Tag Archives: jails

Price Check! Are analogue insulins worth their hefty price?

The analogue insulins were introduced into the United States in the late 1990s and early 2000s. They are called “analogue” insulins because their chemical structure is subtlety different than native human insulin, which gives them different, advantageous properties. Analogue insulins include the short acting insulins Humalog (insulin lispro) and Novolog (insulin aspart) and the long acting insulins Lantus (insulin glargine) and Levemir (insulin detemir).

Since their introduction, the insulin analogues have pretty much taken over the insulin market in the US. That is why I only mentioned human insulins in passing in the JailMedicine post “Insulin Dosing Made Simple.” It is unusual to see patients show up at the jail on any other insulin regimen than analogue insulins, usually Humalog and Lantus. And I have to admit; the analogue insulins are easier to use than human insulins. I like them.

But here is the problem: the analogue insulins have become insanely expensive! When they were first introduced, the price of Humalog and Lantus was around $20.00 per vial of 100 units. That compared to the price of human insulins like Humulin R and NPH of around $5.00 per vial. So the analogues were expensive, but doable. However, since around 2006, analogue insulins have dramatically increased in price—whereas the price for most other diabetic therapies has actually decreased over time. (You can read more about this price increase here)(In the graph above, notice the huge increase in insulin prices since 2006, while every other diabetic therapy price has actually fallen) Continue reading

Inmates cannot go out to find good doctors in the community. Good doctors have to choose to go to them!

I remember the first time someone told me that I was “wasting my talents” by working in a jail. At that time, I had no ready witty rebuttal. I love my job and I especially appreciate working with a patient population that is disadvantaged and underserved. Of course, the idea that incarcerated inmates are worthy recipients of medical care is, well–controversial. Inmates are not as politically correct as other medically disadvantaged populations.

As an example, if you were to tell your family and friends that you were going to work with at a medical clinic for the homeless in an inner city, or to provide medical care in a needy third world country, the reaction probably would be something along the lines of “Good for you! I admire your selflessness and dedication!” Yet when you tell these same people instead that you are going to work in a prison, you are much more likely to get this reaction: “What’re ya, nuts? Why would you waste your talents working with them?” I personally have heard the “you’re wasting your talents” line more than once. Continue reading

Treating Heroin Withdrawal: Methadone, Suboxone and . . . Tramadol?

In my last JailMedicine post, I wrote that clonidine is an excellent drug for the treatment of opioid withdrawal. In response, several people have asked about methadone and Suboxone. Why not use one of those drugs instead of clonidine?

The short answer is that both methadone and Suboxone are excellent drugs for the treatment of withdrawal. However, both are much more complicated to use in jails due to DEA legal requirements and a much larger potential for diversion and abuse. If you are using Suboxone or methadone, great! I believe that clonidine is a better choice for most jails. Those interested in using methadone or Suboxone need to be fully aware of the DEA laws surrounding their use. Before you use one of these drugs, you must make sure that you are following the law. I know of two physicians in my hometown who were disciplined by the DEA for prescribing narcotics to treat addiction without registering. The DEA are not kidders!

By the way, Jail practitioners should also be aware that Tramadol has been used successfully to treat withdrawal, as well. Continue reading

A Better Way to Drain Abscesses: The Berlin Technique

One of the consequences of the heroin epidemic we all are experiencing is a marked increase in the number of skin abscesses presenting to the jail medical clinics.  Jails have always had to deal with skin abscesses.  In fact, the single most popular JailMedicine post has been the Photographic Tutorial on Abscess I&D (found here).  But since the heroin epidemic, the number of skin abscess we see has exploded.  It is not unusual nowadays to lance an abscess every day!

The reason for this big increase in skin infections, of course, is that heroin users tend to share needles to shoot up, and these dirty needles leave behind the bugs that cause abscesses.  And since shooting up causes the abscesses, they tend to be found where addicts commonly shoot up–like the inner elbow, the forearm and even overlying the jugular veins of the neck.

Fortunately, just in time for this onslaught of abscesses, my good friend Neelie Berlin PA taught me a new method of lancing simple abscesses that is quicker and easier—yet just as effective—as the method I had been using for my entire career. I’m going to call this new method of draining abscesses “The Berlin Method.”

Who says you can’t teach an old Doc new tricks?  I have wholeheartedly gone over to the Berlin procedure.  It is THE method I use now to drain simple abscesses.

Today’s JailMedicine post is a pictographic tutorial on how to do this new easier method of lancing simple abscesses. Continue reading

Correctional Medicine is a Great Job! Who Knew?

I have a confession to make.  Before I knew anything about Correctional Medicine, I had a bad opinion about it.  I’m not proud of this.  I even turned down my first opportunity to get into Correctional Medicine because of my preconceived prejudice. Thank goodness I got a second opportunity, because Correctional Medicine changed my life! Who knew that Correctional Medicine was such a great job and a great career?

Certainly not my colleagues.  Back when I made the mid-life career change to jail medicine, my physician friends asked me, bewildered, “Why in the world would you want to work in a jail?”  Without knowing anything about it, they had a preconceived notion of Correctional Medicine as being low skill and basically without redeeming features.

What a difference 15 years makes! careersprisondoctor Continue reading

Correctional Medicine Is Different: Our Patients Don’t Go Home!

This post is the final in a series exploring how Correctional Medicine is different than medicine practiced outside of jails and prisons.  The previous three differences were The Principle of Fairness and All Clinical Encounters are Discussed Back in the Dorms and We Can’t Fire Our Patients and They Can’t Fire Us!

The final major difference between correctional medicine and medicine in the outside world is this: Our patients do not go home. We have a captive audience. Literally! Believe it or not, this is a very important medical point.

Back in my previous life as an ER doc, if I asked a patient to come back tomorrow to be rechecked, I knew that few of them would. It was just too much hassle. They had to find a ride back to the ER (especially hard for the homeless or those without cars), they had to endure another prolonged wait in the ER waiting room. And they would be charged big bucks for another ER visit! No wonder so few of my scheduled follow-ups actually returned!

Once I began to practice in a jail clinic, I soon realized that the situation is much different. The patient I see in clinic today will not go home. She will go to her housing dorm down the hall. I know exactly where she will be tomorrow–or in a week. If I want to see her again tomorrow, I can. In fact, I can reliably see her in follow up anytime I want to.

One might think, “So what? What difference can it possibly make on the practice of medicine that our patients do not go home?” The answer is that this fact does indeed have several important consequences for the practice of clinical medicine. I can think of at least four.unknown-1 Continue reading

Correctional Medicine is Different: We Can’t Fire Our Patients—and They Can’t Fire Us!

This post is the third in a series exploring how Correctional Medicine is different than medicine practiced outside of jails and prisons.  The previous two differences were The Principle of Fairness and All Clinical Encounters are Discussed Back in the Dorms.

There is a controversy in pediatrics that I have been following recently. Some pediatricians have been dismissing children from their practice if their parents will not allow them to be vaccinated. This practice has been criticized as punishing innocent children for the actions of their parents but the pediatricians defend it by saying they are just trying to protect their other patients from being exposed to pertussis, measles and other transmittable diseases in the waiting room.

unknown-1This story illustrates an extreme example of something that we all know: that the practice of “firing” patients is commonplace in outside medicine. Many of my jail patients have been dismissed from medical practices, some more than once! Patients can be fired for variety of offenses. Some violate the contracts of their pain clinics. Some are dismissed for simply not following the doctor’s advice—like to get their children vaccinated. Many are no longer welcome when they cannot pay their bills or have lost insurance coverage. (One orthopedist that I know routinely sends a dismissal letter to his patients on their 65th birthday since he refuses to participate in Medicare). Finally, patients can be fired for just being too difficult to deal with. One jail patient in particular I remember screamed drunkenly at his doctor’s secretary to the point that she called the police. He received his official dismissal letter while he was in jail.

Well! Things are different in Correctional Medicine! We can’t fire our patients. Our patients remain our patients no matter what. It doesn’t matter if they violate the terms of a pain contract by, say, diverting medications. It doesn’t matter if they refuse to follow our advice. It doesn’t matter if they are difficult to deal with. Continue reading

Correctional Medicine: The Principle of Fairness

I am often asked by my non-correctional colleagues what it is like to work in a jail. I tell them that practicing correctional medicine is different in many ways than medicine in the “free” world. Many of them scoff at this. How could the practice of medicine be different in a jail than it is anywhere else? “Medicine is medicine,” they say.

But correctional medicine is different. In my experience, if you just throw a practitioner into a jail or prison clinic without any training, he likely will not do well. It took me two full years before I was comfortable in my sick call clinics and I am still learning things as I go. Experience matters in Corrections!

This is obvious to those of us who have experience working in jails and prisons. But how do you explain the intricacies of a jail medical clinic to an outside physician? I have thought about this a lot over the many years I have practiced correctional medicine and I have come up with several concrete examples of how correctional medicine is different from medicine “on the outs.” The first, and perhaps the most important, difference is the Principle of Fairness.Unknown-1 Continue reading

Do Uncomplicated Lacerations Need To Be Closed Within Six Hours?

Dr. Keller,
What do you think of the rule for lacerations that says a laceration has to be sutured within six hours or it cannot be sutured at all? At our facility, we send lots of inmates to the ER for simple cuts because the PA isn’t scheduled to be at the facility until the next day. If a cut is 10 hours old, why can’t it be fixed?  Where did this rule come from?
Kim A.

Thanks for the question, Kim. The short answer to this question is that that this belief is a myth. Uncomplicated lacerations can, indeed, wait more than 6 hours to be repaired.

“There is a common misconception that all wounds must be either sutured within a few hours or left open and relegated to slow healing and an unsightly scar.”  Roberts and Hedges’ Clinical Procedures in Emergency MedicineUnknown

Continue reading

The M-Word–Malingering

I went to the always excellent NCCHC spring convention in Nashville last month. One of the many outstanding presentations was done by frequent lecturer Deana Johnson. Deana talked about the risks of using the word “malingering.” Her basic message was to be very careful about saying that an inmate is malingering—in fact, perhaps we should never use that word.

I was surprised by the degree of spirited disagreement from several members of the audience. They pointed out that “malingering” has a specific medical meaning and sometimes—even often—it is an appropriate medical diagnosis. They pointed out that malingering is listed as an official diagnosis in DSM-5 and that outside medical agencies, like mental hospitals, use the term malingering. If we can’t say that an inmate who is clearly faking is malingering, what are we supposed to say?

Today in Jail Medicine, I am going to tackle the term malingering. It turns out that there is indeed a correct and proper way to use the term malingering in correctional medical practice—but it is tricky and most often (in my experience) done incorrectly, with resultant bad consequences.

There are three important reasons for this. First, most people have an inaccurate idea of what malingering actually means in a medical sense and so use the term inaccurately. Second, the use of the term “malingering” also carries with it an emotional definition that MUST be taken into account when it is used in a medical document. Finally, use of the term “malingering” has important consequences for patient relations, patient behavior and time management.

The bottom line, in my opinion, is that “malingering” is a term that should very rarely be used in correctional medicine. There are better and more precise ways to convey medical information. But if you do absolutely want to use the term “malingering,” you need to know how to use the term correctly. Continue reading