Tag Archives: Jeffrey Keller

You Need a Plan for Corona virus in your Facility

Unless you’ve been living under a rock, you have been hearing about the threat of a Corona virus pandemic. Every day, the evening news anchor breathlessly gives an update of the number of new cases, the number of new countries affected and the number of new deaths.  You probably already know that this disease was originally found in China.  What you may not know (but you should if you work in corrections) is that Chinese prisons were especially hard hit.  This disease spreads most rapidly where people are enclosed together, like nursing homes, cruise ships and prisons.  If this disease gets a foothold in the United States, correctional institutions are likely to suffer. 

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The Rules for Treating Benzodiazepine Withdrawal

Patients are dying in correctional facilities from benzodiazepine withdrawal!  This is not just a theoretical observation; this really is happening. This fact bothers me since benzo withdrawal deaths are preventable.  Benzodiazepine withdrawal is easy to treat!  It is certainly easier to treat benzo withdrawal than the other two potentially deadly withdrawal states, alcohol and opioids.   By far, the most common cause of benzodiazepine deaths is, of course, not treating it!    

So, is your facility at risk to have a patient die of benzodiazepine withdrawal?  To find out, compare your policies to the following Rules for the Treatment of Benzodiazepine Withdrawal.             

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How Can You Violate the Hippocratic Oath by Providing Medical Care to the Needy?

Five months ago, the Journal of the American Medical Association (JAMA) published an editorial entitled “Can Physicians Work in US Immigration Detention Facilities While Upholding Their Hippocratic Oath?”  (Spiegel, Kass and Rubenstein, JAMA online August 30, 2019). This article generated a lot of interest and comment in the lay press. As just one example, NBC News wrote “Medical care for detained migrants violates doctors’ oath, says physician in JAMA commentary.”

Who’s going to provide medical care for these people?
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Gabapentin for Musculoskeletal Pain?

At one of my recent jail medical clinics, three patients in a row requested prescriptions for gabapentin.  One was a patient newly arrived from the Idaho Department of Corrections to be housed at my jail due to prison overcrowding.  He had already been prescribed gabapentin at the prison for complaints of low back pain radiating to one leg and wanted me to continue it–forever.  The second patient was prescribed gabapentin by his outside practitioner for a boxer’s fracture that had been surgically repaired years ago.  The third was prescribed gabapentin at a previous jail due to “nerve damage” from an old gunshot wound to the upper arm (he had a large scar but no functional disability or decreased sensation).

Gabapentin prescriptions for nonspecific musculoskeletal pain have clearly become common in the community and in corrections.  These three patients represent only a fraction of the similar cases I see in my jails! I suspect that this gabapentin-mania is being driven by a belief that gabapentin is preferable to prescribing narcotics (though I would not think any of the three patients above would be candidates for narcotics).  Gabapentin, in fact, is often prescribed for musculoskeletal pain in my community first line—before NSAIDS and Tylenol, even—and many, like these three patients, subsequently believe that gabapentin is something they will need to take for the rest of their lives. 

The problem is that prescribing gabapentin for musculoskeletal pain is not evidence-based and (in my opinion) bad medicine.

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Oral Testing of Reported Penicillin Allergies?

Penicillin is miraculous.  It was discovered in 1928 by Alexander Fleming (founding the modern era of antibiotic medicine) and is still the most common antibiotic prescribed in my jails.  The dentist and I use Penicillin VK as our preferred initial agent for dental infections.  I prescribe PCN VK, as well, for strep throats.  I use amoxicillin occasionally for sinus infections and UTIs and even amoxicillin/clavulanate (Augmentin) occasionally. 

Because penicillin is so useful (and inexpensive), I hate to hear the words “I’m allergic to penicillin.” If a patient with a dental infection can’t take penicillin, for example, the dentist commonly prescribes clindamycin, which is expensive, a pain to administer three times a day and has potentially bad side effects.  I have seen more than one patient who developed C. difficile after getting a broad-spectrum antibiotic because of a reported penicillin allergy–probably unnecessarily!

This problem is pretty common since about 10% of the adult population will report a penicillin allergy.  However, research has shown that, when tested, more than 90-95% of patients who state that they have a penicillin allergy really do not. These patients can be harmed by giving them an inferior antibiotic more likely to cause them harm than plain old penicillin.

The test most commonly used to gauge true allergic status is Penicillin Skin Testing (PST). No jail or prison that I know of does skin prick tests.  We also don’t refer patients reporting penicillin allergy to an allergist for testing.  We just groan and prescribe an inferior antibiotic. 

However, this could potentially change based on research published this year on the safety and efficacy of “Direct Challenge” penicillin allergy testing.  Direct challenge means giving a low-risk (this is important) patient an oral dose of whatever penicillin you want to prescribe and observing them for an hour for an allergic reaction. This has been done in studies and has been reported to be safe and effective.

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Reducing NSAID Use PLUS NSAID Prescribing Guideline

Through many years of experience in correctional medicine, I occasionally have come up with a speech or dialogue that works especially well with patients; a speech which I then use over and over again. One of these speeches is one I use to get patients to take fewer NSAIDs.

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Prescribing Without an Exam?

The State Board of Medicine in my home state recently sent out a bulletin about the practice of “friendly prescribing” to people who the practitioner has not examined.  For example, a friend might call me and say something like “I have a sore throat.  Will you call me in a prescription for antibiotics?”  I’m sure that almost everyone who has practiced medicine has received such phone calls!  The Board of Medicine was concerned about this. They went so far as to to condemn as unethical the practice of issuing such prescriptions without ever examining the patient or documenting the encounter.

In my opinion, this applies to correctional physicians prescribing to new inmates they have never seen, as well.

Examining a patient through the phone.
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When Should Medical Clearance Be Done? PLUS Sample Guideline!

When arresting officers arrive with their charges at a certain large urban jail, the first person they see when they come through the doors is a nurse. The nurse quickly evaluates the arrested person to determine whether a medical clearance is needed before the person can be booked. If a clearance is needed, the arresting officer has to transport the prisoner to a local ER and then return with the medical clearance in hand.

One evening (so the story goes), an arresting officer arrives at the jail bodily dragging a prisoner through the pre-book door by the backseat of his pants and coat. “This guy’s an a**hole,” the officer says. “He won’t do anything I ask. He just ignores me.” He then dumps the prisoner on the floor. The nurse kneels down by the prisoner briefly, looks up and says, “That’s because he’s dead!”

Medical clearances are a hugely important and often neglected part of the jail medical process.

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Words Matter. “Inmate” or “Patient?”

Words matter.  What we write about our patients in our medical notes to a great degree reflects how we feel about them. Our words also mold our future relationship with our patients. One good example cited by Jayshil Patel, MD in a recent JAMA editorial (found here) is the common phrase “the patient was a poor historian.” There may be many reasons why a patient is not able to answer our questions well, such as dementia, delirium or psychosis.  In fact, the inability to present a cogent narrative usually is an important symptom of an underlying condition.  “Poor historian” does not reflect this fact.  To the contrary, “poor historian” implies that the patient is at fault for my poor documentation, not me!  “Poor historian” leaves out that there are other ways for me to get a medical history (medical records, talking to family, etc).  “Poor historian” also implies that the patient was deliberately not cooperative—even though perhaps I spent maybe two minutes attempting to get a history.

Many other common medical phrases also subtly disparage patients. Two good examples are the words “denies” and “admits” as in: “The patient denies drinking” or “the patient admits to IV heroin use.”  The implication of these words is that we are engaged in something akin to a hostile cross examination where I forced the patient to “admit” (against their will) to drinking and I really don’t believe the patient who “denies drug use.” Words guide how we think about our patients, even if on a subconscious basis.    When I use these words, I am saying that my patient and I are not on the same team.

In corrections, perhaps the single best example of a word that negatively influences our relationship with our patients is “inmate.”

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Do You Understand the Requirements for Multiple DEA Licenses?

I have found that many correctional practitioners, especially in jails, do not understand the license requirements of the federal Drug Enforcement Agency (DEA) and, as a result, do not have all of the DEA licenses that they are legally obligated to obtain. 

Take, for example, a correctional physician that we will call Dr. K who is employed full time a a large urban jail and has had a DEA license for that jail for many years.  On the side, she also provides medical services to three other smaller jails, where she does clinics once a week. The question is whether her one DEA license covers her activities at the other jails.  Dr. K has always thought that she only needs one DEA license—just like she only needs one Driver’s License—and it will cover all of her activities. 

But the real answer is, “No,” Dr. K is not in compliance with DEA regulations.

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