Hey Jeff, like you I am an ER doc and am the Medical Director of a 550 bed jail. I would like you thoughts on body cavity searches. We had a case last week where an inmate was seen putting a baggy in his rectum. A search warrant was issued and the inmate was sent to the ER for a body cavity search. The inmate refused to let the ER personal touch him. He told the ER doc that it was a baggy of tobacco. The ER observed him for several hours and sent him back to the jail. No cavity search was done. The ER doc felt she would have to sedate the inmate to do the search and felt uncomfortable doing this against his will. The NCCHC frowns on the jail medical providers doing evidence related procedures or searches. My policy is to do the searches if the inmate will sign an informed consent and allow it to be done. If the inmate were to have a complication of sedation or the removal procedure that was done against his will, I would think a malpractice claim could be supported. How do you handle these types of situations in your jail? Thanks, BJF Continue reading
I am curious to see how other jails/prison handle fasting during Ramadan. We only KOP inhalers and creams at my facility and have no medical commissary. We do a very early medication pass for those who are fasting, but it does cause occasional problems with the management of diabetics and some other chronically ill patients. How do other facilities handle this?
Thanks, Jill McNamara Continue reading
If you have read the title of today’s blog post, you already know the answer to today’s case. The answer is “Lithium Toxicity.” I could have instead presented a “Can you figure this case out?” type of format. But I did not want to do that because, really, what was causing this particular patient’s symptoms is not obvious, especially early on. This is an introspective learning case. I want you to read the case knowing the answer. The answer is “Lithium Toxicity.” As you read this case presentation, I want you to ask yourself when the possibility of lithium toxicity would have first entered your head and when you would have stopped this patient’s lithium? Continue reading
Your patient is a 29-year old male who presents to the medical clinic stating that he has been having a feeling of a racing heart off-and-on for the last couple of months. It comes and goes, maybe two or three episodes a week. They only last a few minutes. He feels odd when this happens but he does not have to stop his activities. He has noticed no pattern to these; they have happened at work (he is an inmate worker), in the middle of the night and every time in between.
His physical exam is normal including blood pressure of 124/78, regular heart rate of 68 and normal heart sounds.
What do you think is going on? Would you order any tests? Continue reading
My friend Al Cichon recently asked the following questions:
I have been asked when I would not approve an existing prescription – non-compliance (over / under); diagnostic mismatch (extreme example anti-viral for bacterial infection); – can you think of others? Continue reading
Imagine that you are a healthcare provider in a jail medical clinic. One of the jail nurses comes to you and says “Will you call me in a prescription for my hypertension meds? I have no more refills and my doctor charges $100.00 for a visit just to get more!” Or perhaps it is a detention deputy who asks, “Can I get a few Ambien from you? This shift work kills me and I need them occasionally.” Or “Can I get some Augmentin? I have Bronchitis.”
I am pleased to announce the Essentials of Correctional Medicine Conference 2014!
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.
So here is a report that actually can have immediate impact on correctional medicine: NYTimes: No Benefit Seen in Sharp Limits of Sodium in Diet
For many years, the American Heart Association and other Big Hitters in medicine have extolled the health benefits of a very low salt diet. Patients who have known heart disease were commonly counseled to eat a very low salt diet of less than 1,500 mg a day (compared to the average U.S. daily salt consumption of 3,400 mg a day).
I experienced this myself. When I was growing up, my father had three separate heart attacks and, among other things, was told to eat low salt. So, for several years, that is what my mother cooked for all of us.
Very Low Salt Diets as a treatment and preventative for heart disease has become the prevailing wisdom. Since these less-than-1,500 mg-of-salt-a- day-diets were so commonly prescribed in the community, most jails and prisons had to have such a Very Low Sodium Diet among the various medical diets that could be ordered by a practitioner.
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!
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|
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!
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