Category Archives: Uncategorized

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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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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Top 2018 Medical Research Articles for Corrections

One thing I look forward to each day is looking through my medical feeds that keep me up to date with medical research.  Most of this content ranges from bogus to unhelpful (in my opinion), but every once in a while, a truly game-changing article appears.  Over the years, I have noticed that most of the game changing articles are debunking articles.  They show that something that is commonly done in medicine actually has no value.  I love these!  Not only do they improve the medical care of my patients, they also make me more cost-effective.  As I have said before, the main way to save money in Correctional Medicine is to eliminate (and stop paying for) medical practices that have no value—or even worse, are harmful to patients.

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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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My Thoughts on MAT in Jails

I recently ran across this news article on NPR (found here) about the problem of treating the large number of opioid addicted patients who are coming to our jails. There is a growing movement that all opioid addicted patients should be offered Medication-Assisted Treatment (MAT) while in jail–meaning one or more of three drugs: methadone, Suboxone or Vivitrol. The article does a good job in pointing out that this is a complicated problem. Having been on the front lines of this problem for many years in my own jails (and so having that great teacher–experience), I would like today to present my own thoughts on using MAT in jails. (MAT in prisons is a separate subject that I will address later).

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Shoulder Dislocations

NP here….What are your thoughts on shoulder dislocations? Does an anterior dislocation require immediate reduction? What if they go out to ED and come back dislocated again? It is thought that these offenders dislocate on purpose in order to go on a field trip. I have heard that anterior dislocations do not need to be reduced as they do not cause neurovascular problems. What has been your experience? Thought?  Thank you for your time!

Great topic! You have asked two questions here. The first question is whether shoulder dislocations need to be reduced immediately (since transporting a jail patient to the ER after hours can be a hassle) or whether the dislocation can wait until the next day to be reduced. The second questions is how to handle those patients who can dislocate and relocate their shoulders at will, and will use this trick to manipulate both the jail and ER staff.

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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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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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Utilization Management is Different in Corrections

This is an important fact that I have learned from many years working in prisons and jails: Most correctional practitioners do not understand how Utilization Management in a prison system works. They misunderstand what the goal of the UM process is. They misunderstand the process of submitting requests. And they misunderstand how decisions are made. It took me a full three years of working in a prison system before I wrapped my head around how UM was supposed to function. This is because UM within a correctional system is fundamentally different than UM in the outside world and also new incoming correctional practitioners are not taught how prison Utilization Management works or how to make UM requests properly.

To show how a prison is different than Utilization Management in a typical Health Maintenance Organization (HMO) in the outside world, let’s say that I am a primary care practitioner in the community who wants to order an MRI on one of my patients. As we all know from long experience, I can’t just order the MRI. I have to get it pre-authorized. To do that, I have to submit paperwork to the patient’s insurance company explaining why I want to do the procedure. Someone will review my request, but I will have no idea who this person is or what their qualifications are. The reviewer could be a physician, or it could be a nurse referring to UM guidelines.  I just don’t know and never will. Whoever that person is, they will either approve payment for the procedure or deny it.

Notice several important things about this interaction: Continue reading

Guest Post–How I Assess Weight Loss in Correctional Facilities

Today’s Post was written by Todd Wilcox, MD.  Todd is the Medical Director of the Salt Lake County Jail in Salt Lake, Utah. He is a past president of the American College of Correctional Physicians and a frequent–and excellent–lecturer.  This article was originally published in CorrDocs, the journal of the ACCP.

Weight loss is a common complaint among our patients and the evaluation of this problem takes up a lot of clinical and administrative time. In many instances, the weight loss complaints are unfounded and the patients are not medically compromised by their weight loss. However, there are a lot of situations where the weight loss is indeed medically concerning and sorting out the two groups presents some challenges. Continue reading