Tag Archives: inmates

Chemical Sedation–Right Follow Up

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.

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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.150

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:

  1. To investigate the question of why the patient was so agitated in the first place, and
  2. 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.154

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:

  1. Acute psychosis.
  2.  Acute mania.
  3.  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:

  1. Appropriate candidate.
  2. Reversible medical causes.
  3. Appropriate agents.
  4. Safe and effective onset of sedation.
  5. 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!

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Judges Practicing Medicine Continued

With regard to the recent article about judges issuing court orders for medical treatments while in jail, I wanted to get a legal perspective, so asked my friend David Tatarsky, who is General Council for the South Carolina Department of Corrections, for his thoughts.

South Carolina Department of Corrections

South Carolina Department of Corrections (Photo credit: Wikipedia)

Here is his response:

My thoughts   (all of which must be considered in light of the particular judge you are dealing with):

1.         You are exactly right about the major cause of this problem—–no one in the courtroom representing the interests of the jail/prison. The parties just want to get the plea completed and move on to the next case. Your solution is great if you can successfully develop the type of relationship you have created with the prosecutors.

2.         In some states, judges may be expressly prohibited from requiring particular medical treatment in a sentencing order.  Jails/prisons should check with Legal on this.  The analogous situation is when a judge sentences an inmate and requires the DOC to house the inmate in a particular prison.  In South Carolina, there is a state statute that says the DOC has the exclusive authority to determine where an inmate is housed:

(A) A person convicted of an offense against this State and sentenced to imprisonment for more than three months is in the custody of the South Carolina Department of Corrections, and the department shall designate the place of confinement where the sentence must be served.

Here is another one I use in South Carolina:

SECTION 24-1-130. Management and control of prison system.

The director shall be vested with the exclusive management and control of the prison system, and all properties belonging thereto, subject to the limitations of Sections 24-1-20 to 24-1-230 and 24-1-260 and shall be responsible for the management of the affairs of the prison system and for the proper care, treatment, feeding, clothing, and management of the prisoners confined therein. The director shall manage and control the prison system.

This is basically what attorneys call a “separation of powers” argument.  Managing inmates belongs to the DOC, a part of the Executive Branch of government.  A judge who tries to assume this power is going outside the power/authority of the Judicial Branch of government.

3.         Sometimes the problem can be solved via education.  Judges, like lawyers, have continuing education requirements.  See if you can get this issue addressed at a CLE for the judges.  My office does a lot of training for prosecutors, public defenders and (sometimes) judges on sentencing issues.  Maybe ask the legal office for the DOC in your state if they can help.

4.         Tied in with the education issue—many (most??) judges know little or nothing about how jails and prisons operate, because most attorneys, before they become judges, learn little or nothing about the corrections system.

5.         If your agency has in-house counsel, ask him/her to contact the judge when you get one of these orders.  What I sometimes do is write to the prosecutor and defense attorney, letting them know that the order is improper and asking them (nicely) to have it corrected.  If I get an unsatisfactory response, I sometimes contact the judge’s law clerk.  Judges do not want to look stupid.  If someone points out the issue to the judge (without embarrassing him/her), he/she may fix it.

6.         A “split the baby” approach is to have the judge “recommend” rather than order some form of treatment on the sentencing order.  Then you can just look at the medical issue when the inmate arrives and exercise your own professional judgment.

These are all excellent points.  I wonder how many other states have a “separation of powers” statute like South Carolina’s.  Mine does not (sadly).

I also like David’s idea of trying to get on the judge’s required Continuing Education schedule.  I intend to do this, myself.  If I am successful, I will write about the experience here.

Davis County Jail Success Story

Tied in with David’s thoughts, I especially liked James Ondracek’s comment about his experience:

I have been the Nursing Director at Davis County Jail for almost 20 years now. I have the e-mail addresses and phone numbers of every court clerk in Davis County. I contact them every time we have a medical issue that requires assistance from a judge. None of our current Judges will grant medical furloughs without contacting me first. I have inmates tell me all the time that they requested a medical furlough and the judge told them to talk to the jail medical staff first because he will not grant a furlough without receiving a recommendation from the jail. Likewise we do not currently, have a problem with judges ordering medications in the jail. It has taken many years of working with judges and attending judge meetings and getting prosecutors to help reverse court orders in the past, but it has paid off in the long run. I have met with many of the judges in court chambers about specific inmate needs and discussed having the judge grant medical furloughs and releases from jail when appropriate. It is very worth it to build relationships and understanding with prosecutors, judges, and attorneys. You will not win every battle but from my experience, most judges are glad to contact the jail with a concern and glad to tell the inmate that the jail will take care of his medical needs and he is not qualified to make medical decisions as a judge. Incidentally, I have never had any of our doctors come to a meeting with a judge. I will occasionally ask him for a note to take with me to meet with a judge or the prosecutor but we have always been able to handle this with our in-house staff.

The key quote here is this: It has taken many years of working with judges and attending judge meetings and getting prosecutors to help reverse court orders in the past, but it has paid off in the long run. It takes time and effort to cultivate a close relationship with judges and prosecutors.  But it is well worth the effort.  Besides being a medical care issue, it is also a time-management issue.  I believe that if you spend the time and effort to cultivate these relationships now, you will spend much less time in the long run—by a substantial margin. 20031105

What About Defense Attorneys?

Besides prosecutors and judges, it may also be worthwhile to cultivate a relationship with the defense attorneys.  Here in my hometown, one local defense attorney (who happens to be a friend of mine) organized a tour of the jail for the County Bar Association.  It was surprisingly well attended by around 40 attorneys.  The 1 ½ hour program featured short presentations by sheriff and the jail commander who talked about jail procedures  and another by me about jail medical services.  The attorneys then took a tour of the jail.  The attorneys had lots of questions.  Basically, like David Tatarsky said above, the attorneys did not know much about how jails work.  It was quite eye-opening for most of them.

The feedback was overwhelmingly positive. As part of my presentation, I gave each of the attorneys my personal cell phone number and invited them to call me if they had any questions about the medical services their clients were receiving.  (I reminded them that they had to have a Release-of-Information form signed by the inmate before I could talk to them in detail).  As a result of this, I have received several phone calls in the last month.  But as I told the attorneys, inviting them to call me directly is a time management issue for me.  It takes much less of my time to talk to them directly than to answer their letters, requests for records, subpoenas, etc.

Have you ever invited the Bar Association to tour your facility?  Please comment!

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Involuntary Chemical Sedation–The Right Patient

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.

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

  1. 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.
  2. 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.
  3. 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.
  4. 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:

  1. 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.
  2. 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.
  3. 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.
  4. 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

  1. Hypoglycemia
  2. 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

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.Judge with One of Those Days Look.

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

20100526To 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:

  1. No evidence was presented at the hearing to substantiate the patient’s claims.  No expert witness spoke.
  2. In order for the order to be issued, the prosecutor (who is our representative) had to agree to the court order.
  3. 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:

  1. 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.
  2. Describe the problems with the various medical court orders, including medications, furloughs, double mattresses, etc.
  3. 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.”)
  4. 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

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?

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.

  1.  Do nothing!  Let him hurt himself if he wants.
  2. Physically restrain him in a restraint chair or on a board.
  3. 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.

  1. 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.
  2. Prolonged physical restraint, for example in a restraint chair or board, carries significant risks of injury, including death.  Chemical sedation is much safer.
  3. 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!

 

 

Nurses and Chronic Care Clinics. What Do You Think?

TaserCamIn my last post, I discussed the differences between how nurses are used in Acute Care Clinics in the community versus how they are used in corrections.  Today, I would like to discuss the differences between the community and corrections on how nurses are used in Chronic Care Clinics.

Again, these remarks are based on a talk that Dr. Marc Stern gave at the Essentials of Correctional Medicine conference last year.  It was quite a thought-provoking talk.

First, let’s define the difference between an Acute Care Clinic and a Chronic Care Clinic.  An Acute Care Clinic is one where the patient has asked to be seen because of some problem or complaint.  Examples would be “I have a rash,”  “I have chest pain,” or “I am having a hard time breathing.”  The patient is asking for a diagnosis (“What is causing this?”) or for relief of symptoms (“I want pain medication for this headache!”) or both.  The key is that the clinical encounter is patient driven—the patient has asked to be seen—due to some acute symptom.

Visits to a Chronic Care Clinic, on the other hand, are scheduled by the medical provider to assess progress made in treating some chronic medical problem.  These are scheduled months in advance and occur even if the patient is doing well.  One example is a patient on blood pressure medications who is scheduled for a follow-up visit to see how the blood pressure is doing.  Another example is a patient with hypothyroidism who is scheduled for a thyroid panel blood test to see if she is on the correct levothyroxine dose.  Patients taking warfarin come to an anti-coagulation clinic to have their INRs checked.  Each chronic disease, from COPD to rheumatoid arthritis, has a different set of monitoring tasks which are routinely done in a Chronic Care Clinic.

The key difference here is that chronic care visits are scheduled by the clinic, not the patient, and are expected to occur even if the patient is feeling well and has no complaints. Also, what will occur at the clinic visit is known beforehand.  Usually, there is a checklist of tasks that are scheduled to be done each visit.

However, nurses once again tend to be used differently in Correctional Chronic Care Clinics than they are in the Community.  But interestingly, the situation is exactly reversed from the Acute Care Clinic situation!

Community Chronic Care Clinics

In the Community, Chronic Care Clinics are most commonly run by nurses.  The patient may not see a practitioner every time.  Take the case of a Type 2 diabetic in the community.  Three or four times a year, this patient is scheduled to come to the diabetes clinic for a Chronic Care visit.  At that time, routine blood work (a Hemoglobin A1C, for example) is drawn, the patient is screened for diabetic complications (a foot exam, say, and blood pressure) and the patient receives counseling and teaching (for example, about the importance of the diabetic diet).  All of these tasks are typically done by a community nurse.  The patient may not see the doctor unless the nurse identifies a problem or unless the Chronic Care protocol specifies a practitioner visit.  Otherwise, if the patient is doing well, the practitioner may only see them once a year.  This is the community standard.

Correctional Chronic Care Clinics

However, as pointed out by Dr. Stern in his lecture, this is not how Chronic Care Clinics are typically done in corrections.  In jails and prisons, Chronic Care Clinics tend to be run exclusively by practitioners. And using practitioners to do work done by nurses in the community tends to be inefficient for a couple of reasons (these are my opinions, not necessarily Dr. Stern’s).

  1. Practitioners tend not to do as good of a job with Chronic Care Clinic tasks as nurses do.  Chronic Care, properly done, is a time intensive process that includes meticulously going through a checklist, answering questions and teaching.  Practitioners (and I am including myself here) tend to go too fast.  Nurses do a better job.
  2. Every minute a physician spends doing Chronic Care Clinic tasks typically done in the community by a nurse is a minute she cannot spend doing acute care evaluations and diagnostics she is better trained to do.  This is a time management issue.  The nurses will let the practitioner know if they find something during the chronic care visit that needs acute attention.

The practitioner, of course, should review the work done by the nurse in the Chronic Care clinic.  The easiest way to do this is to use a Chronic Care Flow Sheet filled out by the nurses at the chronic care visit and signed off by the practitioner at review.  And the practitioner should still be scheduled to see each chronic care patient periodically, say once a year.  But other than that, the system will run more efficiently if nurses run chronic care clinics as is done in the community.

Interesting Article of the Week

Right in line with the theme of who should run Chronic Care Clinics is this interesting article:

Delegating responsibility from clinicians to nonprofessional personnel: the example of hypertension control.  Margolius, et. al. J Am Board Fam Med. 2012 Mar-Apr;25(2):209-15. doi: 10.3122/jabfm.2012.02.100279.

In this study, the researchers delegated responsibility for Chronic Hypertension Follow-up to non-medically trained “Health Coaches.” These lay Health Coaches spoke to patients in the study frequently and counseled them on hypertension control and answered questions.  These untrained Health Coaches were even authorized to titrate patient blood pressure medications according to a written protocol!  Whoa! This was a “Mikey-Likes-It” type of study–after 6 months, the clinicians involved were asked how they liked the program–and most did, though some disagreed with the medication titration aspect.

I personally do not see those of us in corrections delegating responsibility for chronic care visits to a non-medically trained deputy.  However, if practitioners are running your facility’s Chronic Care Clinics exclusively, I agree with Dr. Stern that it is perfectly appropriate to delegate that responsibility to nurses, as is done in the community.

Who runs the Chronic Care Clinics at your facility?  Nurses, practitioners or a combination of the two? Please comment!

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Nursing Clinics and Scope of Practice. What Do You Think?

20130123-1At the last Essentials of Correctional Medicine conference, Dr. Marc Stern gave a thought-provoking lecture about the proper use of nurses in the correctional setting. I have to admit that his talk was a bit controversial; some of the nurses in attendance were uncomfortable and even a little offended.  But whether you like Dr. Stern’s talk or not, his thoughts deserve some consideration.

The main thrust of his talk was to compare how nurses are used outside of corrections—the community standard as it were–as opposed to how nurses are used inside jails and prisons.  There are quite a few differences.  Why is this so?  And if nurses are used inside of correctional facilities differently than the community standard, is this proper?

Dr. Stern brought up two distinct differences between how nurses are used in the community and how they tend to be used in corrections:  Acute Care and Chronic Care.  I am going to discuss the Acute Care issue today and the Chronic Care issue in my next post.

The Nursing Role in Acute Care Clinics–Community vs. Corrections

The single major difference between how nurses are used in the community and how they are used inside correctional facilities is this: in the community, nurses do not run acute care clinics–ever.  Nurses in the community do not diagnose or prescribe treatment.  It does not matter whether you go to your doctor’s office or a hospital emergency department or a “Doc-in-the-Box” urgent care clinic or even one of those mini-clinics you find in grocery stores nowadays.  In each case, you will be seen by a medical practitioner of some sort; whether a doctor, a physician assistant or a nurse practitioner.  Nurses will be there, but in the role of assisting the practitioner.  It just will not happen in the community that a patient will be seen only by a nurse—no practitioner in sight—who does an examination, makes a diagnosis like, “You have bronchitis,” and hands out a prescription.

On the other hand, acute “sick call” clinics in correctional facilities are commonly run only by nurses.  These nursing clinics tend to be of three main types:

  1.  Triage clinics.   In this type of clinic, a nurse sees every patient who puts in a medical request and schedules them to see a practitioner depending on the urgency of the complaint.  For example, a patient complaining of abdominal pain might be scheduled for the very next medical clinic whereas a patient complaining of dandruff might be scheduled a week out.  The Triage nurse could also have the on-call practitioner come in urgently to evaluate a patient with, say, chest pain or decide to send that patient to the ER.  However, in this model, nurses never diagnose or prescribe treatment.
  2. OTC clinics.  “OTC” stands for “Over-the-Counter” medications that do not require a doctor’s prescription.  In this type of nurse clinic, a nurse again sees every patient with a medical request and schedules medical clinic appointments, but also is authorized to dispense over-the-counter medications for common minor complaints.  For example, a patient with abdominal pain still would be scheduled in to medical clinic, but a patient with athlete’s foot might be given OTC clotrimazole cream by the nurse without the patient ever seeing a practitioner.  Some facilities have quite detailed protocols to guide nurses in this endeavor, but not all.
  3. Full Service Nurse Clinics.  In some correctional facilities, nurses take care of almost all sick call patients.  The nurse will still schedule complicated patients to see the practitioner, but will take care of other, simpler, problems even if these require a prescription medication.  If a nurse thinks that a patient needs a medication requiring a doctor’s prescription, he/she usually will call the on-call practitioner for authorization.  An example would be a female inmate thought to have a Urinary Tract Infection.  The nurse would call the practitioner for orders, say an antibiotic, and then administer it.    Sometimes, this patient will be seen by the practitioner in a subsequent clinic, but not always.

As Dr. Stern pointed out in his talk, it is clear that this system of using nurses in jails and prisons is very different from the “community standard.”  Dr. Stern also pointed out that in many correctional facilities, the nurse performing these tasks is not an RN, but an LPN or even a “Correctional Medical Technician” with even less formal medical training than an LPN.  The concern is that by running acute care clinics, which involves making diagnoses and prescribing treatment, nurses may be exceeding their scope of practice.

Why Are the Two Systems Different?

Personally, I can easily see how this system of nursing duties evolved within corrections.  Community urgent care clinics have a practitioner in attendance at all times.  These clinics are never staffed with nurses only.  But jails and prisons are not that way.  Consider very small jails, for example, where the doctor’s sick call clinic may only be held once a week.  Someone, then, has to evaluate inmate medical requests to decide if the inmate can safely wait until the next scheduled clinic, which may be days away.  You certainly don’t want the inmate with appendicitis to wait a week to see the doctor!  And the jail nurse is certainly a better choice to do this evaluation than a detention deputy!

But what if the inmate complaint is so simple that it only requires an Over-the-Counter medication?  Say heartburn?  The inmate can certainly wait until clinic but why can’t the nurse just give out some OTC ranitidine?  Or foot fungus cream for athlete’s foot?  Is it even ethical to make the inmate suffer until clinic for such a simple problem?  On the outside, the inmate would not even have to go to medical.  They could just go to the store and buy ranitidine.  Can’t a nurse just give the patient some OTC ranitidine?

Other simple inmate complaints can be just as easily resolved with prescription medications.  Take the young healthy woman who has the classic symptoms of a urinary tract infection: dysuria, urgency and frequency.  Can’t we get the antibiotics started before the doctor’s clinic?  Do we make her wait?  And what about other, more serious, medical problems like alcohol withdrawal that absolutely should not wait until the next sick call.  Librium must be started now, whether there is a doctor on site or not.

But then, it is but a short, dangerous step to the next level:  By the time the doctor comes in for clinic, the woman with the UTI is cured!  The alcohol withdrawal patient is doing well!  The patient with heartburn has no complaint!  Isn’t it just a waste of the doctor’s valuable time to see these asymptomatic patients?

In the end, you have the scenario where a nurse has made a diagnosis and perhaps prescribed treatment without a practitioner ever having seen the patient and maybe even without ever having been contacted!  Somewhere along that continuum is a fine line that, when crossed, means that nurses are diagnosing and treating beyond their scope of practice.

In prisons, where a practitioner may be present in the facility every single day, it may be possible to run acute care clinics as they are done on the community.  However, it also may not be feasible.  Since I don’t practice in a prison setting, I will leave the discussion of the proper role of nursing clinics in prison to my prison based colleagues!  Please comment below!

However, in jails, it is simply not possible to run acute care clinics like the community standard.  No 50-bed jail can afford to have a doctor show up for clinic every day.  Even large jails don’t typically have practitioners on site every day.  There has to be some sort of partnership with nurses to triage medical requests and to take care of simple problems.  However, jails should take care not to cross the line where nurses exceed their scope of practice!

The following reflects my personal opinions on the subject:

  1. Nurses should have a protocol or guideline to follow when they evaluate simple complaints that can be treated with OTC medications.  Patients with complaints like “I have athlete’s foot and need cream for it” or “I have heartburn–can I have some Zantac?” do not necessarily need to be seen by a doctor since they do not need to see a doctor on the outside to obtain these items.  But even these simple complaints can be fraught with some danger—like when the guy with “heartburn” is really having a heart attack.  Nurses should have written guidelines that indicate when OTC remedies are appropriate and what “Red Flags” indicate a referral to clinic.  If nurses have such guidelines, they are not diagnosing and treating independently; they are instead assisting patient to obtain appropriate OTC medications.
  2. Why make inmates see a nurse to get OTC medications in the first place?  People outside of jail don’t have to go to a clinic to get Zantac or foot fungus cream or whatever.  They just go to the store and buy them!  So why do we make them do it in jails?  It is a waste of both the nurse’s time and the inmate’s time.  Put appropriate OTC medications on the commissary (see You Need a Medical Commissary in Your Facility! and Obstacles to a Medical Commissary Program.
  3. If a nurse thinks a patient needs an urgent prescription drug before the next medical clinic, the on-call practitioner must be called for an order! Nurses should not start prescription medications based on protocols alone.  That is not done in the community; it should not be done in correctional facilities.  For example, if a nurse sees a MRSA lesion and wants to start antibiotics before the next clinic, he must call for an order.  Does an alcoholic need to begin therapy for withdrawal tremors?  Call.  If these calls are not made, then the nurse has diagnosed and prescribed treatment independently, outside of the scope of practice.  The only exception to this rule is emergency treatment, like epinephrine for anaphylaxis.
  4. Every patient who receives a prescription medication should be seen by a practitioner!  I don’t mind authorizing antibiotics over the weekend for a woman with a UTI.  But I then am obligated to see her, however briefly, in my next medical clinic.  It doesn’t matter if she is better—that just means that the clinic visit will be brief.  But if I prescribed the medication, I need to document a history and an examination in her chart.  If I don’t, the nurse again diagnosed and prescribed beyond her scope of practice, albeit with my “rubber stamp.”  Interestingly, here in Idaho, the Board of Medicine recently condemned the practice of prescribing medication without examining the patient.  The Board was specifically addressing situations like when a family member or friend calls and says, “I have a sore throat.  Will you call something in?”  But the principle applies to this situation in corrections, as well.  If I prescribe something, I need to see the patient and document a history and physical.

As always, I have expressed my own opinion here.  Feel free to disagree.  I might be wrong!  But if you do disagree, please comment and explain why!

Next Post:  Chronic Care Clinics in Corrections vs. the Community!

In the Essentials of Correctional Medicine Conference, Dr. Stern’s lecture on nursing roles raised some eyebrows.  What is your opinion on nursing roles in corrections?

What Makes a Good Medical Scoring System?

20050629My good friend Al Cichon wrote the following comments to me about my article on the 10 Point Pain Scale.

Use of a ‘scale’ to measure subjective factors is a true oxymoron (heavy on the moron part). The ‘fifth vital sign’ is a misdirected effort to solve a true quality care problem – in my opinion. Vital Signs are objective (as in measurable) indicators that have been demonstrated to provide consistently valid data for patient care.

JCAHO has imposed the ‘Pain Scale’ in an effort to assure that the assessment of pain will be factored into patient care. Unfortunately, it is a bureaucratic response to a clinical situation – if it can be made to be measurable (regardless of practical validity) it can be enforced. My apologies to proponents and defenders – but no matter how well intended; it is still dysfunctional.

Yet, we are obliged to employ some process of assessment to determine the impact of subjective symptoms in an efficient / effective manner. The many schemes (Pain 1-10; Cardiac pain 1-5; etc.) developed have achieved relative success / adoption / adaptation. It does seem that these processes have provided some benefit – yet they all suffer from the same susceptibility – subjectivity. Whether you are working in corrections (where any subjective report must be verified) or the community (where verification is not always considered) any of these schemes has the same risk – because there is no objective validation.

One possible option to stabilize the use of any such scale is some method of anchoring the initial or end point of the scale. That would then provide a somewhat stable reference for guiding care and transmitting information (about the patient) to other providers. Also, this mechanism can be employed in other subjective areas.

Begin with asking the patient – ‘What is the worst pain you have ever experienced?’ (the response is usually associated with fractures, renal calculi, child-birth, etc.) Now, lets’ label that as a 10 (or 5) and now –‘What is the discomfort you have now in comparison to that prior event?’ Then document the exchange in the record: Worst Pain: fractured wrist – 10); Current Pain: pulled muscle – 7. Now, no matter the number system you have an ‘anchor’ to both the scale and the present condition that can be related to the care process and others. It is important to document the ‘source’ of pain too – as this may be quite useful if you are explaining the case later (DOC, court, etc.)

One variant of this is: If you had a ‘bucket labeled depression and a stick marked off from 0 to 10 what is the worst you’ve ever felt and when”? The response will then provide an anchor (9 when I was admitted to the hospital after trying to kill myself). Additional questions are: How deep is that bucket now? Has it ever been at 0? If I could make it happen (wave magic wand) and get you released and home now – what would it be? (interestingly it can go up with release for many reasons)

When you ‘anchor’ the ‘pain scale’ it establishes the assessment in a relatable setting and can be quite helpful in guiding patient care. The ‘anchor’ can also be quite useful in discerning the ‘historical validity’ of the case as well – ‘Doc when I had that car accident with multiple fractures it was a 10; now my sprained (non-swollen, non-bruised) ankle is a 10 too!’

Clinical judgment is always the most important skill in any patient care situation. The data subjective & objective is helpful but must be understood / applied in the clinical context.

Also confounding the assessment is the different types of acute / chronic discomfort (myofascial, neuropathic, visceral). As important as assessing the level of pain is the type – physiologic source – since it is critical in guiding treatment.

As noted – ‘chronic pain’ is better measures by an assessment of the patients ADL (what daily activities are disrupted and is that new). If a patient can function (nutrition, hygiene, elimination) and participate in some activities then treatment of the physiologic cause is the most important clinical consideration.

Thanks, Al!  Excellent comments.  Let’s summarize:

  1. The 10-Point Pain Scale is not the only scoring system in medicine for subjective complaints. There is the Hamilton Rating Scale for Depression, for example.  Also, the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) for alcohol withdrawal.   There are scoring systems to rate abdominal pain and chest pain and the likelihood of pulmonary embolism.  I could go on and on.  All of these systems have the same limitations and liabilities, though some do a better job than others.
  2. Just because you assign a number to a complaint, that does not make it objective.  Because each of these scoring systems assigns a number to the complaint, there is a tendency to think of them as objective rather than subjective.  But as Al points out, this is not the case.  There is no real difference between someone who says his pain is “a six” and someone who says that he has “moderate pain.”
  3. In order for a subjective scoring system to work, it needs to be “anchored” in some way.  Al anchors the 10-Point Pain scale on the patient’s own worst experience.  Another commonly used clinical pain scale, the Visual Analogue Pain Scale, anchors the scale onto facial expressions.  The more “anchored” a system is, the better it is.  The less anchored it is, the less useful it will be.Unknown
  4. The more numbers in the scoring system, the less reliable it becomes.  Let’s say instead of a 10-Point Pain Score, we used a 1000-point pain score and were asking patients “would you say your pain is a 671 or a 672?”  Of course, a pain score of “672” gives us no more useful information than a “6.”  In fact, it gives us less useful information because it is more confusing.  In a scientific sense, the more numbers a subjective rating system has, the less “inter-rater reliability” that system has. The simplest subjective scale has only two scores, “None (zero)” and “Some (one),” as in “Do you have pain or not?”  The subjective scale perhaps used most often in daily life (Like when you go to a Thai restaurant and are asked how hot you want your food to be) is a four score scale:  None, Mild, Medium, Severe.  The Visual Analogue score is a 6 point scale.  CIWA-Ar uses 8 points.  And the 10-Point JCAHO Pain Scale uses 11 points (zero plus one through ten). Is the 10-Point JCAHO scale more accurate than a simple “mild-moderate-severe” system?  Probably not. In fact, no “probably” about it.  No.
  5. Subjective scoring systems work better at evaluating changes over time than the initial severity of a symptom.  If a patient says his pain is a “6,” I may not know exactly how that is different from a “7” or even a “4.”  But later, when the same patient now rates his pain as a “5,” I am pretty confident that his pain has decreased, at least by a little.
  6. Subjective scoring systems only work if the patient understands and is cooperative with the process.  Al helps the patient to understand the process with his excellent “anchoring” technique (which I will be adopting, by the way).  But the system still will not work if the patient always, no matter what, says “my pain is a 10.”   That is the main problem I run into in my jails; deciding when patients are exaggerating their symptoms.  For example, if a patient complains of “severe” constipation, what weight do I give to their use of the word “severe?”
  7. There are two types of subjectivity in scoring, the patient’s and ours.  The patient is subjective when rating her own pain or depression or whatever.  Then we clinicians make our own subjective assessments.  How sick does the patient look?  Often, the two assessments do not coincide, as when the patient rates his abdominal pain as a ten while munching on Cheetos and looking bored.  If I do not trust the patient’s own subjective assessment, sometimes I must substitute my own clinical judgment.
  8. Scoring systems for pain perform worse for chronic pain than for acute pain.  For chronic pain, a more useful assessment tool is to evaluate how the chronic pain affects Activities of Daily Living (ADLs).  Is the pain too debilitating to hold a job?  Play golf?  Go to the store?  Walk?  ADLs are usually much easier to assess in a correctional facility than in the outside world.  You can go down to housing and watch the patient.  How easily does the patient sit, stand, walk?  Does the patient go to recreation?  Sit for long periods of time playing cards or watching TV?  This sort of assessment is very useful for gauging the impact of chronic pain.

Any thoughts?  Please comment!

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Understanding Pharmacy Prices. Can It Be Done?

20130206There are several good reasons to know what your pharmacy is charging you for each of the drugs you order. You need to know actual prices in order to assess the value of similar drugs, like two different first generation cephalosporins. In fact, you will have to know this in order to be able to set up a Pre-Approved Drug List. You need to know when a particular drug has a sudden price decrease or increase so you can switch to the most cost effective drug. Finally, you want to know that you are being charged fairly. If a pharmacy sells you a drug for 5% more than the price they paid to the wholesaler to obtain it; that seems fair. But if they jack up the price literally by 46 times, well, that does not go down so well. (See story below)!

Unfortunately, pharmaceutical prices are among the most convoluted and hard to understand of all drug prices. They are kind of like airline ticket prices. Have you ever heard of the game in which passengers on a commercial airline flight compare what each of them paid for their ticket with the lowest price being crowned the winner? (Their reward is the deep satisfaction that comes from knowing that everyone else is jealous of them). Airline tickets are kind of a unique item in the economy in that the price varies depending on many factors like when you book, how you book, how often you fly, how many bags you check and on and on.

Who Can Understand Pharmacy Industry Jargon?

Pharmacy prices are similar to this. What you pay per pill for drug X at your facility may be far different than what the facility down the street pays. The system is so convoluted, in fact, that it sometimes can be hard to even find out what your pharmacy is charging you and how they derive this price.

Pharmacies have their own professional jargon that can be hard for outsiders to understand—just like us! We say, for example, that a patient has an “erythematous urticaria” when we mean “itchy red rash.” Pharmacists say “I’m charging you the Average Wholesale Price minus 12%.” What the heck does that mean?

It turns out that there are many pricing systems in the pharmaceutical industry. You only really have to know about two of them, but it is worthwhile to peruse a list of the others:

Average Wholesale Price (AWP)
Actual Average Acquisition Cost (AAC)
Wholesale Acquisition Cost (WAC)
Average Manufacturer’s Price (AMP)
Maximum Allowable Cost (MAC)
Federal Supply Schedule (FSS)
Federal Upper Limit (FUL)
Estimated Acquisition Cost (EAC)
Average Sale Price (ASP)
Usual and Customary Charge (UCC)

And that is not all of them! The problem is that each of these pricing systems can give amazingly different prices for the exact same medication.

Fortunately, you only have to know about two of these pricing schemes; one that you don’t want to use and one that you do want to use. Forget about all of the others.

Average Wholesale Price (AWP)

The one that you don’t want to use is the Average Wholesale Price (AWP). Historically, this is the most common price system used by pharmacies. The problem is that it is a misleading term. You would think that the “Average Wholesale Price” would be the average price that the wholesalers charge for a drug. Well, you would be wrong. AWP is not a wholesale price and it is not an average. It is just a price set by the pharmaceutical industry. It is debatable exactly where that price comes from. However, AWP is, on average, 20% higher than the true wholesale price. But can be as much as 120% higher!  That means if a pharmacy says to you “I’m going to charge you AWP less 12%,” that means that they will be making somewhere between 8% and120% profit on these sales.  (They were probably smiling when they said it).  And that is in addition to their “Fill fee,” which I will discuss in a future post.

In addition to being an inaccurate representation of wholesale costs, AWP is quite hard for the typical consumer, like you and me, to find. You can’t just look up AWP online. AWP are listed in certain pharmacy trade publications like The Red Book, but access to the Red Book is quite expensive. And even if you get one, you will find that a certain medication, say ranitidine 150mg, has not just one AWP like you would expect, but a bewildering array of AWPs that range in price from one cent a tablet to well over one dollar a tablet. Some AWPs apply only to hospitals, some to huge bulk purchases like Wal-mart would make. It is often almost impossible to decipher what would apply to your situation. I know. I have tried.
Some pharmacies really like to use AWP and I can see why. It has many advantages for them. AWP overestimates wholesale costs to the advantage of the pharmacy. The pharmacy understands it, but you don’t. In essence, AWP is what the pharmacy says it is! How are you going to know differently? If possible, do not deal with the AWP!

Average Actual Acquisition Cost (AAC)

The price that you want to use instead is the Average Actual Acquisition Cost (AAC). AAC is an estimate of the actual wholesale cost your pharmacy pays for medications. Instead of being head-scratchingly hard to understand, AAC is easy to understand. It is the true wholesale price. And instead of being almost impossible to find out, you can find out the AAC in one of two easy ways. First, you can ask your pharmacy for the AAC of medications you commonly order. Some pharmacies will give this information to you, no problem. If you have a pharmacy like this, consider yourself blessed. Other pharmacies can be quite loathe parting with this information.

Fortunately, there is a second way to find AAC prices: You can look them up online. Most state’s Medicaid programs utilize AAC to set Medicaid drug prices and publish the AAC on their website. If your state does not offer online access to AAC, feel free to use Idaho Medicaid’s AAC website, found here.

How Much Difference Does It Really Make?

Is the difference between AAC and AWP really that important? Here is a true story that illustrates the difference.

Like many doctors, I have a little black bag with some doctor tools and medications that I can use in urgent situations. One such “stat” medication that I keep in my black bag is ondansetron (Zofran), which is, of course, used to treat nausea. A couple of weeks ago, I went to a local chain pharmacy to get some new ondansetron for my black bag. I had looked up the AAC online before I went to the pharmacy and found that the AAC of generic ondansetron 8mg tabs was 15 cents apiece. For 30 of them, the total AAC would be approximately $4.50. Figure in a percentage markup and a fill fee and I thought I would be charged approximately $10.00-$15.00 for this prescription.
Instead, the pharm tech looked me in the eye and said “That’ll be $235.43.” The pharmacy had calculated the price using AWP!

$10.00 vs. $235.43. Now that is the difference between AWP and AAC in a nutshell. What would your facility have done had it been charged $235.43 for this prescription? Paid it without question, I suspect.

So getting back to the original question: Is it possible to understand pharmacy prices? The answer is Yes! As long as you use the Actual Average Acquisition Price. You can understand the numerous other pharmacy pricing schemes only if you understand their relationship to AAC.

Do you have a good relationship with your pharmacy? What do you pay for your pharmaceuticals?  Please Comment!

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What Do You Think of The 10 Point Pain Scale?

20050824I was asked via email what I thought of the 10 Point Pain Scale.  I have never been a big fan of the 10 Point Pain Scale, but I think that it is a particularly poor fit for Correctional Medicine and I don’t use it in my jails.

Hospitals have to use the 10 Point Pain Scale because it is mandated by JCAHO, the hospital accreditation body.  But JCAHO has no authority over jails and prisons. We don’t have to use it and I personally think we practitioners of Correctional Medicine are better off without it.

I used the 10 Point Pain Scale quite a lot when I worked in a busy Emergency Department, both because I had to (it was a JCAHO mandate) and because it can be useful in an ER setting.  The 10 Point Pain Scale is not bad at evaluating acute pain, like the pain from appendicitis or a broken leg.  However, it is not as useful when evaluating chronic pain like what we see in corrections.

Even in an ER setting, I noticed problems with the 10-Point Pain Scale.  First, it is entirely subjective.  In other words, patients say a number and there is no objective way to know if they are being honest or not.  In the ER, I suspected that many patients inflated their numbers.  For example:

My pain is 13-out-of-10.”

My abdominal pain is 10-out-of-10 (said while the patient was eating Cheetos).”

The 10 Point Pain Scale is more useful evaluating responses to therapy via changes in the pain scale.  So if a patient tells me that he has 10-out-of-10 pain, I may not be exactly sure what that means.  But if he later tells me that his pain now is 8-out-of-10, I know that he has improved.  But even that did not happen all of the time.

I had cases where I would treat patients with IV Dilaudid, say, until they were asleep.  Yet when the nurse woke them to ask about their pain, the patient would say (with slurred words) “itsh shtill a ten.”  Should I have given more Dilaudid based on that report of 10-out-of-10 pain?  Of course not!

Let me give an example from the other end of the spectrum.  Tough, stoic cowboy-types would come to the ER with long bone fractures and would rate their pain a “2-out-of-10.”  Do I then use Tylenol instead of IV narcotics to treat the pain from this femur fracture?  Again, of course not.

Finally, what do I do with a patient who rates her pain high–say 9 out of 10–but refuses narcotic pain medication?  Don’t laugh, that actually happens!  Some people are tough and can handle pain better than others.  Others would rather have pain than be gorked by pain meds.

In the end, even using the 10 Point Pain Scale, ER doctors still have to rely on their clinical judgment.  Yet that means there will be discrepancies between what the patient says his pain is and how it is treated.  Let’s say the nurse dutifully records in the medical record that the patient says his pain is 10-out-of-10, but, based on my clinical judgment, I do not give pain medication.  Later, when the medical record is reviewed by JCAHO, a hospital committee or a plaintiff’s attorney, I look like an uncaring sadist:  ”My client was crying out that his pain was as bad as pain could possibly be and you did nothing, Doctor?”

And those are just the problems when the 10-Point Pain Scale is used to evaluate acute pain in ERs.  It is even worse when used to evaluate chronic pain in Correctional Medicine clinics.  Chronic pain patients tend more than acute pain patients to rate their pain 10 out of 10 and to admit to little change.  There is also more discrepancy between what chronic patients say (The pain is 10 out of 10) and what they do.  For example, consider the patient I actually had in one of my jails who told me in clinic that his chronic back pain was 10/10 in intensity.  Later in the day, I looked into the recreation area just in time to see this patient perform a perfect basketball reverse layup.  This did not mean that this patient did not have back pain at all—he probably really did–but it did mean that he probably did not have true “10 out of 10″ pain.  It also meant that I could not trust this patient’s subjective pain scale scores.

It seems to me that I have to use even more clinical judgment in a jail than I did in the ER.  I have to weigh the potential adverse effects that narcotics have on the safety and security of the facility.  I have more patients with addiction problems and have to try to sort out true chronic pain from addiction.

Plus, in a jail, I have more true objective evidence to base my clinical decision on than I did in the ER since I can observe patients away from the medical clinic.  I can watch them at recreation.  I can watch them walk and talk and eat in their dorm.  I know the legal circumstances that landed them in jail, like illicit drug use, that an outside doctor may not ever know about.

The subjective 10 Point Pain Scale in such a setting is more hindrance than help, I believe.

I still ask the patients about their pain. I even use a pain scale, though a simpler one consisting of just four points: none, mild, medium and severe.  I also ask about changes in  pain:  “Is your pain improved since yesterday?”  But more importantly, I ask patients how their pain affects them in everyday life.  Can you sit?  Stand?  Watch TV?  Walk during recreation?  I record the answer and then compare that (if necessary) to observation of those activities.

The 10-Point Pain Scale does have its uses.  In my opinion, it works best for monitoring responses to therapy of acute pain.  For example, when I used to give IV Dilaudid in the ER to a patient with a femur fracture, her responses to the 10-Point Pain question would help me to know that I was getting somewhere with pain relief and when to stop.  Whether it worked better than asking “Is your pain improved?” or “Do you want any more pain medication?” is a debatable point.

But the 10 Point Pain Scale is not as useful for rating chronic pain.  In my opinion, it is the wrong tool for this task.

Feel free to disagree with me, though!  I could be wrong in my opinions!

What is your experience with the 10 Point Pain System used in hospitals?  Do you use it in your correctional facility?  Please comment!

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