My good friend Al Cichon writes:Posted in: Inmate issuesLegal mattersMedical PracticeUncategorizedTagged in: Read more... 3 comments
Dr. Keller - would you consider a discussion of balancing the autonomy of patient decision-making and the risk to the facility for not providing appropriate care. Examples 1. Individual is on disability but wants to sign a 'waiver' of responsibility so he/she can work 2. Diabetic (NIDDM) individual that wants to refuse diet and be placed on insulin so he/she can eat what ever they wish 3. Individual with a comminuted jaw fracture - cut wires on episode of nausea - now wants regular food despite oral surgeon advising limited jaw movement Documentation of appropriate exam and advice to the individual is, of course, the foundation of addressing the issue - but do you allow the 100% (physically) disabled person work; allow the diabetic to sign a refusal of the diet & prescribe insulin; give the individual with the broken jaw (who is asking for more hydrocodone) a regular diet? I believe your expert ability to address these thorny issues will help us allThank you for the kind words, Al! The issue you highlight is indeed a thorny one—when a patient wants to refuse strongly recommended medical care. Sometimes these are true refusals, meaning the patient understands the medical intervention being offered and truly does not want it. More often, though, such refusals are a form of manipulation to get something else that the patient wants. I would like to address these two scenarios first and first and then discuss your three specific examples.
I had a lot to learn when I began practicing medicine in county jails. One of the most important of those lessons was how properly to assess and manage alcohol withdrawal. In my previous life as an ER physician, I had seen a few alcohol withdrawal patients and even one or two cases of DTs. I thought I knew what I was doing. Wrong-o! I was first unprepared for the sheer number of alcohol withdrawal patients I would see as a correctional physician. Alcohol withdrawal in jails is simply very common. But I was also unprepared because much of what I had been taught about alcohol withdrawal was inaccurate or misleading. Nothing teaches like experience! After many years of treating a lot of alcohol withdrawal, I have gained some insights.Posted in: Drugs of AbuseMedical PracticeUncategorizedWithdrawalTagged in: Read more... 1 comment
The analogue insulins were introduced into the United States in the late 1990s and early 2000s. They are called “analogue” insulins because their chemical structure is subtlety different than native human insulin, which gives them different, advantageous properties. Analogue insulins include the short acting insulins Humalog (insulin lispro) and Novolog (insulin aspart) and the long acting insulins Lantus (insulin glargine) and Levemir (insulin detemir). Since their introduction, the insulin analogues have pretty much taken over the insulin market in the US. That is why I only mentioned human insulins in passing in the JailMedicine post “Insulin Dosing Made Simple.” It is unusual to see patients show up at the jail on any other insulin regimen than analogue insulins, usually Humalog and Lantus. And I have to admit; the analogue insulins are easier to use than human insulins. I like them. But here is the problem: the analogue insulins have become insanely expensive! When they were first introduced, the price of Humalog and Lantus was around $20.00 per vial of 100 units. That compared to the price of human insulins like Humulin R and NPH of around $5.00 per vial. So the analogues were expensive, but doable. However, since around 2006, analogue insulins have dramatically increased in price—whereas the price for most other diabetic therapies has actually decreased over time. (You can read more about this price increase here)(In the graph above, notice the huge increase in insulin prices since 2006, while every other diabetic therapy price has actually fallen)Posted in: DiabetesDrug EvaluationsMedical PracticePractice ManagementStudiesUncategorizedTagged in: Read more... 3 comments
Inmates cannot go out to find good doctors in the community. Good doctors have to choose to go to them!2017-08-07 11:00:18
I remember the first time someone told me that I was “wasting my talents” by working in a jail. At that time, I had no ready witty rebuttal. I love my job and I especially appreciate working with a patient population that is disadvantaged and underserved. Of course, the idea that incarcerated inmates are worthy recipients of medical care is, well--controversial. Inmates are not as politically correct as other medically disadvantaged populations. As an example, if you were to tell your family and friends that you were going to work with at a medical clinic for the homeless in an inner city, or to provide medical care in a needy third world country, the reaction probably would be something along the lines of “Good for you! I admire your selflessness and dedication!” Yet when you tell these same people instead that you are going to work in a prison, you are much more likely to get this reaction: “What’re ya, nuts? Why would you waste your talents working with them?” I personally have heard the “you’re wasting your talents” line more than once.Posted in: Inmate issuesJail culturePractice ManagementUncategorizedTagged in: Read more... 7 comments
In my last JailMedicine post, I wrote that clonidine is an excellent drug for the treatment of opioid withdrawal. In response, several people have asked about methadone and Suboxone. Why not use one of those drugs instead of clonidine? The short answer is that both methadone and Suboxone are excellent drugs for the treatment of withdrawal. However, both are much more complicated to use in jails due to DEA legal requirements and a much larger potential for diversion and abuse. If you are using Suboxone or methadone, great! I believe that clonidine is a better choice for most jails. Those interested in using methadone or Suboxone need to be fully aware of the DEA laws surrounding their use. Before you use one of these drugs, you must make sure that you are following the law. I know of two physicians in my hometown who were disciplined by the DEA for prescribing narcotics to treat addiction without registering. The DEA are not kidders! By the way, Jail practitioners should also be aware that Tramadol has been used successfully to treat withdrawal, as well.Posted in: Drugs of AbuseMedical PracticeUncategorizedWithdrawalWithdrawal SyndromesTagged in: Read more... 11 comments