I learned about Bounce-Backs back in my Emergency Medicine days. A bounce-back is a patient who you saw in the ER and discharged but then returned within 48 hours with the same complaint. A lot of time is spent in emergency medicine education talking about how to handle bounce-backs. The basic message is “Beware! You may have missed an important diagnosis the first time!”
Bounce-backs happen in correctional medicine, too. Bounce-backs can happen in jails, where we often deal with new patients who we do not know well, but also in prisons, when patients we do know well have a new complaint. Just like in emergency medicine, a bounce-back in a jail or a prison is a patient who comes to the medical clinic with a new complaint, receives a diagnosis and treatment and then re-kites for the same complaint within a couple of days. Here are a couple of examples.
When Covid-19 burst onto the scene three months ago, the jail administrators and the medical teams in my jails initiated several common sense practices to reduce the possibility of Covid infiltrating the jails. These included screening and quarantining new inmates before allowing them into the dorms, screening jail employees daily, doing lots of Covid tests and, perhaps most importantly, having deputies wear masks at work. The good news is that, so far, there have been no cases of Covid-19 in any of my jails (knock on wood here).
However, there seems to be growing evidence of “Covid
Fatigue” in my community. When I go out
in public, I am one of the very few still wearing a mask. And this is unfortunately spilling over to
the correctional facilities. I did a
clinic at one of my smaller jails this week and was surprised and dismayed to
see that the deputies were no longer wearing masks. In the meantime, Community Covid cases are
climbing, so the risk of transmitting Covid to the jail is actually greater
than it was, say, a month ago.
I am seeing a 52-year-old male in my jail medical clinic who
was booked yesterday on a felony DUI charge.
He says he drinks “a lot of beer” but denies having a drinking problem. He is cranky and not really cooperative. He does not want to be here. However, the deputies tell me that he did not
sleep much last night and did not eat breakfast. I note that he has a mild hand tremor and a
heart rate of 108. According to the
clinical Institute Withdrawal Assessment for Alcohol–revised version (the most
common tool used in the United States to assess the severity of alcohol
withdrawal since 1989) my patient needs no treatment for alcohol withdrawal. But this is wrong! In actuality, my patient is experiencing
moderate withdrawal and should be treated immediately and aggressively.
Using CIWA is like
using a wrench to pound in a nail. It
can be done, but it is not really efficient or accurate. A different tool (a hammer) could drive the nail
much more quickly and effectively. CIWA is simply not the right tool to assess
alcohol withdrawal. We should be using
I recently published the official position paper of the American College of Correctional Physicians (ACCP) on the treatment of Hepatitis C in incarcerated patients (found here). However, some state legislatures (and others who which authorize funds for inmate medical care), have been reluctant to fully fund Hepatitis C treatment. Because of this, ACCP has formally approved the following Position Paper to encourage full funding of HepC treatment among incarcerated inmates.
“We’ve got another one,” My nurse told me on the phone. “He
says he was exposed to Covid.”
Ever since Covid-19 came to my town, many people being
arrested have begun to say that they have Covid or have been exposed; the
thought being that “If I have Covid, they can’t put me in jail.” Of course, it doesn’t work that way. They go to jail anyway.
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.
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.
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.