Tag Archives: evidence based medicine

Is this a Medical Refusal–or Manipulation?

My good friend Al Cichon writes:

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 all

Thank 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. Continue reading

Random Thoughts on Alcohol Withdrawal

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. Continue reading

Price Check! Are analogue insulins worth their hefty price?

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) Continue reading

Treating Heroin Withdrawal: Methadone, Suboxone and . . . Tramadol?

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. Continue reading

Effective Treatment of Heroin Withdrawal in Corrections

Imagine this: You’re practicing medicine and a patient comes to you with an illness. You make the diagnosis and then say to the patient, “I can see that you are very sick. And there is a highly effective treatment for your condition that would make you feel a lot better. It’s simple and it isn’t even expensive. But, you know what? I’m not going to give it to you! You’re not sick enough. Come back tomorrow. If you’re sicker tomorrow—well, if you’re sick enough—I will treat you then. But not right now.”

Crazy, right? We’d never do such a thing.

But . . . the problem is, we frequently do that exact thing with our heroin withdrawal patients. I’m not singling out correctional medicine practitioners here. I think that, in general, heroin withdrawal is treated better in correctional settings than it is in the community. Nevertheless, it is a fact that heroin withdrawal is often not properly treated in jails and prisons. I have seen it.

I believe that there are four main reasons that some facilities do not appropriately treat heroin (and other opioid) withdrawal. Continue reading

Medications at High Risk for Diversion and Abuse In Correctional Facilities

The practice of Correctional Medicine has many strange differences from medicine outside the walls. It took me a couple of years to get comfortable with the various aspects of providing medical care to incarcerated inmates. Of all of these differences, one that stands out in importance is the fact that many seemingly benign medications are abused in correctional settings.

Of course, the Drug Enforcement Agency (DEA) has established a list of drugs known to have potential for abuse and even addiction. The DEA even ranks these drugs according to the severity of this risk. Schedule I drugs carry the most risk, followed by Schedule II, and so on, all the way down to Schedule V, which are thought to have the least risk.

However, the drugs that we are talking about here are not on the DEA’s list. These are medications that are not abused (or, at least, not thought to be abused) in mainstream medical settings. But these drugs are, in fact, abused and diverted in jails and prisons.

The reasons for this are somewhat complex, but in my mind, it boils down to this: These are drugs that have psychoactive effects that mimic, to some degree, the effects of the drugs on the DEA Schedules. If you are addicted, or even if you just like to get high once in a while, and you can’t obtain your preferred drugs of abuse because you are incarcerated, these are the drugs that can serve as an alternative in a pinch.

It is critically important for medical professionals in corrections to know which seemingly benign drugs have the potential to be abused and diverted. Even if a particular inmate doesn’t care about getting high himself, he can still profit by selling these drugs to others who are. Vulnerable inmates can be (and are) bullied into obtaining these drugs for distribution–if we make them available. Continue reading

A Better Way to Drain Abscesses: The Berlin Technique

One of the consequences of the heroin epidemic we all are experiencing is a marked increase in the number of skin abscesses presenting to the jail medical clinics.  Jails have always had to deal with skin abscesses.  In fact, the single most popular JailMedicine post has been the Photographic Tutorial on Abscess I&D (found here).  But since the heroin epidemic, the number of skin abscess we see has exploded.  It is not unusual nowadays to lance an abscess every day!

The reason for this big increase in skin infections, of course, is that heroin users tend to share needles to shoot up, and these dirty needles leave behind the bugs that cause abscesses.  And since shooting up causes the abscesses, they tend to be found where addicts commonly shoot up–like the inner elbow, the forearm and even overlying the jugular veins of the neck.

Fortunately, just in time for this onslaught of abscesses, my good friend Neelie Berlin PA taught me a new method of lancing simple abscesses that is quicker and easier—yet just as effective—as the method I had been using for my entire career. I’m going to call this new method of draining abscesses “The Berlin Method.”

Who says you can’t teach an old Doc new tricks?  I have wholeheartedly gone over to the Berlin procedure.  It is THE method I use now to drain simple abscesses.

Today’s JailMedicine post is a pictographic tutorial on how to do this new easier method of lancing simple abscesses. Continue reading

ACCP Conference!

The list of educational opportunities specifically geared towards correctional medicine is woefully short.  We correctional specialists need to take advantage of as many of our own conferences as we can.

One excellent resource for several years has been the one day conference put on by the American College of Correctional Physicians (formally known as the Society of Correctional Physicians).  Historically, this conference has always been held on the Sunday before the NCCHC National Conference held in October.  These ACCP conferences have always been excellent, but only held then.

This year, however, is different.  This year, the ACCP is also hosting a spring conference tied to yet another excellent educational opportunity in correctional medicine: the Academic Consortium on Criminal Justice Health.  The Academic Consortium conference will be held this year in Atlanta on March 16th and 17th.  ACCP’s one day conference will be held immediately afterwards, on March 18th, a Saturday. Continue reading

Correctional Medicine is Different: All Clinical Encounters are Discussed in the Dorm

On my last post, I began a series discussing how Correctional Medicine is different from medicine in the “outside world.”  The first (and arguably the most important difference) is that medicine inside corrections has to be fair, whereas the bigger world of US medicine is not fair.

The second big difference between Correctional Medicine and outside medicine is this:  Every clinical encounter in correctional medicine is discussed back in the housing dorm.  This does not occur in outside medicine and is critically important to understanding doctor-patient relationships in corrections.

For those not familiar with the housing situation in jails and prisons, most inmates are housed in large housing dorms or pods.  Depending on the size of the institution, these can house anywhere from 10 inmates to over a hundred.  As you might expect from this situation, inmates spend a lot of time talking with each other, especially since they generally have more free time than your average person in the outside world.  Inmates spend a lot of time talking to one another.

So when an inmate returns to the dorm from a visit to the medical clinic, it is natural for the encounter to be discussed.  If the encounter was unusual or noteworthy in any way, this quickly becomes known throughout the pod.  And since different housing pods also communicate with each other, information about clinical encounters quickly spreads throughout the entire institution.Dorm 1 Continue reading

Correctional Medicine: The Principle of Fairness

I am often asked by my non-correctional colleagues what it is like to work in a jail. I tell them that practicing correctional medicine is different in many ways than medicine in the “free” world. Many of them scoff at this. How could the practice of medicine be different in a jail than it is anywhere else? “Medicine is medicine,” they say.

But correctional medicine is different. In my experience, if you just throw a practitioner into a jail or prison clinic without any training, he likely will not do well. It took me two full years before I was comfortable in my sick call clinics and I am still learning things as I go. Experience matters in Corrections!

This is obvious to those of us who have experience working in jails and prisons. But how do you explain the intricacies of a jail medical clinic to an outside physician? I have thought about this a lot over the many years I have practiced correctional medicine and I have come up with several concrete examples of how correctional medicine is different from medicine “on the outs.” The first, and perhaps the most important, difference is the Principle of Fairness.Unknown-1 Continue reading