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
Remember our patient? He was the guy who repeatedly ran his head into the wall. Probably everyone in corrections (if you have worked in the field long enough) has seen someone like this guy , who is working hard to harm himself.
I have argued that chemical sedation is safer than prolonged physical restraint in managing this patient. We reviewed which patients are appropriate candidates for involuntary chemical sedation and which drugs are best used for this indication. By now, in our series on chemical sedation, we have reached the point where the patient has actually been injected with the sedating agents.
Of course, once the patient has been given Haldol and Ativan IM, we cannot just walk away. Most of the time, chemical sedation occurs without incident. Well within an hour, most patients are asleep and can be removed from physical restraints. But as with everything in medicine, problems sometimes occur. Therefore, following the administration of involuntary chemical sedation, the medical team must ensure and document the safe and effective onset of sedation. Then, there must be appropriate follow-up. Chemical sedation is an unusual occurrence that has both medical and legal implications. Follow up visits investigate why the patient became so unmanageable as to need chemical sedation and make sure that the sedation was administered correctly.
Safe Onset of Sedation
Generally, most patients who have received an IM injection of Haldol and Ativan will be asleep well within an hour. In the normal course of events, the nurse caring for this patient should observe him long enough to document that the patient has become sedated and has been removed from physical restraints. Once the patient is out of restraints, the nurse should take vitals signs and document that the patient is sedated but arousable and is in good shape.
Problems sometimes occur, however. The single most common problem is that the first shot was not enough and the patient is still awake, thrashing and agitated, an hour after the IM injection. When this happens, the proper course is to start over from the beginning. Does the patient have an unrecognized medical cause of the agitation, like hypoglycemia or hypoxia or delirium? Have the vitals signs improved or deteriorated? Is the patient just as agitated as before or is he (more likely) partially, but incompletely, sedated? After this re-evaluation, most patients in this situation just need a second dose of Haldol and Ativan to complete the sedation process. Rarely, though, the appropriate call is to send them to the ER.
All patients who have received involuntary chemical sedation should have two follow-up check ups, preferably within 24 hours. The reason for these visits is twofold:
- To investigate the question of why the patient was so agitated in the first place, and
- Whether the patient needs further interventions, like further work up (labs, say), changes in his maintenance medication regimen, or commitment.
The first of these visits should be in the medical clinic with a medical practitioner. The practitioner should document absence of harm from the procedure and, if possible, pinpoint a medical reason for the agitation, if there was one. The two most common medical reasons for agitation of this severity are amphetamine or alcohol intoxication. Confusional states, like dementia and delirium, are also possible.
The patient should also normally be seen by the mental health. The purpose of this visit is to determine if there was a psychiatric reason for the agitation. The three most likely possibilities are:
- Acute psychosis.
- Acute mania.
- Misbehavior as a manifestation of a personality disorder, especially the “Big Three: Borderline, Antisocial and Narcissistic Personality Disorder.
Questions that should be specifically addressed in the mental health visit are whether the threat of aggressive behavior is over (usually it is), whether the patient is a candidate for commitment to a psychiatric facility (usually not) and whether changes should be made in the ongoing psychiatric medication regimen.
Finally, each and every case of involuntary sedation should be reviewed in a quality assurance capacity. This can be done by the facility medical director or within a CQI committee. Chemical sedation can be misused and overused. Once the medical and security staff see how much easier and better involuntary chemical sedation is than physical restraint, there is a tendency to want to use it all the time—in patients who really are not a danger to self or others–just for the convenience of the staff. The purpose of the CQI review of all instances of involuntary chemical sedation is to ensure that this extraordinary therapy is not misused or overused.
Involuntary Chemical Sedation Checklist
Involuntary chemical sedation tends to be a high adrenaline affair. When you are in a situation involving a yelling, agitated patient and correctional staff amped up on adrenaline, it is hard to remember everything you are supposed to document. The charting of these incidents often contains important omissions, at least in my experience.
The solution to this problem is to borrow a procedure from airline pilots, who have a written checklist of everything they must remember to do before they take off. Without the checklist, something will be missed eventually. The documentation of involuntary chemical sedation is likewise made easier by using a checklist that contains the following sections:
- Appropriate candidate.
- Reversible medical causes.
- Appropriate agents.
- Safe and effective onset of sedation.
- Appropriate follow-up.
I have attached below a PDF file of a Sample Involuntary Chemical Sedation Form. You are welcome to download it and use it to develop one for your own facility!
How often do you have to use involuntary chemical sedation at your facility? Please comment!
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.
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.
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.