A couple of years ago, I first started to see microdermal implants in my jail patients. This is, of course, jewelry that is implanted in the skin. These have become so popular as to be almost universal. If you work in a jail or prison (or even if you have looked around at your local grocery store), you certainly have seen these. Microdermal implants can be problematic in correctional settings, because they cannot be easily removed like the older bolts and rings. Microdermal implants are imbedded in the skin, and removal requires making an incision to extract them.
But in corrections, even though it is difficult, microdermal implants often must be removed, either as a security issue or because the patient requests that they be removed. Nowadays, these implants are so common that all correctional practitioners really should know how to deal with microdermal jewelry. But most of us were never taught how to do this in our training! I certainly never learned about these in my residency training. Such a thing would have been inconceivable back then. Cutting edge fashion in those days was long hair and grungy jeans!
So I was grateful when an opportunity for education presented itself recently. A friend of mine asked me if I would remove two of her micro dermal implants and kindly consented to have the procedure photographed. Todays JailMedicine post is a photographic tutorial on how to remove microdermal implants.Continue reading →
I was talking to a physician colleague of mine the other day and he was quite interested in what I was doing and in correctional medicine in general. Like most people (it seems), he had no idea what the difference was between jails and prisons and what the practice of medicine is like in the two settings. While the term “Correctional Medicine” encompasses medicine practiced in both jails and prisons, the actual practice of medicine in the two settings can be as different as that of an emergency department and a nursing home.
A good way to illustrate the difference between jails and prisons and between jail medicine and prison medicine is by using patients as models. To this end, let’s consider the cases of two patients entering the correctional system for the first time, a homeless alcoholic and a successful middle aged business man who sees his primary care physician regularly.Continue reading →
If you’ve ever gone looking for books, articles, or–well anything! written about correctional medicine, you will quickly notice that there really isn’t very much out there. The specialty of correctional medicine is in its infancy. You can count the number of published books about the subject on less than two hands.
So a day in which a new book about correctional medicine is published is always a good day. And if by chance that book also happens to be well written and truly useful, well, that’s a true bonus and time for celebration.
Lorry Schoenly has written such a book that I recommend for all of us who practice in jails and prisons. This is a book that has universal applicability, whether you are a nurse, a practitioner, a mental health provider or an administrator. The name of the book is Correctional Health Care Patient Safety Handbook. You should read this book!Continue reading →
About a year ago, the American Heart Association released new cholesterol management guidelines. These guidelines changed how we practitioners should deal with cholesterol evaluation and management almost to a revolutionary degree. They are a BIG departure from past thinking. For example, under the old system, we practitioners were supposed to follow cholesterol labs. We were supposed to get LDL levels down below 100. Not anymore! In fact, under the new guidelines, once you have started someone on therapy, you really don’t have to check their cholesterol ever again! Really!
Also, the new guidelines say that there is basically only one therapy for almost all lipid patients: statins. According to the new guidelines, we should get rid of all other lipid therapies. Niacin? Throw it away. Gemfibrozil and fish oil? Get rid of them.
What about triglycerides? The new guidelines say that you should only treat hypertriglyceridemia with medications when the triglyceride level is greater than 1000mg/d. Holy cow, 1000! Where did that come from?
This document is almost revolutionary in its sweeping changes. It makes treating hyperlipidemia so very much easier. In my opinion, all correctional practitioners and nurses involved in chronic care clinics should know the new guidelines. If you have not already done so, you need to re-write your lipid protocol.Continue reading →
Everyone who has worked in corrections for any length of time accumulates a litany of anecdotes about the funny and crazy things that go on. These tend to get passed around whenever correctional personnel get together at parties or conferences. Invariably, someone eventually says, “You know, someone should write these stories down.” Well, finally someone has.
Dr. William Wright has published a sparkling and humorous memoir of his time working in a county jail entitled “Jailhouse Doc.” This book is well worth reading. In fact, it is almost a “must read” for those of us who work in correctional medicine. Not only is it the only book I am aware of about jail medicine, it is well written, funny and informative.Continue reading →
Back when I worked in the ER, we often would have patients come to the ER who were homeless or otherwise had not been taking care of themselves. Of particular concern was their feet—many had not removed their shoes for days or even weeks. When these shoes were removed, we often were confronted by a dreaded medical malady: Toxic Sock Syndrome. These feet could be unbelievably odiferous—I have seen hardened paramedics retch.
So we had to be careful. If a patient was suspected of having Toxic Shock Syndrome, shoes and socks would be quickly removed into a plastic bag and the feet immediately washed and covered with clean slippers.
That was about the end of ER involvement with poorly-cared-for feet. As an ER Doc, I never had to do much with the underlying foot disease.
The situation has been reversed now that I work in jails and prisons. I don’t have to deal with Toxic Sock Syndrome anymore. (I’m sure the booking deputies do, though. Bless them). Instead, a day or two later I typically am confronted in the jail medical clinic with the grody feet themselves. Here is a typical example:
One of the greatest concepts I have run across since I finished school is the Number Needed to Treat (abbreviated NNT). NNT was never taught back when I went to medical school (we had barely given up The Four Humors!). Instead, we were taught “the p-value.” Does anyone else remember the p-value? The p-value of a study, it turns out, is a relatively poor measure of study validity, partly because it implies an “all-or-nothing” kind of understanding of studies: either the study is “valid” (meaning a p-value of >95%) or it is not. Either the treatment being studied works or it does not. And if a treatment works, it must work for all people.
Of course, in real life, this is not the case. No drug is universally good or bad. All drugs help some people, harm some people (with adverse side effects) and make no difference one way or another in some people. These numbers can be derived from any study’s data. There is even a fabulous website devoted to this where you can look up the NNT and its corollary, the Number Needed to Harm (NNH) for all sorts of drugs and treatments (found here).
Since it is influenza season and time for us to get our flu shots (I got mine yesterday), I thought it would be a great time to see how beneficial the flu vaccine is. What is the NNT for the flu vaccine? And while we are at it, why don’t we also look at the data on oseltamivir (Tamiflu) while we’re at it?
The question of whether a seizure-like event is a true epileptic seizure or some type of pseudoseizure is often very hard to sort out. Oftentimes (in fact, most of the time) these events do not happen in front of us. We just hear reports from the deputies of “something happening–looked like a seizure.” Or perhaps the patient himself will tell us that he had an seizure, like the patient I saw recently who told me “I’ve had four seizures this week.” Of course all of them were un-witnessed by anyone else.
Even though you might suspect that these un-witnessed seizure-like events are pseudoseizures, you should be very cautious about labeling such events “fake.” The absolute worst mistake that you as a medical provider can make in these cases is to declare an event “fake”—and be wrong. Until you are very sure, it is better to assume that un-witnessed events are real–or at least keep that possibility in the forefront of your mind. Until you have more evidence, you just don’t know for sure.
That is why it is so valuable when a patient has one of these seizure-like events right in front of you. This is the one opportunity to use objective findings to distinguish a true epileptic seizure from a pseudoseizure. I discussed in my last post the various differences in presentation between epileptic seizures and pseudoseizures, such as the nature of the shaking, eye deviation and a post-ictal period. Unfortunately, however, none of these findings are perfect.Continue reading →
Every once in a while, because of changing drug prices, I discover that my formulary has become outdated. More expensive medications are on my formulary and less expensive equivalents are non-formulary. Depending on how long the price change occurred before I noticed it, I may have overpaid hundreds of dollars unnecessarily. Oops!
This situation arises more frequently than you might expect. Drug prices can change rapidly. And formularies do not get updated often enough. I try to go through mine quarterly, but, to be honest, it probably happens only once or twice a year. As a result, I miss opportunities to save my jails some money.
Today’s example is extended release antidepressants. For many years, I never even looked at extended release drug prices. I just “knew” that ERs were much more expensive than their immediate release cousins. But wait long enough, and everything goes generic, including extended release.
If you have not yet noticed, you can save quite a bit of money (and time!) by switching to extended release venlafaxine (Effexor) and bupropion (Wellbutrin). Continue reading →
As we all know from long experience, hypertension is the single most commonly seen and treated condition in primary care medicine. It is an important risk factor for strokes, heart attacks, kidney failure and overall death. It has been exhaustively studied. And yet there is still significant controversy over hypertension, including how to define it and what the best agents for treatment are.
Against this background, The 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults was released last December in JAMA. It was written by the 8th Joint National Committee, and so, of course, is referred to as JNC 8.
JNC 8 has a couple of important and surprising changes from JNC 7. One of these, at least, is controversial enough that some members of the committee rebelled and released a dissenting “Minority Report” (apologies to Tom Cruise). Today’s JailMedicine post is a summary of JNC 8 recommendations and changes to JNC 7.Continue reading →