The recent suicide of Jeffrey Epstein while in custody at a Manhattan detention facility has focused intense media scrutiny into jail suicide prevention procedures. Suicide is the biggest cause of death in jails in the United States—by far. Because of this, all jails (including the facility where Mr. Epstein was housed) have a suicide prevention policy. Since the suicide prevention process was an epic failure at the facility where Mr. Epstein was housed, it might be useful to discuss how a jail suicide prevention program is supposed to work.Continue reading
I will be meeting a new jail patient with multiple medical problems today in my clinic. I know this much before I even meet him: He will almost certainly be scared, especially if this is the first time he has ever been to jail. He will likely be suspicious of me. He may even be downright hostile. I know this because this is the norm for correctional medicine. I can’t be an effective doctor unless I can turn this attitude around.
Consider the situation from my patient’s perspective. Prior to seeing me, he was arrested, handcuffed and driven to jail in a police car. Once at the jail, he was thoroughly searched (spread-eagle against the wall), fingerprinted and had his “mug shot” taken. His clothes were taken away and he was given old jail clothes (including used underwear). He was placed in a concrete cell. Now he is summoned by a correctional deputy and told (not asked) to go to the medical clinic.
He did not choose me to be his doctor. Though he doesn’t know anything about me, he has no choice but to see me for his medical care. Not only did he did not choose me; he cannot fire me or see anyone else. He may fear that I am not a competent doctor; otherwise why would I be practicing in a jail?
This is the attitude that I have to overcome. How to do this is an essential skill for correctional practitioners. And, of course, the single most important encounter is the first one. A negative first impression is hard to overcome–and I am already starting out at a disadvantage. What I have to do in only a few minutes is convince my patient that I am a legitimate medical doctor and that I care about him. I have learned in many years of doing this that these things are essential:Continue reading
Perhaps the strangest aspect of practicing medicine in a jail or prison is “comfort requests.” This is when an inmate comes to the medical practitioner asking for something like a second mattress, the right to wear their own shoes, a second pillow, a second blanket, etc. This, of course, never happens in an outside medical practice. When was the last time you heard of a patient asking for a prescription for a pillow? Yet such requests are extremely common in correctional medicine. You might think, “Well, just give them the second pillow—what harm can it cause?” But it is not that simple. Like every medical issue, there is a right way and a wrong way to handle these requests. To understand why, let’s consider the single most commonly requested comfort item in a correctional medical clinic: a second mattress.Continue reading
I work at a prison and your blog has been such a resource for our unique niche of medicine. There’s nothing like practicing “behind the walls!” . . .
Recently I’ve been incorporating more conversations about functionality and short-term/long-term goals and visits are mostly positive. However, there are the difficult patients . . . wanting to bargain “well if you’re not going to do anything, can I have an extra mat?” Or “Can I have a bottom floor restriction?” “Transfer me then!” “Give me insoles.” …and other requests like this. How do you recommend I come to an agreement with these patients that are difficult to have conversations with? . . . If by the end of the appointment we do not come to some sort of agreement, they end up right back in sick call with the same complaint. Then the cycle repeats. KR
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.Continue reading
One thing I look forward to each day is looking through my medical feeds that keep me up to date with medical research. Most of this content ranges from bogus to unhelpful (in my opinion), but every once in a while, a truly game-changing article appears. Over the years, I have noticed that most of the game changing articles are debunking articles. They show that something that is commonly done in medicine actually has no value. I love these! Not only do they improve the medical care of my patients, they also make me more cost-effective. As I have said before, the main way to save money in Correctional Medicine is to eliminate (and stop paying for) medical practices that have no value—or even worse, are harmful to patients.Continue reading
My last post about MAT in jails generated a lot of excellent responses–so many, in fact, that I realized that my discussion of MAT in jails was incomplete. I would like to enlarge the discussion about the proper role of MAT in jails by responding to these comments. Before I do, I want to make sure that we are all looking at the issue from the same perspective. Please consider how MAT should be used in three different jails.READ MORE
NP here….What are your thoughts on shoulder dislocations? Does an anterior dislocation require immediate reduction? What if they go out to ED and come back dislocated again? It is thought that these offenders dislocate on purpose in order to go on a field trip. I have heard that anterior dislocations do not need to be reduced as they do not cause neurovascular problems. What has been your experience? Thought? Thank you for your time!
Great topic! You have asked two questions here. The first question is whether shoulder dislocations need to be reduced immediately (since transporting a jail patient to the ER after hours can be a hassle) or whether the dislocation can wait until the next day to be reduced. The second questions is how to handle those patients who can dislocate and relocate their shoulders at will, and will use this trick to manipulate both the jail and ER staff.Continue reading
Hi Dr Keller,
I work in the prison system in the UK. I wanted to ask you if the prisoners have in-possession medication in America or is it all supervised?
If you do have in-possession medication, have you seen or thought of a way for the inmates to keep the medication safe i.e. lock box in their room (this then highlights a security issues as can store contraband etc. in lock boxes? Is there a feasible and reasonable way that inmates who want to keep their tradable medication to them self and not fear being bullied by peers for them?
Any ideas would be greatly appreciated!
After doing research in my current jail. The percentage of people who actually pass random meds check is currently 18%. Now obviously not all those that failed had them “pinched” from their possession and most certainly commonly abused meds such as trazadone and mirtazapine have been sold as “sleepers” on the wings. But for those people who genuinely get bullied for their medication or do in fact get them stolen what is the alternative measure to help them apart from to put them not in-possession and supervise them daily?
If you have any ideas I would greatly appreciate it.
Thanks for the questions Dez! In the United States, most medications are passed in a supervised setting. “In-possession” medications are referred to as “KOP,” which stands for “Keep on Person.” I’m going to use this term despite the fact that not all KOP meds are kept on person. Different facilities handle KOP medications in different ways, which I’ll get into. Here are the basics of KOP medications:Continue reading