Essentials of Correctional Medicine was held last week in Salt Lake City, Utah and included some great talks. Today’s post is a list of Pearls I gleaned from the conference speakers.
The definition of a “Pearl” is a bit of pithy and insightful information that can be communicated in one or two sentences. Hopefully, it is also something that you have not thought of yet and will change your practice for the better.
I ran into several Pearls at the Essentials conference. Here is a sampling (in no particular order): Continue reading →
My last post introduced the subject of diabetic malingering. In this post, I present several patients I have encountered in my correctional medicine career and the various scams they have used to manipulate their blood sugars. Continue reading →
In corrections, we see an awful lot of malingering, symptom magnification, and outright medical deception. This comes in many forms, from alleging vomiting when none has occurred, to falsely claiming to be hearing “voices,” to deliberately abrading the skin and then complaining that medical can’t get rid of “my rash.” From never-ending back pain with vague leg numbness to pseudo-seizures. But of all of the many kinds of behaviors of this sort, the one that is perhaps the hardest of all to deal with and carries the greatest risk of adverse outcomes is diabetic malingering. Continue reading →
People come to jail taking the weirdest insulin regimens. Often times, I don’t know whether these insulin schems are the result of a practitioner who does not understand insulin dosing well, or whether the patient “tinker” with their insulin dosing, themselves. Here is a case from one my jails (I have changed some of the data and patient characteristics to protect patient privacy).
Banting and Best, Discoverers of insulin
A type 1 diabetic comes to jail taking Lantus 15 units in the morning and 40 units in the evening. He says he takes his Humalog on a sliding scale, but when asked to define exactly what the parameters of his sliding scale are, it becomes apparent that he basically decides his Humalog dose based on gut-feeling. He may take nothing; he may take up to 15 units. He certainly has no concept of counting carbs. He thinks his average Humalog dose is 6 units. His admission HbA1C is 12.8, or an average blood sugar of over 300. In other words, he is not doing a very good job of controlling his blood sugars on the outside.
Sgt. Tracy Cox has permission to wear her own shoes in the jail.
Everyone who works in corrections is familiar with inmates wanting medical authorization to wear their own shoes. A typical case would go something like this: “I have chronic back pain and walking on these hard concrete floors makes it worse. Will you authorize me to wear my own shoes? You did last time I was in here and it really helped.”
We need to keep in mind, however, that allowing an inmate to wear his own shoes gives that inmate secondary gain. Shoes from home are, indeed, more comfortable than the typical jail sandals. Also, any inmate who is granted a special privilege, like wearing his own comfy shoes, gains status among the other inmates. When we approve inappropriate requests for “own shoes,” we are bestowing prestige upon that inmate. And we are denying that prestige to those who we refuse. The unfairness of this is not lost on inmates. Finally, “own shoes” are occasionally used to smuggle contraband into the facility. I remember one pair that had an ingenious hollow space carved out of the sole that was not easy to find on a typical security examination. If you routinely grant requests for “own shoes,” you will inevitably get burned in this way. Continue reading →
I have found, in my years of practicing correctional medicine, that few practitioners who come to corrections are comfortable with insulin dosing. In my experience, this is especially true for physician assistants and nurse practitioners, but many physicians have problems, too. Insulin dosing can be complicated and tricky at times, but for most patients, 10 simple rules will get you to where you need to be.
We first need to cover some groundwork and some terms. Insulin terminology can be confusing. First, it is very important to remember that this discussion applies to type 1 diabetics only. Type 2 diabetics sometimes use insulin, but that’s a “whole ‘nother ballgame.”