Tag Archives: evidence based medicine

Essentials Of Correctional Medicine, February 2014

I am pleased to announce the Essentials of Correctional Medicine Conference 2014!

It will be held February 18-21, 2014 in the Downtown Hilton Hotel in Salt Lake City, Utah.

Last year’s conference was a great success. We had much greater participation than we had anticipated and the comments we received from the conference participants were almost all positive. However, we did get some suggestions for improvements that we are using to make Essentials 2014 even better!

Much like last year’s conference, here is what you can expect:

This is a working conference. Do not expect a lot of free time. Do expect to learn a lot.
This is a conference for Correctional Medicine Professionals. Each and every lecture will specifically pertain to medicine practiced in jails, prisons and juvenile facilities.
Excellent, engaging speakers. We have three requirements of our speakers. First, that they teach up-to-date, useful material. Second, that they are enthusiastic and engaging. Useful information does no good if the presentation is so boring that you slept through it. Finally, they must relate their presentations to correctional medicine. We in correctional medicine must always keep safety, security, and the possibility of symptom magnification for gain in the back of our minds in a way that outside physicians find foreign.

We have made several changes and improvements to the conference format based on the suggestions and critique of last year’s participants:

Fewer speakers speaking on more topics.
More time for questions. Each speaker will devote time to answering questions. Also, each day we will bring all of the speakers together with the conference participants and have a question and answer and discussion session. Expect debates!
Protocols. Each clinical lecture will come with a sample protocol. Whether you call them Policy and Procedures, Standard Operating Guidelines or simply Protocols, writing these suckers is hard work. So besides lecture notes, conference participants will leave with a good number of clinical policies that they can easily adapt to their particular institution.
More vendors. We especially are looking for vendors with new products that can make our lives better.
More “working on a full stomach.” Since this is a working conference, continental breakfast and lunch will be provided most days so we can keep on learning!

2014 Conference Topics.

Infectious diseases. Our Keynote Speaker, Dr. Joseph Bick, is an expert in infectious diseases and a great speaker. He is currently on sabbatical working as a correctional physician at a prison in Malaysia, of all places. Dr. Bick will share those experiences with us in the Keynote Address, and then will address many of the infectious disease conundrums we face in Correctional Medicine.
Dermatology. Every correctional physician needs a dermatology consultant to send grody rash pictures to. Mine is Neelie Berlin, enthusiastic rash expert who also happens to also be a wonderfully entertaining speaker.
Medico-legal matters. I personally always enjoy legal discussions and case analysis. Hearing about bad-outcome legal cases is like driving by a bad wreck on the freeway—you just can’t look away.
Symptom magnification and malingering. Does any medical profession have to deal as much with this issue as we in corrections do, day after day after day? Answer: Ah, no. Essentials will have presentations about detecting deception, properly documenting these encounters in a medico-legal friendly way and dealing effectively with these inmates without confrontation. Forensic Psychiatrist Dr. Noel Gardner will discuss symptom magnification and malingering in the psychiatric realm. Wonderfully entertaining as well as essential information.
Formulary development and maintenance. It is easier than you think!
Chest Pain and Abdominal Pain. Simplified approaches to assessing these complaints.
And More!

More conference information is found under the “Essentials Conference” tab at the top of the page!

Do you have questions? Suggestions about how to make this and future conferences better? Contact Us information is found at the conference website: Essentials of Correctional Medicine.

A Low Salt Diet. Do You Really Need One?

However, I personally have never been a big fan of these Low Salt Diets in general and especially in Corrections.

There are two reasons for this. The first, as I can tell you from my own experience as I was growing up, is that very low salt diets are not very palatable. Most people find the food quite bland and will not eat it long term. Correctional inmates experience this, too, and commonly sabotage the diet by liberally salting the Low Salt Diet at the table (as I myself used to do) and by ordering lots of salty commissary foods like Ramen, and chips.

We practitioners commonly sabotage the Low Sodium Diets as well, by ordering medications with lots of attached sodium, such as naproxen sodium or omeprazole sodium.

So I challenge you to check the commissary purchases and prescriptions of the inmates at your facility who are prescribed a Low Salt Diet and find out how many truly ingest less than, say, 2,300 mg of salt a day. I guarantee, it won’t be many.

The second problem with the Very Low Salt Diet hypothesis is that the science for its efficacy has been pretty tenuous. Basically, eating less salt lowers blood pressure slightly in some individuals. Since people with lower blood pressures tend to have fewer heart attacks and strokes, then, the theory goes, eating less salt will lower blood pressure which will thereby decrease heart attacks and strokes. The Magic Number for salt consumption was pegged at less than 1,500-2,300 mg a day, compared with the average U.S. daily salt intake of 3,400 mg. But until 2006, no one had studied salt consumption directly.

Now comes this report, Sodium Intake in Populations: Assessment of Evidence,
from The Centers for Disease Control and Prevention’s Institute of Medicine, which analyzed the data directly linking salt consumption to death, heart attacks and strokes—no blood pressure middle-man. It turns out, according to the CDC, that all of these bad things (death, heart attacks, strokes, congestive heart failure) did increase with salt intake greater than 7,000 mg a day—but also (and who would have guessed this) for salt intake of less than 3,000 mg a day.

The report has already come under criticism. Most of the criticism I have read so far has been of the “I don’t believe it” variety. But one good observation, in my mind, is that the most common source of big-time salt in American diets is fast food and processed food, rather than overly salted prepared foods. I think we all will agree that most fast foods and processed foods are not the best health-wise, and for more than just their excessive salt content.

This is true in jails and prisons, as well. The biggest source of excess salt in most inmate diets is the junk food found in the commissary, not the food prepared in the kitchen. That is certainly the case at my jails. The prepared meals in my jails do not have a huge amount of salt.

So what is the take home message from the CDC report?

1. It may be OK to get rid of your Very-Low Salt Medical Diet (1,800 mg a day) as long as the standard diet served to your inmates has reasonably low salt content, like less than 3,400 mg a day. It probably does, unless you are serving lots of processed foods.

2. If you do order Very-Low Salt Medical Diets anyway, perhaps it would be prudent to check commissary purchases and NSAID prescriptions to make sure that the patient is really ingesting low amounts of sodium. If, despite the Very-Low Salt Diet, your patients are still ingesting over 3,400 mg a day, what is the point of the diet? It is a lot of time and effort that is not accomplishing anything.

How many Low Sodium Diets do you prescribe? What do you think of the CDC report? Please comment!

Price Check! Estrogens.

1 Reply

I don’t have a lot of women in my jails who take estrogen. The post-menopausal women I see usually are not prescribed replacement hormones by their outside doctors very often. The main reason for this is the momentum generated by the landmark study Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial published ten years ago in JAMA which said that the risks of hormone therapy following menopause outweighed the benefits. Most of the major women’s groups (here is one example) have backed off a little from this, saying now that for some women, post-menopausal hormones are OK, but should be done for as short of a time as possible.

Nevertheless, most of the women who are taking replacement estrogen are younger women who have had a total hysterectomy. Since these women are young, it is appropriate for them to take replacement estrogen. Since they do not have a uterus (for the most part), they do not need to take progestin. But which estrogen should be on our “Preferred Drug List” (otherwise known as a Formulary)?

In many drug categories, ACE inhibitors, say, there are several options that are equally effective and equally priced. I don’t care if a patient is taking lisinopril or enalopril. They are equivalent.

That is not the case with estrogens. It turns out that in the estrogen department, there is a clear winner.

Here is the price-per-pill breakdown. The doses listed are the typical standard doses for adult women.

Estrogen	Dose	Price Per Tablet
Esterified Estrogen (Menest)	0.625mg	$1.11
Estradiol (Estrace)	1 mg	$0.04
Synthetic conjugated estrogens (Cenestin, Enjuvia)	0.625mg	$3.27
Conjugated equine estrogen (Premarin)	0.625mg	$3.09
Estropipate (Ogen)	1.5mg	$0.24

Premarin has been around since 1942 and for many years, was the only available estrogen product, to the point that ”Premarin” became almost synonymous for all estrogens in the same way that people say “Kleenex” for all nose-blowing tissues. Premarin continues to be the most prescribed replacement estrogen.

In fact, however, all of the estrogens are therapeutically equivalent. The only differences are these:

1. Premarin (conjugated equine estrogen or CEE) is derived from pregnant horse urine. That is the only thing (except price) that sets it apart from the others.

2. All the others, including synthetic conjugated estrogen, are made from plant proteins.

3. 17-beta-estradiol (usually just called estradiol, brand name Estrace) is the only formulation that is “bio-identical” to human estrogen.

So there you have it. By curious happenstance, the one estrogen that is bio-equivalent to human estrogen happens to be the one that costs 4 cents a tablet.

Estradiol should be the preferred estrogen in your facility.

Do you still use Premarin in your facility? Why or why not? Please comment!

Case Study: “I Fell and Hurt My Hand”

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An inmate presents to the medical clinic with a laceration on his hand overlying the knuckle of his small finger. He insists that he fell getting off of his bunk. He has no other injuries on examination. What do you think happened? How would you treat this? Continue reading →

Chemical Sedation–Right Follow Up

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Remember our patient? He was the guy who repeatedly ran his head into the wall. Probably everyone in corrections (if you have worked in the field long enough) has seen someone like this guy , who is working hard to harm himself.

I have argued that chemical sedation is safer than prolonged physical restraint in managing this patient. We reviewed which patients are appropriate candidates for involuntary chemical sedation and which drugs are best used for this indication. By now, in our series on chemical sedation, we have reached the point where the patient has actually been injected with the sedating agents.

Of course, once the patient has been given Haldol and Ativan IM, we cannot just walk away. Most of the time, chemical sedation occurs without incident. Well within an hour, most patients are asleep and can be removed from physical restraints. But as with everything in medicine, problems sometimes occur. Therefore, following the administration of involuntary chemical sedation, the medical team must ensure and document the safe and effective onset of sedation. Then, there must be appropriate follow-up. Chemical sedation is an unusual occurrence that has both medical and legal implications. Follow up visits investigate why the patient became so unmanageable as to need chemical sedation and make sure that the sedation was administered correctly.

Safe Onset of Sedation

Generally, most patients who have received an IM injection of Haldol and Ativan will be asleep well within an hour. In the normal course of events, the nurse caring for this patient should observe him long enough to document that the patient has become sedated and has been removed from physical restraints. Once the patient is out of restraints, the nurse should take vitals signs and document that the patient is sedated but arousable and is in good shape.

Problems sometimes occur, however. The single most common problem is that the first shot was not enough and the patient is still awake, thrashing and agitated, an hour after the IM injection. When this happens, the proper course is to start over from the beginning. Does the patient have an unrecognized medical cause of the agitation, like hypoglycemia or hypoxia or delirium? Have the vitals signs improved or deteriorated? Is the patient just as agitated as before or is he (more likely) partially, but incompletely, sedated? After this re-evaluation, most patients in this situation just need a second dose of Haldol and Ativan to complete the sedation process. Rarely, though, the appropriate call is to send them to the ER.

Appropriate Follow-Up

All patients who have received involuntary chemical sedation should have two follow-up check ups, preferably within 24 hours. The reason for these visits is twofold:

To investigate the question of why the patient was so agitated in the first place, and
Whether the patient needs further interventions, like further work up (labs, say), changes in his maintenance medication regimen, or commitment.

The first of these visits should be in the medical clinic with a medical practitioner. The practitioner should document absence of harm from the procedure and, if possible, pinpoint a medical reason for the agitation, if there was one. The two most common medical reasons for agitation of this severity are amphetamine or alcohol intoxication. Confusional states, like dementia and delirium, are also possible.

The patient should also normally be seen by the mental health. The purpose of this visit is to determine if there was a psychiatric reason for the agitation. The three most likely possibilities are:

Acute psychosis.
Acute mania.
Misbehavior as a manifestation of a personality disorder, especially the “Big Three: Borderline, Antisocial and Narcissistic Personality Disorder.

Questions that should be specifically addressed in the mental health visit are whether the threat of aggressive behavior is over (usually it is), whether the patient is a candidate for commitment to a psychiatric facility (usually not) and whether changes should be made in the ongoing psychiatric medication regimen.

Finally, each and every case of involuntary sedation should be reviewed in a quality assurance capacity. This can be done by the facility medical director or within a CQI committee. Chemical sedation can be misused and overused. Once the medical and security staff see how much easier and better involuntary chemical sedation is than physical restraint, there is a tendency to want to use it all the time—in patients who really are not a danger to self or others–just for the convenience of the staff. The purpose of the CQI review of all instances of involuntary chemical sedation is to ensure that this extraordinary therapy is not misused or overused.

Involuntary Chemical Sedation Checklist

Involuntary chemical sedation tends to be a high adrenaline affair. When you are in a situation involving a yelling, agitated patient and correctional staff amped up on adrenaline, it is hard to remember everything you are supposed to document. The charting of these incidents often contains important omissions, at least in my experience.

The solution to this problem is to borrow a procedure from airline pilots, who have a written checklist of everything they must remember to do before they take off. Without the checklist, something will be missed eventually. The documentation of involuntary chemical sedation is likewise made easier by using a checklist that contains the following sections:

Appropriate candidate.
Reversible medical causes.
Appropriate agents.
Safe and effective onset of sedation.
Appropriate follow-up.

I have attached below a PDF file of a Sample Involuntary Chemical Sedation Form. You are welcome to download it and use it to develop one for your own facility!

Click here for the Sample Involuntary Chemical Sedation Form

How often do you have to use involuntary chemical sedation at your facility? Please comment!

Inmate or Convict? What’s in a Name?

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For many years after I came to work in jails, I was confused as to why those incarcerated in my jails were referred to with such varied and stilted names.

IDOC (the Idaho Department of Corrections) calls its charges offenders. The Federal Agencies, both ICE and the Federal Marshals, say detainees. The deputies and administrators of the jails use the word Inmates.

I have always been interested in linguistics and etymology (the study of where words come from). I had always thought that inmate was the correct term for someone incarcerated in a jail or prison. It turns out that the word inmate dates from the 1500s and originally meant someone who was living in a house rented by another. It derives simply from inn (an inn, of course, but also inside) and mate (companion). Over time, inmate came to refer to anyone who lived with many other people in a single dwelling. By the 1830s, the term inmate carried the connotation of the person being confined to the residence, i.e., housed involuntarily. You were an inmate if you lived with many other people but were housed there against your will.

Among the places where you could be housed against your will originally included hospitals but I don’t think it does, anymore. If your grandmother was on the medical floor of the local hospital, you would not refer to her as being an inmate. I think this is so because even though grandma might not have wanted to be there at the hospital, she could leave anytime she liked.

So this is the meaning of the word inmate as it is understood now: a person who has been has been remanded by some sort of authority to stay at some facility against their will and which they cannot simply leave. That would apply to residents of jails, prisons and juvenile facilities but also secure psychiatric hospitals.

Understood in this way, inmate seems to be an appropriate descriptive term for residents of our correctional facilities. It also is without any sort of negative connotations, at least that I was aware of. So why the use of offender or detainee? They just seem cumbersome and don’t work as well as the original English word inmate.

But then I ran across this interesting website, Prison News Blog, in which the incarcerated author explains the hostility to the word inmate. Evidently, there are two terms in prison culture for someone incarcerated there: inmate and convict. One does not want to be an inmate. Inmate is a derisive term, even an insult, because it is believed to imply that the person is a fawning “good little boy,” so to speak.

In the parlance of the penitentiary, we generally understand an inmate as one who becomes a little bit too closely aligned with the institution and its rules. Inmates are quick to engage in conversation with staff members. It seems as if inmates suffer a bit from the Stockholm Syndrome, where they identify more with their captors than with others who share their captivity.

Instead, those incarcerated in prisons prefer to think of themselves as “convicts.” A convict, in prison culture, is defiant and his own man.

Convicts differ from inmates. Convicts may abide by the rules, but only because they want to avoid additional aggravations or frustrations. Yet if he believes breaking a rule would be in his interest, he will make his choice and live with the consequences. A convict would never cooperate with a staff member in some kind of diabolical deal to spare himself. Convicts have an air of defiance. He may suppress that defiance, though he feels it coursing through his veins.

After reading this, I wondered who had decided that inmate and convict had these different meanings in prison? And on what basis? I understand better where this definition of “convict” came from. As a convict, you have been convicted of some crime. By the rules of polite society, you are a bad boy. By preferring to be called a convict, you are embracing your antisocial nature. It also has some cool harsh consonants that sound manly!

The term inmate, however, has never implicitly meant that you are a good boy or that you are a sheep. That meaning has been made up. Throughout its history, inmate has never meant complicit or cooperative. Quite the opposite, in fact. The historical meaning is that you are being held against your will. The closest synonym is prisoner.

And this inmate vs. convict dichotomy cannot be applied to many correctional institutions. Most inmates in jails have not been convicted yet, and so cannot properly be called convicts. They are pretrial detainees. And also inmates, of course. It does not even apply to all prisons. Many of the residents of Guantanamo prison are not convicts; but they are all inmates.

Nevertheless, I understand that the inmate/convict labels, as described in the Prison News Blog, have become well established usage at most of the prisons in the United States to the point that it truly is a grievous insult to refer to someone as an inmate. Prison officials haven’t wanted to perpetuate the anti-social meaning of the word convict, and so they have come up with the clumsy term offender. Similarly, federal officials prefer the term detainees. (Although I wonder what would have happened if prison officials instead had adopted the term convict and applied it to everyone, the cooperative and non-cooperative, alike. Would that eventually have defused the antisocial meaning being given to the word?)

So far, this has not been a problem in my jails, which are off the beaten path in a less populous state. We still use the term inmate and so far, have not had any objections, even from the IDOC, ICE and Federal Marshal inmates that we house. If it ever becomes a problem in the future—well, I guess I will be saying “the detainees that we house.”

Do you use the term inmate at your facility? How about convict? Please comment!

Involuntary Chemical Sedation–The Right Medications

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Let’s start by setting the stage: Our patient is a 35 year-old man who is angry that he has been arrested in a domestic dispute case. He cooperated with the booking process, but then, several hours later, began to repeatedly ram his head full force into the wall. There is blood on his face and on the wall. The word “uncooperative” does not do him justice. He is agitated and belligerent and wants to fight. He is screaming offensive obscenities.

Of course, he cannot be allowed to continue to hurt himself. The deputies take him down and strap him to a restraint chair. A spit mask is required. Nobody really expected him to calm down after he is placed in the restraint chair and they are not disappointed. 30 minutes later, he is still screaming.

This patient certainly meets the criteria for chemical sedation. He is an acute danger to himself. He is an acute danger to others. He has refused voluntary sedation. He is not hypoxic or hypoglycemic (but if there is a suspicion of this, it is easy enough to get a pulse oximetry reading or a finger stick blood sugar).

What medications should be used to sedate this patient?

Remember that our goal is to sedate the patient so that he can be released from physical restraints. We would like him to be sedated and drowsy and even go to sleep, but to be easily arousable. We do not want respiratory depression or other serious side effects.

The two main drug classes that have been traditionally used for this type of chemical sedation are the benzodiazepines and the antipsychotics. I was taught in my Emergency Medicine residency that the benzos were “minor sedatives” and the antipsychotics were “major sedatives.” However, there have been several studies comparing the two when sedating agitated patients, including this 2010 Cochrane Review, and, in fact, both work well. They may work even better when given together. Each has advantages and disadvantages that should be considered.

Antipsychotics for Sedation–Haloperidol

The best overall antipsychotic for rapid sedation of agitated patients in a correctional setting, in my opinion, is good, old haloperidol. Haldol has been safely used for this indication (probably) millions of times world-wide. It is “tried and true.” It is Vitamin H. The Velvet Hammer.

The main advantage of haloperidol is that it is so safe. It does not cause respiratory depression and so can be given to intoxicated patients. It has no dose limit for safety reasons. This means that it can safely be given to patients who are already taking antipsychotics. The dose is the same whether po or IM, so if a patient changes his mind and accepts oral meds, it is easy to change course. It can be given IV as well as IM (though we would seldom give haloperidol IV in a correctional facility as is done routinely in ERs).

“Haloperidol has been evaluated in a large number of clinical trials alone and in combination with benzodiazepines. These studies demonstrate that intramuscular haloperidol is both safe and effective in the treatment of agitation caused by virtually any etiology” Roberts: Clinical Procedures in Emergency Medicine, 5th ed.

Any other antipsychotic that can be given IM can also be used for rapid sedation. Possibilities include Inapsine (droperidol), Geodon (ziprasidone), and Zyprexa (olanzapine). There is nothing wrong with any of these agents, and if you already use them and are comfortable with them, that is great. They offer no advantages to Haldol, however. None are more effective and none are safer.

The major potential adverse effects of acute one-time dose Haldol administration are exceedingly rare. One of these is Q-T prolongation that can, potentially, cause dysrythmias. Another is Neuroleptic Malignant Syndrome. Both of these are very rare, however, and the risk is far less than the risk of prolonged physical restraint. Haldol has also been reported to lower the seizure threshold, but this is controversial.

The one reasonably common adverse effect of acute IM Haldol administration is a dystonic reaction. Dystonic reactions involve involuntary muscle contractions usually in the neck, shoulders or face, but also elsewhere. It can also manifest as akesthesia, which can be thought of as a case of restless legs from hell. We are not talking here about Tardive Dyskinesia. Tardive Dyskinesia is also involuntary muscle contractions but these occur after years of neuroleptic medication use and are irreversible. Acute dystonic reactions are easily reversible, using an antihistamine, like Benadryl. Unlike tardive dyskinesia, dystonic reactions are a nuisance, trivial and easily treated.

Because of the possibility of a dystonic reaction to IM Haldol, some practitioners give Benadryl 50mg IM at the same time as the Haldol. I do not do this for the following reasons:

The dystonic reactions from Haldol tend to occur the day following the IM injection. Benadryl is so short acting that it is gone by then. Theoretically, then, it may not be effective in reducing dystonic reactions. This has never been studied, as far as I know.
Only 1 in 6 or 7 patients who receive a single Haldol injection will develop dystonia. If you give Benadryl to everyone, you are treating the majority of patients needlessly. Benadryl has its own set of ill effects and side effects.
If a patient does develop dystonia the next day, 50mg of Benadryl given orally will solve the problem quickly at that time. That is when I prefer to treat these nuisance reactions.

The standard adult dose of Haldol for rapid sedation is 5-20 mg IM.

Benzodiazepines for Sedation–Lorazepam

Any benzodiazepine that can be given IM can be used for chemical sedation. I like to use Ativan (lorazepam), myself. Valium can be used but is not as good because it is not well absorbed from an IM injection. Versed (midazolam) is an acceptable alternative to Ativan.

The main disadvantage of Ativan as a chemical sedative is that it can cause respiratory depression, especially when combined with other sedating drugs. For example, it should be used cautiously in the obnoxious drunk. Haldol alone is a better choice for him. It also reportedly can cause hypotension, though I have never seen this.

On the other hand, lorazepam is an excellent choice for stimulant overdoses. It almost can be thought of as an “antidote” to stimulant “poisoning.” So the patient who is agitated while “tweaking” on meth would do well receiving lorazepam.

The standard dose of lorazepam for chemical sedation is 1-4mg IM.

Combination Therapy

One cool thing about Haldol and Ativan is that they play well together. The medical term for this is that they are synergistic—they increase each other’s effectiveness. In practical terms, this means that if they are combined, you can use a smaller total dose of each agent. Instead of needing 4mg of lorazepam IM to sedate a patient, if you combine it with Haldol, you only may need 1 or 2 mg and vice versa. The two drugs are so compatible that you can mix them together in the same syringe.

The standard dose of the combination used for chemical sedation of the agitated patient is “ten and two” meaning 10mg of Haldol and 2mg of Ativan. You can reduce this to “five and one” or increase it depending on the circumstances. You can also vary the ratio or use just Haldol or just lorazepam depending on a particular case. For example, what would you use in these cases?

The Standard Jerk. This is the patient who is agitated and belligerent not because of drugs or alcohol, but because of frustration, manipulation or whatever. Chemical Sedation: “Ten and Two” (Haldol 10mg and lorazepam 2mg IM).
The “Mean Drunk.” This patient is still intoxicated, so you might not want to use lorazepam since it potentially could cause respiratory depression in combination with the alcohol. Chemical Sedation: Haldol 10mg IM. It will not cause respiratory sedation and can be used safely in an intoxicated patient.
The Acutely Psychotic or Manic Patient. Chemical Sedation? “Ten and two.” Sometimes these patients need a second dose in an hour. Should we be worried that the patient is already taking antipsychotics (let’s say Abilify, for example)? The answer is no. You can still safely give Haldol.
Methamphetamine Intoxication. Lorazepam is the “antidote” for the patient who is tweaking on meth or cocaine. Chemical Sedation? Lorezepam 4mg IM. You can add 5mg of Haldol, as well if you want.
“Undifferentiated.” If you just do not know why the patient is agitated and belligerent, remember that “intramuscular haloperidol is both safe and effective in the treatment of agitation caused by virtually any etiology” Roberts: Clinical Procedures in Emergency Medicine, 5th ed. If you are reasonably sure the patient is not drunk, add the lorazepam, as well.

Next installment in the series: Chemical Sedation: Right Documentation and Right Follow –Up.

What medications do you use for Involuntary Chemical Sedation at your facility? Please comment!

Involuntary Chemical Sedation–The Right Patient

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In my last blog post, I argued that chemical sedation was safer that prolonged physical restraint for patients who represent an acute threat to themselves or others. Today, I would like to explore who is an appropriate candidate for involuntary chemical sedation—and who is not. This is the first part of the Four Rights of Chemical Sedation: Right Patient, Right Medication, Right Follow-Up and Right Documentation.

First, let’s define what we are talking about here. The key concepts in Chemical Sedation-Restraint are:

It is an urgent situation. Consider again the patient who is running his head into the wall. We have to stop him now. There is no time to consult with superiors or obtain a court order. The patient is harming himself now and we must stop him–now.
It is an alternative to prolonged physical restraint. We are restraining patient behavior using medication because this is safer for the patient than is prolonged physical restraint. In fact, we are using chemical sedation precisely so that we can release the patient from physical restraints.
It is involuntary. The patient does not want it to be done. Sometimes, when a patient is in a restraint chair and you say, “Would you like something to help you calm down?” They will say “Yes.” The sedation there is not involuntary anymore. We are talking here about someone who is refusing any type of medication.
We are using sedating psychotropic medications. There are many medications that can be used for sedation but they all have in common that the patient will be sedated at the end. The end goal is that the patient will be asleep (but arousable) and no longer requires any type of physical restraints.

There are many terms we could use to convey these concepts. We could say: Urgent or Emergency for the first concept, Restraint or Sedation for the second, Involuntary or Forced for the third, and Chemical or Psychotropic for the last concept. This could lead to some cumbersome terms like “Emergency Involuntary Psychotropic Restraint” or “Urgent Forced Chemical Sedation.” The emergency medicine literature tends to use the more concise term “Chemical Sedation” for this procedure. Since the overall goal is to get the patient out of physical restraints, I prefer the term “Chemical Sedation” instead of “Chemical Restraint.”

Who Is A Candidate for Emergency Involuntary Chemical Sedation?

There are four indications for Chemical Sedation in a correctional facility:

The patient is a danger to himself. The patient who is running his head forcibly against the wall is an obvious example. I once had a patient who kept climbing up onto the sink in his cell and doing a swan dive onto the floor. Head-bangers, I think, would qualify as would those patients who pull out fist-fulls of hair or gouge at their eyes. I also would include poop-eaters, since as a trained medical professional, I know that eating poop is considered bad for one’s health. Poop-smearers probably qualify, as well. On the other hand, screamers may not qualify since screaming obscenities, even for prolonged periods of time does not represent a danger to self.
The patient is a danger to others. There is an element of a judgment call here in assessing the level of danger involved with those inmates who threaten others with violence. For example, if you happened to have John “Bones” Jones (world champion mixed martial arts fighter) in your facility and he were to say “I will kill anyone who comes into my cell,” you should believe him. Mr. Jones would represent a true danger to others and probably should be chemically sedated. On the other hand, a frail 90-year old man who makes the same threat might not be a real danger to others and chemical sedation based on that statement alone might not be warranted. Other examples of inmates who pose a true threat to others might include poop-throwers, biters, and maybe even spitters.
The inmate represents a threat to the integrity and security of the institution. For example, an inmate who is tearing apart his cell, damaging the door or plexiglass, might qualify for chemical sedation. Another example would be an inmate who screams racial taunts at other inmates, inciting them to anger and a potential riot, also could qualify for sedation.
To assist in the medical assessment and management of the patient. Sometimes, I don’t know for sure why an inmate is being aggressive and threatening. An example here would be a newly booked inmate who is acting bizarrely. Let’s say he is not talking coherently. He will not cooperate even with getting vitals signs. Is he high on meth? Delirious? Drunk? Psychotic? Sometimes, the only way to be able to assess this patient is to chemically sedate him so that we can examine him..

Two Reversible Medical Conditions Can Cause Agitation

When deciding to chemically sedate someone, we need to keep in mind that there are two easily reversible medical conditions that can cause agitation. These are

Hypoglycemia
Hypoxia

Fortunately, both can be quickly and easily assessed if there is any question in a particular patient (say the patient described above, who is acting bizarrely in booking and we do not know why). Once a patient is physically restrained, and before injecting the chemical sedating agents, it is simple to check a blood sugar and an oxygen saturation in appropriate patients. It is embarrassing to sedate a patient and then find out later that he had a blood sugar of 20. Oops.

Other medical conditions can potentially cause a patient to be agitated, such as brain tumors, delirium, and being post-ictal after a seizure. However, these are not easily reversible as are hypoglycemia and hypoxia. If a patient has one of these, they usually will be sedated and then the underlying medical cause will hopefully be sorted out thereafter.

Chemical Sedation Should Never Be Punitive!

Always remember that the goal of restraining and sedating patients is for their benefit, not ours. I have found that when jail deputies find out how much better chemical sedation is than prolonged restraint, both for the patient and for them, they sometimes want to chemical sedate everyone who is a management problem. However, most jail management problems are not candidates for chemical sedation.

Even patients who are appropriate candidates for chemical sedation should always be offered less restrictive means of calming down. Sometimes, just putting a patient in a restraint chair preparatory to getting chemical sedation is enough for them to settle down. More often, however, patients facing a cell extraction, or who are already in a restraint chair will accept oral medications rather than receive an injection.

Summary. Is This the Right Patient for Chemical Sedation?

1. Is he a danger to himself?

2. Is he a danger to others?

3. Is he a danger to the safety and security of the facility?

4. Is sedation the only way he can be medically assessed?

5. Does he have a reversible medical condition?

6. Will he accept a less restrictive form of sedation?

What is your experience with chemical sedation? Please comment!

Judges Practicing Medicine–The Right Response

14 Replies

I received a court order last week, ordering me to provide a certain inmate with several medications (some of them misspelled) during her six month incarceration. Upon investigation, it turned out that she did not even have a current prescription for all of the medications, but I was ordered to provide her with them nevertheless. Oh, and I was ordered to give her a double mattress, too.

Nothing in correctional medicine irritates me more than when a judge tries to practice medicine like this. It makes me want to tear out my hair and gnash my teeth. And thus begins THE RANT:

THE RANT

You mean to tell me, Judge, that this patient has to remain on these medications while in jail, no matter what? I cannot exercise any medical judgment? What if she suffers a severe reaction to one of the medications? By court order, I cannot change it! What if the patient herself wants to stop one of the medications? I cannot accede to her request without violating the court order. What if her outside doctor wants to withdraw a prescription? Nope, by court order, that is not allowed. Do you really intend for her to be on these exact medications for the rest of her life?

Not only is this terrible medicine, Judge, but an insult as well. Do you believe that I will not do what is best for my patient? Do you truly believe that I do not care what treatment my patient has received in the past? Do you truly believe that I am such a bad doctor that the only thing that will keep me from committing medical malpractice is this stupid court order?

OK. I have wiped the spittle off my computer screen and I feel better now.

But that is not all! Earlier in the year, a judge approved a medical furlough for an inmate so he could see his “own doctor.” However, when this inmate went to the doctor’s office upon his release, they would not see him because he did not have an appointment! What a waste. Another patient released for a medical furlough did have an appointment, but never showed up for it. What did she do in the six hours she was away from jail? I don’t know and neither does the court. They never checked. Not only were these furloughs a security breach, both furloughs were totally unnecessary. I was well aware of each patient’s medical condition and even had talked to the outside doctors to coordinate care. What a waste of everyone’s time, including the court’s.

Am I the only correctional physician to be cursed with such orders? Nope. Having talked to many colleagues, such orders seem to be ubiquitous in correctional medicine! The question is what to do about them.

It Is Our Duty And Obligation to Oppose These Orders

In my opinion, we cannot simply indulge in a rant, but then shrug our shoulders and blithely obey medical court orders. Such orders from the court are bad medicine. It is our obligation and duty to protect our patients from this bad medicine. The court is, in fact, incompetent to make medical decisions. It is also our duty and obligation to educate all parties involved that we are competent to deal with inmate medical problems. We don’t need the court’s “help.”

In order to formulate a game plan, we need look no further than the hearing that resulted in this court order.

Anatomy of the Hearing

To begin, think about the players who were present in the courtroom when this order was issued. There was the judge, of course. The defense attorney was there along with our patient, the defendant. And a deputy prosecutor was there, too. Now, think about who was NOT in attendance. The outside doctor(s) who prescribed the medications were not there, provided no testimony and probably did not even know that the hearing was taking place. In fact, there was no medically trained person in the court room at all.

Who, then, provided the expert testimony about what medical services the patient would need while in jail? The patient herself, via her attorney! She acted as her own “expert witness!” The procedure went something like this: The patient’s attorney told the judge that the patient had medical problems and would require certain medications and treatments while in jail. The patient and her attorney then said that they were afraid that these necessary medicines would be stopped as soon as she arrived at the jail. And this, they alleged, would result in horrible consequences for this patient.

Since none of this patient’s outside doctors was in attendance, no evidence was presented to back up any of these claims. There was no evidence presented that the patient actually had the diseases she claimed to have. There was no evidence that the medications she listed were necessary or that they should be continued indefinitely, no matter what.

So why then would the judge issue the order, despite the absence of any medical evidence? The critical answer is that the prosecutor present at the hearing said he had no objection! There is the crux of the matter. If the prosecutor had said, “This court order is unnecessary. Jail medical can handle this patient’s medical needs,” then the judge would never have issued such an order. At most, she would have set a date for a formal hearing on the matter. Or just said, “No.”

So why didn’t the prosecutor object to the issuance of this order? There are several possible reasons. The prosecutor is interested in criminal charges, not medical issues. Whether the inmate gets certain medications or not is no skin off his nose. Also, if he objects, a formal hearing might be scheduled. He is busy and he does not want to have to prepare for yet another hearing. It is much easier just to go along. Finally, everyone in attendance, from the judge to the attorneys, are ignorant of the medical services available in the jail. For all the prosecutor knows, everything the patient said is true. She needs these meds! Maybe the jail Doc will stop them for no good reason!

To summarize, here are three critical facts about the hearing that resulted in the medical court order:

No evidence was presented at the hearing to substantiate the patient’s claims. No expert witness spoke.
In order for the order to be issued, the prosecutor (who is our representative) had to agree to the court order.
Nobody in attendance understands what medical services are available to incarcerated inmates. They might not even know that there is a medical service at all.

Fighting Back—What We Can Do To Combat Irrational Medical Court Orders

It would be irresponsible not to do what we can to reverse these bad medical court orders. There are two priorities here. The first is to get this particular court order reversed and the second is to do what we can to make sure that no such court orders are issued in the future.

The key to reversing the original court order is to remember that no medical expert attended the original hearing and no medical evidence was introduced. So to get it overturned, all I need to do is to introduce medical evidence. The legal term for a written statement of evidence is an affidavit. The person who will help me prepare this affidavit is the prosecutor who signed off on the original order. I need to call him (or his boss) and explain that this court order is bad and needs to be reversed. The prosecutor and I then need to write an affidavit to the court stating all of the reasons that this court order is bad medicine. The affidavit should basically restate everything I said in the rant above, but in a nice way. For example, I need to introduce myself and list my qualifications. That establishes that, hey, there is a real, competent doctor at the jail. Then I should list the blatant problems with the court order, for example, there is no room for any clinical judgment, I cannot, by court order, change the medications under any circumstances, such as side effects, or even by patient choice. If I think that some of these medications are inappropriate for the patient, I can state that and briefly say why (major potential drug interaction, controversial off-label use, dose higher than manufacturer recommendation, etc).

Almost always, the affidavit alone is enough to have the judge rescind the order mandating certain treatments. Occasionally, the judge will schedule a formal hearing on the subject, but that always seems to go well because the correctional physician is the only medical professional who attends. I have yet to see an outside physician at one of these hearings.

Writing an affidavit and then perhaps attending a hearing on the matter may seem like a lot of work. In reality, it will save time in the long run, because it will result in fewer medical court orders in the future. The defense attorney will be less likely to seek such a court order in the future knowing it will be challenged, the prosecutor won’t blithely sign off such orders without calling me first and the judge will be less inclined to issue such orders.

Educating the Courts. Meet the Prosecutors.

After the original court order has been reversed, the next task is to do what we can to prevent such orders being issued in the future. The way to do this is to set up meetings in which you will provide education about jail medical services. I have had meetings with the judges themselves, but these are often hard to set up. You can set up meetings with the public defenders, but to meet with every defense attorney in town is hard. (I have had success setting up such meetings, however).

Fortunately, the easiest meeting to set up is also the most important and that is the one with the Prosecutor’s Office. A typical Prosecutor’s Office will already have a meeting attended by all of the prosecutors at least weekly. I have found it quite easy to get a half hour scheduled to talk about jail medicine and the problems with the courts. In fact, the Prosecutors Offices I have dealt with have been happy, even enthusiastic to discuss jail medical issues. The main goals for the prosecutors are:

Introduce yourself and your credentials. It very much helps that, just by talking to the prosecutors face-to-face, they can see that you are a rational, reasonable person.
Describe the problems with the various medical court orders, including medications, furloughs, double mattresses, etc.
Explain how these medical histories are assessed and evaluated in the jail, including discussions with the outside doctors when necessary. Expect a lot of questions about how meds are approved or disapproved for use in the jail (This is the single most prevalent complaint that they hear in the courts: “I’m not getting my meds.”)
And most importantly, ask the prosecutors never, ever to approve medical court orders without talking to you first.

I always give the prosecutors my personal cell phone number and invite them to call anytime. I point out that it will take less time and effort for both them and me if they call me initially rather than have to fill out an affidavit after the fact.

I have attended many such meetings with prosecutors. These have always gone well. I usually get several phone calls in the weeks after the meeting from prosecutors asking about certain allegations that were made in court. But when the prosecutors are armed with the facts, nonsensical medical court orders stop. Commonly, patients have fudged the truth or outright lied about their medical problems and what has been prescribed for them. When judges find out this out (from me via the prosecutors), they tend to be irritated—and less likely to entertain medical requests in the future.

Occasionally, I have had to testify in court about medical processes in the jail. These have always gone well, also, and are again an opportunity to educate the judge about what goes on in the jail. It sounds especially good when I testify that I have contacted the outside physician and that we jointly have agreed to a treatment plan while the patient is in jail.

By the way, I have never once seen an outside physician testify at one of these court hearings about jail medical issues. Outside physicians hate to go to such hearings for many reasons: It disrupts their busy practice schedule, they don’t get paid, and they usually have no objection to the medical treatment the patient is getting in jail, anyway. This means of course, that I am the only “expert witness” that the court hears.

In the case I initially introduced, I filed an affidavit with the court the next day with the help of the county attorney and the deputy prosecutor in the case. The court order was amended that very day to read “The foregoing order is subject to the exercise of medical judgment of the medical staff . . .including, if deemed appropriate, consultation(s) with those physicians who have prescribed the above medications.”

This was good enough for me. I called the outside physician (which I would have done anyway), and we jointly agreed on a treatment regimen to be used while this patient was incarcerated. Interestingly enough, this treatment plan did not include most of the medications on the initial court order.

How do you handle medical court orders at your facility? Please Comment.

Chemical Sedation is Safer than Prolonged Physical Restraint

11 Replies

Here is the clinical scenario: You have an inmate in your facility who is running his head into wall, bull-like, at full speed. He then backs up and does it again. He may be suicidal. He may be high on meth. He may just be a jerk throwing a tantrum. But he will not stop just because you have asked him to.

How should we stop this patient from hurting himself?

What would you do in this situation? It seems to me that there are only three options for how to deal with this inmate.

Do nothing! Let him hurt himself if he wants.
Physically restrain him in a restraint chair or on a board.
Administer sedating medications as a form of chemical sedation.

These three responses clearly are different in the risk of a bad outcome. And there are two possible bad outcomes to consider. The first is the medical risk. Which approach is most likely to result in a serious injury to the patient? The second is the legal risk. Which approach is least likely to result in a successful lawsuit?

I hope that no one reading this would opt to do nothing. You simply cannot continue to let this inmate run his head against the wall. The risk of a bad outcome, both medical and legal is just too high. On the medical side, I personally am aware of three cases where inmates running their heads into the wall of their cells fractured their necks. One was left a quadriplegic. The risk of legal action is also high. In fact, this could be Deliberate Indifference: You knew that running his head into the wall could potentially result in serious injury and yet you did nothing to stop him. I will leave the Deliberate Indifference question to the lawyers, but even without this, the threat of a nasty lawsuit following such an injury is almost inevitable.

So the prudent action, both medically and legally, is to restrain this patient in some way. But which method of restraint is safer for the patient? Which method of restraint is safer legally?

In my strongly held opinion, restraint by chemical sedation is safer than prolonged physical restraint for those who are a threat to injuring self or others. I have several reasons for believing this.

Chemical Sedation is the community standard of care in the other two areas of medicine that also routinely restrain patients who are a threat to self or others. Those two areas are Emergency Medicine and Inpatient Psychiatric medicine.
Prolonged physical restraint, for example in a restraint chair or board, carries significant risks of injury, including death. Chemical sedation is much safer.
As long as the chemical sedation is done properly, there is less risk of successful legal action with chemical sedation than with prolonged physical restraint.

Chemical Sedation is the Community Standard of Care

I practiced in a busy emergency department for many years before I came to correctional medicine. There, chemical sedation is routinely practiced. Every Emergency Department does chemical sedation routinely. It is not controversial in ERs at all. I was taught how to do chemical sedation in my ER residency. It is an Emergency Medicine “Core Competency.” Chemical Sedation is discussed in every major Emergency medicine textbook. As a matter of fact, physical restraint is viewed in Emergency Medicine as a tool to facilitate chemical sedation rather than a viable option on its own.

It is a similar situation in inpatient psychiatric hospitals. I have asked several psychiatrists whether they leave dangerous inmates in a psych hospital physically restrained for long periods of time. The typical response is to laugh and say “No. They get sedated.”

I’m not sure why chemical sedation has such a bad reputation in some quarters of the correctional medicine world, because it is the Standard of Care for patients who are an acute danger to self or others elsewhere in medicine. Why is this so? It is because:

Chemical Sedation is Safer than Prolonged Physical Restraint

Unfortunately, I cannot point to any published studies that show that chemical sedation is safer than prolonged physical restraint. That is because there are none. However, I personally know of at least five cases of death from physical restraint. The mechanism of death in these cases has ranged from suffocation to acute pulmonary embolism to “excited delirium.” The point is that prolonged physical restraint carries substantial risks that range from minor (contusions, abrasions, broken bones) to serious (death, loss of limbs from too-tight restraints).

On the other hand, I am not aware of any deaths from chemical sedation, whether in an Emergency Department setting or in corrections. I actually have never heard of any serious complications from chemical sedation. There may have been one somewhere and I am just not aware of it. If you know of such a case, please contact me!

Chemical Sedation Carries Less Legal Risk Than Does Prolonged Physical Restraint

Again, there are no published studies on the incidence of lawsuits after restraints. I have spoken to several different Risk Management experts on the subject, both in Emergency Medicine and Correctional Medicine, and they have unanimously agreed that chemical sedation of a dangerous patient carries less legal risk than does prolonged physical restraint.

Here is one example. I contacted Rick Bukata and Greg Henry, who together publish Risk Management Monthly, a publication on how to reduce medico-legal risk in Emergency Departments. I asked them about the legal risk of administering chemical sedation to a dangerous patient against his will. This was their response:

“Jeff Keller has malpractice concerns about the patient who is sedated against his/her will. This situation is not likely to be problematic if the patient is being sedated because he or she poses a danger to self or others, and if the reason for sedation is meticulously documented. A physician might be at greater medicolegal risk if he or she fails to sedate a problematic patient who is placing the staff in jeopardy.”

After talking to several Risk Management experts in Correctional Medicine about this subject, I am unaware of any successful lawsuits arising from chemical sedation of an incarcerated inmate who was an acute danger to self or others. Once again, if you are aware of such a lawsuit, I want to know about it! Please contact me!

I believe that the legal risk of restraining an inmate depends on two factors. The first is harm. If a patient has been harmed by the restraints, he is more likely to sue and is more likely to be successful. So the method of restraint least likely to injure the patient is the safest legally. Chemical sedation is safer than prolonged physical restraint and so is safer legally as well.

The second factor is that the sedation was done on the right patient (one who is an acute danger to himself or others) and that this was documented properly.

In fact, chemical sedation is very like administering any medication. You must have the right patient, give the right medications in the right dosages, do the right monitoring and follow-up care, and document in the right way. If you do all of that, your legal risk will be low. More details on that later.

What does your facility do for out-of-control inmates who are a threat to themselves or others? Chemical sedation or prolonged physical restraint? Please comment!