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 →
Today on JailMedicine, I am happy to present a guest post by Dr. Bill Wright.As you may remember, Dr. Wright is the author ofMaximum Insecurity: A Doctor in the Supermax, which I reviewed hereand which you canpurchase here.
Correctional medicine attracts more than its share of argumentative and demanding patients. We all feel the tightening in our stomachs when finding certain names on the clinic schedule, anticipating the disputes that are almost certain to follow. It doesn’t need to be that way. Continue reading →
Today, I am adding more sites to the CFOAM page found at the top of the blog. Remember that FOAM stands for Free Online Access to Medicine and is a movement that seeks to utilize the full potential of the internet for medical education. In order to make it as FOAM, a web site must be free, provide useful education on a medical topic, and be easily accessible online. This can (and does) include audio podcasts, video lectures, and written articles and blogs. If the content is relevant to correctional medicine, well, that’s CFOAM: Correctional Free Online Access to Medicine. Today, I am adding three more CFAOM websites to the list. Continue reading →
Today’s post is an opinion piece. Personally, I think that skeletal muscle relaxers like cyclobenzaprine, methocarbamol and chlorzoxazone are over prescribed for acute and chronic musculoskeletal pain, both in the outside world but especially in corrections. The main reason for this, I think, is that prescribers misunderstand what muscle relaxers do. Contrary to their name, muscle relaxers do not relax muscles, at least as they are commonly prescribed. Muscle relaxers are sedatives, pure and simple, and should be prescribed with that fact in mind. Instead of telling patients (and ourselves) that “I am prescribing a muscle relaxer for you,” in the interest of full disclosure, we should be saying “I am prescribing a sedative for you.” Continue reading →
As you probably know, Sovaldi (sofosbuvir) is an important new treatment for Hepatitis C infection that was released this last December and has been aggressively marketed by its maker, Gilead, ever since. The problem is that Gilead is charging an unheard of, jaw-dropping, $1,000.00 per pill for Sovaldi. This translates into a MINIMUM of $84,000.00 for Sovaldi alone for the simplest course of Hep C treatment. Add on the other necessary drugs and take into consideration more complicated cases, and a single course of therapy for Hepatitis C will cost between $100,000.00 and $250,000.00.
This price has placed prison systems in a no-win situation–and not just prisons, but also Medicaid, insurance companies, and HMOs. On one hand, Sovaldi is a good drug that, in fact, represents a significant advance in Hepatitis C treatment. Lots of Hepatitis C patients could potentially benefit from Sovaldi. On the other hand, no one can afford Sovaldi. Treating every potential Hep C patient using Sovaldi would bankrupt everyone. There is no good way out of this dilemma. Continue reading →
Do these words make you want to head for the clinic exit? If so, you’ll find a lot of company trying to get through the door. Many physicians hate to see dizzy patients because they can’t easily get their heads around the complaint. They can’t see, hear, feel, smell, or touch it, so it’s hard to know where to start. Help is on the way. Continue reading →