Tag Archives: JailMedicine

Transforming Our Approach to Chronic Pain

One of the most fearful and frustrating events in my correctional medicine world used to be when a new chronic pain patient would arrive in my clinic.  A typical patient would be a “Ralph,” a middle-aged man who has had chronic back pain for many years.  Ralph has had a couple of back surgeries, steroid injections and more than one kind of stimulator, none of which has been effective.  He arrived at the jail taking a long list of sedating medications such as muscle relaxers, gabapentin, and sleeping aids plus, of course, big opioids.  In addition, Ralph has alcohol abuse issues.  The reason he is in jail is a felony DUI charge.  Now he is in my medical clinic, looking expectantly at me.  How am I going to fix his pain problem? 

The answer, of course, is that I am not.  I am not that smart.  He has already seen lots of doctors, including pain specialists and surgeons, who have tried almost everything that can be tried and they have not fixed his chronic pain problem.  I’m not going to be able to, either.  In my opinion, the most common and serious mistake made in the treatment of chronic pain in corrections is when we imply that we can eliminate chronic pain. 

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Book Review. Maximum Insecurity: A Doctor in the Supermax

Quick!  Name a book that describes the experience of being a medical professional in a jail or prison!  . . . Can’t do it, can you?  There are lots of books that talk about the life of a lawyer or a doctor in general.  There are books about prison inmates and even correctional officers.  But, to my knowledge, no one has ever written a book describing the experience of working as a physician in a jail or prison. Maximum Insecurity:  A Doctor in the Supermax fills that void.  This is a wonderful book, written by Dr. William Wright, about his experiences providing medical care to inmates in the Colorado State Penitentiary maximum-security prison. And not only is this the first memoir I am aware of written about correctional medicine, Maximum Insecurity is also a gem–funny, informative and engrossing.19960515 Continue reading

Get Updated Information Here…

We have added an ‘event’ on our Facebook page for the Essentials of Correctional Medicine Conference.  Make sure to jump over there and join the event for all of the latest information regarding the conference next month. Continue reading

Six Months Later–Top Posts

Well, JailMedicine is now over six months old and has been more fun to write and much better received than I had imagined it would be.  JailMedicine has had over 30,000 hits!  Thank you especially to those of you who have written comments.  I have my opinions on certain topics (as you have read) but I realize that smart and accomplished people sometimes disagree with me–and sometimes they are right and I am wrong!  We all learn and become more effective clinicians when alternative views are expressed and debated–so please comment!

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Jail Medicine Is Now On Facebook

In an effort to increase our visibility and make Jail Medicine more accessible online, we are pleased to announce that you can now follow us on Facebook. We plan to post special articles, videos, training information, solutions and answer the many questions we have been receiving and much more on the Facebook page, which you can find here:

 

 

 

 

 

The Right Way to Deal with Outside Physicians

Those of us who practice medicine in jails frequently (Frequently? Daily!) run into the thorny issue of our relationship to the doctors who care for our patients outside of the jail.

When patients are in our jails, we are responsible for them; they are our patients. But these patients also have doctors outside of the jail that perhaps they have been seeing for years. The inmate considers their outside physician to be their “real” doctor, not us. (Throughout this article, I am going to use the term “doctors” rather than the more generic “practitioners.” I do not mean to slight nurse practitioners or physician assistants. What I say applies to them, as well.)

What brought this topic to mind is a case that occurred in one of my jails recently. A patient came to jail with a prescription pad filled out by his outside physician authorizing him to have a double mattress, an extra blanket and an extra pillow. (There was no note requiring us to feed him pizza every Friday night—he must have forgotten to ask for that.) So I was left in a little dilemma. What should I do about this note? Ignore it? Allow the inmate to have the extra comfort items?

Dealing with inmates’ outside physicians can be tricky, but I have found (mostly through sad experience) that there is definitely a right way and a wrong way to handle these encounters. The right way involves recognizing three important points:

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A Quick and Easy Solution for Second Mattress Requests!

The Elmore County Jail in Mountain Home, Idaho

I have a quick ‘n easy solution for those pesky requests for a second mattress that plague all correctional facilities.  But before I get to that, though, there are two important points to consider in any discussion about second mattresses in correctional facilities.

First, providing inmates with mattresses, like inmate clothes and toiletries, is the purview and duty of the correctional officers, not the medical staff.  What this means is that when an inmate asks for a second mattress, the question being put to us is this:  Is there a medical need for this patient to have a second mattress?  This is critically important.  The inmate would prefer to frame the question differently, something like this:  “The correctional officers only issued me one mattress, but you can over-rule them and authorize me to have a second mattress.  Will you do me this favor?”  This is a totally different question than “Does this patient have a medical need for a second mattress.”

Secondly, having a second mattress is a status symbol inside the correctional community.  When an inmate receives a benefit that other inmates do not, he gains status and prestige.  Sometimes this motivation is as important for an experienced inmate as is the extra comfort of a second mattress.  I believe that if a jail provided two mattresses to every inmate in the facility, there would be requests to medical for three mattresses.  (Pretty soon inmate beds would rival “The Princess and the Pea!”) So when we grant inappropriate requests for second mattresses, we are conferring status on the inmate in question.  And we are denying status to those who we refuse.  This also, in my mind, is important to consider.

So now to the main topic of the day:  What constitutes a “medical need” for a second mattress?  In my opinion—there are none!  Zero.  Nada.  There is no medical need ever for a second mattress.  I challenge anyone to find a reference in any medical literature saying that second mattresses are a treatment for anything.  For example, a common reason given by inmates requesting a second mattress is that they have chronic back pain.  However, if you pull out any medical textbook that deals with the treatment of chronic back pain, you will not find second mattresses mentioned in any.  Go ahead! Look!

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You Need a Medical Commissary in Your Facility!

When I was an undergraduate, before I switched to pre-med, I was an economics major.  Maybe because of that training, when I look at jail medical practices, I tend to look at all of the costs of medical practice, not just the monetary costs.  For example, the total cost of providing a medication to a patient in the jail includes the cost of the medication (of course), but it also includes the cost of the various people, like nurses, pharmacists, deputies and practitioners, who spend time creating the prescription.  Thinking of costs in this way can change our perspective of what something “costs.”

Consider the case of the man with heartburn.  We’ll call him “Jeffrey.”  He doesn’t know it, but he is about to go to jail.  Before Jeffrey goes to jail, if he wants to purchase something like ranitidine (Zantac) for his heartburn, he would go to a store and buy it.  He doesn’t need to see a medical professional.  He doesn’t need a prescription.  In most places, he doesn’t even need to wait—convenience stores sell ranitidine 24/7.  The monetary price Jeffrey will pay for 50 tablets of ranitidine at the store is around $7.00.  The cost in terms of time is how long it takes him to run to the store.  The total cost in time to the store to provide the ranitidine to Jeffrey is 30 seconds—how long it took the store clerk to ring up the sale.

Now think of the same guy in jail.  Jeffrey still has heartburn.  Let’s say he still has money—now in his commissary account.  He is still willing to buy ranitidine.  But ranitidine is not on the jail commissary list.  He can buy Ramen noodles or a Snickers bar, but not ranitidine.  In order to get ranitidine, he has to put in a “Request for Medical Care” form.  What happens now varies from jail to jail and prison to prison.  I am going to present a typical jail scenario.

The act of requesting non-emergent medical care costs Jeffrey $10.00.  The form is then triaged by a nurse and Jeffrey is scheduled to see a practitioner.  Since the clinics are crowded, the appointment is made for five days hence.  In the meantime, he continues to have heartburn.  On the scheduled day, he comes to the medical clinic.  He waits, say, an hour in the waiting area.  He then has vitals taken by a nurse.  The practitioner, unsurprisingly, orders a prescription of ranitidine from the pharmacy for Jeffrey.  The order is sent to the pharmacy and is delivered the next day.  It is paid for from the jail medical budget.

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Evidence Based Use of NSAIDS—Less is More

When we want to do an evidence-based approach to the use of any drug, we have to consider three factors:

  1. What beneficial effects do we want the drug to have on our patients?
  2. What harm might the drug cause?  How can we maximize benefit while minimizing risk?
  3. How much does the drug cost?  Can we get a better risk/benefit profile from a less expensive drug?

A great place to start using these tools to evaluate appropriate drug use is with the Non-Steroidal Anti-Inflammatory Drugs (NSAIDS).  NSAIDS are commonly prescribed drugs, but, in general, we practitioners use them in inappropriate ways.  We overestimate the benefit they give.  We underestimate the risks they carry.  We completely ignore their costs; preferring, it seems, to prescribe expensive NSAIDS which offer no benefits over the cheap stuff.

In this article, I want to summarize the evidence about NSAIDS and suggest a protocol for their use based on that evidence.  I say summarize, because the body of research on NSAIDS is very large and I cannot include everything in this short paper.  NSAIDS are a very well understood class of medications.  Most of the information I include is not controversial.  It can be found in most textbooks and review articles.  I have included a couple of these at the end of the article.

Let’s start by going over the potential harm that NSAIDS can cause.  Most people know that NSAIDS can cause GI complications like ulcers and GI bleeding.  The question is—how big of a problem is this?  It turns out to be a very big problem, indeed:

  1. An estimated 16,500 patients die from GI bleeding caused by NSAIDS each year.  This is far more people than die of AIDS each year (13,500).  In fact, the CDC ranks deaths due to NSAID induced GI bleeding as the 14th leading cause of death in this country.
  2. Over 100,000 people are hospitalized each year with GI complications caused by NSAID use.  Total spending in theUSto treat NSAID complications is greater than 2 billion dollars annually.
  3. The iatrogenic cost factor of NSAID use is approximately 2.  In other words, for every dollar spent on NSAIDS, approximately one more dollar is spent treating NSAID induced complications.

Evidence-Based Use of Antibiotics Can Save Your Jail Money!

I suspect that almost every physician in theUnited Stateswould agree that antibiotics are over-prescribed.  Unfortunately, since the total number of antibiotic prescriptions in theUnited Statesgiven to people with “cold” has been estimated at 44 million per year, it would seem that most physicians have not actually decreased their own prescribing habits.  I can see how this would be the case.  Physicians are stuck in the inertia of “I have always done it this way.”  Also, “my patients expect an antibiotic when they come in and they won’t be happy if I don’t prescribe one.”  Finally, “The antibiotic can’t hurt and it might help!”  Multiply each incident of an unneeded prescription by, oh, a few million, and it adds up.

Of course, inappropriate antibiotic use can and does hurt.  It hurts every patient who has an adverse effect from inappropriate antibiotic prescriptions, stuff like diarrhea, yeast infections, nausea or an allergic reaction.  It hurts the community by breeding antibiotic resistant bugs.  And it hurts because inappropriate antibiotic use is expensive!  40 billion dollars a year expensive!  How much of that money is being wasted at your facility?

One of the neatest things that I have discovered about the evidence-based medicine movement is that using evidence-based principles almost always saves money.  There is no better example of this than in the area of antibiotic use.

Three years ago, the Centers of Disease Control published evidence-based guidelines for the appropriate use of antibiotics for upper respiratory infections.  The guidelines were developed by a panel of experts which included representatives from infectious disease, family practice, emergency medicine, internal medicine and from the CDC itself.  The panel used evidence-based principles to review the huge amount of literature on these subjects.  In the end, they came up with guidelines entitled “Principles of Appropriate Antibiotic Use for Acute Respiratory Tract Infections in Adults.” The finished guidelines can be found in the March 20, 2001edition of the Annals of Internal Medicine or online at www.cdc.gov/ncidod/dbmd/antibioticresisance/.  The final report included pharyngitis (which I reviewed in the last issue of CorrectCare), acute bronchits, and rhinosinusitis.

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