Category Archives: Practice Management

Beware the Bounce-Back!

I learned about Bounce-Backs back in my Emergency Medicine days.  A bounce-back is a patient who you saw in the ER and discharged but then returned within 48 hours with the same complaint.  A lot of time is spent in emergency medicine education talking about how to handle bounce-backs.  The basic message is “Beware! You may have missed an important diagnosis the first time!” 

Bounce-backs happen in correctional medicine, too. Bounce-backs can happen in jails, where we often deal with new patients who we do not know well, but also in prisons, when patients we do know well have a new complaint.  Just like in emergency medicine, a bounce-back in a jail or a prison is a patient who comes to the medical clinic with a new complaint, receives a diagnosis and treatment and then re-kites for the same complaint within a couple of days.  Here are a couple of examples. 

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Introducing Sharen Barboza

I am pleased to be joined on JailMedicine by my colleague Dr. Sharen Barboza! Dr. Barboza has been providing correctional mental health care for more than 20 years. Her complete bio can be found in the About The Authors tab (here). Besides her broad experience, intelligence and common sense, Dr. Barboza is simply the best speaker I have heard at any correctional medicine conference. I am honored to have her as my co-editor at JailMedicine! Jeffrey Keller

Dr. Sharen Barboza

I am truly honored, grateful and humbled to join Dr. Keller on JailMedicine.com.  I think that now, more than any other time in the past, we are all realizing the impact that our mental health has on our ability to function in the world.  For so many of us, we take the “health” part of our “mental health” for granted.  We trust our thoughts to be based in reality; we rely on our emotions to adequately and appropriately meet the moment; and we have confidence in our ability to cope with what comes our way.  Most days. 

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Using a Wrench Instead of a Hammer for Alcohol Withdrawal

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 something better.

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ACCP Position Paper on the Funding of Hepatitis C Treatment

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.

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You Need a Plan for Corona virus in your Facility

Unless you’ve been living under a rock, you have been hearing about the threat of a Corona virus pandemic. Every day, the evening news anchor breathlessly gives an update of the number of new cases, the number of new countries affected and the number of new deaths.  You probably already know that this disease was originally found in China.  What you may not know (but you should if you work in corrections) is that Chinese prisons were especially hard hit.  This disease spreads most rapidly where people are enclosed together, like nursing homes, cruise ships and prisons.  If this disease gets a foothold in the United States, correctional institutions are likely to suffer. 

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Oral Testing of Reported Penicillin Allergies?

Penicillin is miraculous.  It was discovered in 1928 by Alexander Fleming (founding the modern era of antibiotic medicine) and is still the most common antibiotic prescribed in my jails.  The dentist and I use Penicillin VK as our preferred initial agent for dental infections.  I prescribe PCN VK, as well, for strep throats.  I use amoxicillin occasionally for sinus infections and UTIs and even amoxicillin/clavulanate (Augmentin) occasionally. 

Because penicillin is so useful (and inexpensive), I hate to hear the words “I’m allergic to penicillin.” If a patient with a dental infection can’t take penicillin, for example, the dentist commonly prescribes clindamycin, which is expensive, a pain to administer three times a day and has potentially bad side effects.  I have seen more than one patient who developed C. difficile after getting a broad-spectrum antibiotic because of a reported penicillin allergy–probably unnecessarily!

This problem is pretty common since about 10% of the adult population will report a penicillin allergy.  However, research has shown that, when tested, more than 90-95% of patients who state that they have a penicillin allergy really do not. These patients can be harmed by giving them an inferior antibiotic more likely to cause them harm than plain old penicillin.

The test most commonly used to gauge true allergic status is Penicillin Skin Testing (PST). No jail or prison that I know of does skin prick tests.  We also don’t refer patients reporting penicillin allergy to an allergist for testing.  We just groan and prescribe an inferior antibiotic. 

However, this could potentially change based on research published this year on the safety and efficacy of “Direct Challenge” penicillin allergy testing.  Direct challenge means giving a low-risk (this is important) patient an oral dose of whatever penicillin you want to prescribe and observing them for an hour for an allergic reaction. This has been done in studies and has been reported to be safe and effective.

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Reducing NSAID Use PLUS NSAID Prescribing Guideline

Through many years of experience in correctional medicine, I occasionally have come up with a speech or dialogue that works especially well with patients; a speech which I then use over and over again. One of these speeches is one I use to get patients to take fewer NSAIDs.

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Do You Understand the Requirements for Multiple DEA Licenses?

I have found that many correctional practitioners, especially in jails, do not understand the license requirements of the federal Drug Enforcement Agency (DEA) and, as a result, do not have all of the DEA licenses that they are legally obligated to obtain. 

Take, for example, a correctional physician that we will call Dr. K who is employed full time a a large urban jail and has had a DEA license for that jail for many years.  On the side, she also provides medical services to three other smaller jails, where she does clinics once a week. The question is whether her one DEA license covers her activities at the other jails.  Dr. K has always thought that she only needs one DEA license—just like she only needs one Driver’s License—and it will cover all of her activities. 

But the real answer is, “No,” Dr. K is not in compliance with DEA regulations.

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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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