  inmate and convict. One does not want to be an inmate.  Inmate is a derisive term, even an insult, because it is believed to imply that the person is a fawning “good little boy,” so to speak.

In the parlance of the penitentiary, we generally understand an inmate as one who becomes a little bit too closely aligned with the institution and its rules. Inmates are quick to engage in conversation with staff members. It seems as if inmates suffer a bit from the Stockholm Syndrome, where they identify more with their captors than with others who share their captivity.

Instead, those incarcerated in prisons prefer to think of themselves as “convicts.”  A convict, in prison culture, is defiant and his own man.

Convicts differ from inmates. Convicts may abide by the rules, but only because they want to avoid additional aggravations or frustrations. Yet if he believes breaking a rule would be in his interest, he will make his choice and live with the consequences. A convict would never cooperate with a staff member in some kind of diabolical deal to spare himself. Convicts have an air of defiance. He may suppress that defiance, though he feels it coursing through his veins.

After reading this, I wondered who had decided that inmate and convict had these different meanings in prison?  And on what basis?  I understand better where this definition of “convict” came from.  As a convict, you have been convicted of some crime.  By the rules of polite society, you are a bad boy.  By preferring to be called a convict, you are embracing your antisocial nature.   It also has some cool harsh consonants that sound manly!

The term inmate, however, has never implicitly meant that you are a good boy or that you are a sheep.  That meaning has been made up.  Throughout its history, inmate has never meant complicit or cooperative.  Quite the opposite, in fact.  The historical meaning is that you are being held against your will.  The closest synonym is prisoner.

And this inmate vs. convict dichotomy cannot be applied to many correctional institutions.  Most inmates in jails have not been convicted yet, and so cannot properly be called convicts.  They are pretrial detainees.  And also inmates, of course.  It does not even apply to all prisons.  Many of the residents of Guantanamo prison are not convicts; but they are all inmates.

Nevertheless, I understand that the inmate/convict labels, as described in the Prison News Blog, have become well established usage at most of the prisons in the United States to the point that it truly is a grievous insult to refer to someone as an inmate.  Prison officials haven’t wanted to perpetuate the anti-social meaning of the word convict, and so they have come up with the clumsy term offender.  Similarly, federal officials prefer the term detainees. (Although I wonder what would have happened if prison officials instead had adopted the term convict and applied it to everyone, the cooperative and non-cooperative, alike.  Would that eventually have defused the antisocial meaning being given to the word?)

So far, this has not been a problem in my jails, which are off the beaten path in a less populous state.  We still use the term inmate and so far, have not had any objections, even from the IDOC, ICE and Federal Marshal inmates that we house.  If it ever becomes a problem in the future—well, I guess I will be saying “the detainees that we house.”

Do you use the term inmate at your facility?  How about convict?  Please comment!

 

Enhanced by Zemanta

“Kite?” Where did that come from?

One day’s worth of inmate kites, Ada County Jail

I am wondering today where the term “kite” came from.  Everybody who works in jails or prisons is familiar with “kite,” which in jails and prisons refers to a written request for something.

Inmates can “kite” for anything, but those of us in the medical departments deal with medical kites,  as in:  Inmate:  “I need to see the doctor.  I’m sick.”  Deputy: “Well, fill out a kite then.”  Or “I’m sending your kite back to you because you forgot to sign and date it.”  “Kite” can be a noun (“Fill out this kite.”) or a verb (“I kited medical but I haven’t seen the doctor yet.”)

This term seems to be universal.  Correctional personnel all over the country are familiar with it, whether jails or prisons, state or federal, adult or juvenile.  I have yet to meet someone in the correctional field who does not know what a “kite” is.  It also is commonly used.  Not a day goes by that we don’t hear this term bandied about.

Yet I cannot find this definition of “kite” listed in any dictionary.  I checked several.  Even the dictionaries devoted to slang, like The Online Slang Dictionary or the Slang Dictionary don’t list the term “kite.”  How can a slang term be so common in jails and prisons yet be unknown to linguists?

So where did the term “kite” come from?  I have heard two explanations.  Some inmates believe that the term “kite” implies that we don’t care about them, as in: Inmate: “I’m sick.  I need to see the doctor.” Deputy: “Oh, go fly a kite.”  Although many inmates believe this, I myself don’t think this is where the term comes from.

“Kite” probably came instead from the prison practice of communicating with another inmate in the next cell or even many cells away.  The inmate folds up a note and ties it to a long piece of string.  He then swings the note attached to the string underneath his cell door and into the cell of his friend.  Since the folded up note attached to a piece of string resembled a kite, it was called a “kite,” and the term “kite” then became a universal prison term for any written communication, including requests for medical care.

This explanation of the term makes sense to me, so I tend to believe it.  But is it true?

Can anyone out there shed some light on this subject?  Where did the term “kite” originate?