Jeffrey E. Keller is a Board Certified Emergency Physician with 25 years of emergency medicine practice experience before moving full time into his “true calling” of Correctional Medicine. He is the Medical Director of Badger Medical, which provides medical services to several jails and juvenile facilities in Idaho.
Jeffrey E. Keller is a Board Certified Emergency Physician with 25 years of emergency medicine practice experience before moving full time into his “true calling” of Correctional Medicine. He is the Medical Director of Badger Medical, which provides medical services to several jails and juvenile facilities in Idaho.
Sharen Barboza is a licensed clinical psychologist who has worked in the field of correctional mental health for over 20 years. She is a monitor, consultant, trainer and speaker with expertise in mental health, crisis management, self-injury reduction and trauma-informed care. Dr. Barboza provides workshops on stress management and self-care for custody and healthcare staff. She has published research related to suicide risk factors, dementia, interventions in restrictive housing and reducing self-injury. She holds a master’s degree in Experimental Psychology from Tufts University; a Ph.D. in Clinical Psychology from Fairleigh Dickinson University and she is certified in Wholebeing Positive Psychology.
Dr. Barboza is available for consultation related to the development, provision and evaluation of mental health services in correctional settings as well as staff emotional wellness. Send inquiries to sharen@sharenbarboza.com.
This is a wonderful idea..I hope we get followers from other jails and see how they do things..Lisa, RN
My name is David Garlock and I am working in PA to create parole eligibility for Geriatric individuals in our prisons. Would love to see if you have done any research or articles about our growing elderly prison population.
David Garlock
Thanks Lisa! I also look forward to the exchange of ideas (which sometimes begins “That piece you just wrote is crap!”) Should be fun!
Dr. Keller:
I am a lawyer in Georgia, and you were recommended to me by Dr. Lawrence Mendel in Ohio, who has consulted for me on many cases over the past 10 years. He is no longer practicing correctional medicine and I need someone who is. Can you give me a call on my cell at your convenience?
Craig T. Jones
678-643-0062
Suggest he consider viewing the Expert Witness section on the ACCP web.
http://www.accpmed.org
congrats on this site! thanks for the info, would not expect any less from you, Jeff!!!!
Thanks, Deb!
Would you please tell me where the in depth diabetes management article is? I can no longer find it.
Hello Dr. Keller,
Jail house nurse here and aspiring correctional NP. I saw your article on Med Page elaborating on inmate manipulation. This is something those new to correctional health care don’t yet understand and when i explain to them these same tactics they label me “Nurse Ratchet” I’m already devouring your blog. Thank you so much for your commentary on the field,
All the best,
Nurse Ratchet.
Thank you for the kind words, Amanda!
Excellent information and of course written with your usual wit and humor! I will highly recommend the blog to the DOC contract providers. Thanks, Jeff!
Thanks Rona! Your approval means a lot to me!
Dr. Keller –
I’d love to see what other prisons are doing regarding the use of neurontin.
Tom Moore, MD
Medical Director
South Carolina Department of Corrections
Thanks, Tom! Like you, I have noticed that Neuronitn is one of those drugs that inmates like and that has value in the correctional black market. The question is whether the therapeutic benefits of Neurontin outweigh these problems. It is interesting that Pfizer, the maker of Neurontin, was fined 430 MILLION dollars for inappropriate marketing Neurontin for off-label uses. And that is basically the only way we use Neurontin in corrections–for off-label uses!
We have taken neurontin completely off formulary, with very occasional exception for documented diabetic neuropathy. they know it is futile to ask for it.
I just got started in Correctional Medicine 6 weeks ago, and I’m already telling inmates and staff that we’re not going to be using neurontoin in ‘my’ jails (as a general rule). I’m just trying to find alternatives. Too much abuse.
Very interesting JK.. Proud to be one of your badger nurses….
Hi Jeff – did you see this? Thought of your blog when I read it today
http://www.latimes.com/health/boostershots/la-heb-prison-health-20120419,0,288713.story
Take care,
Katie Clark
Great article Katie! Is it a Federal mandate that all inmates be offered at least 2500 calories a day? Where did that number come from?
Love your site. I was wondering if you have heard that checking an inmates mouth after receiving their medication is considered a body cavity search and not a legal procedure? I have been hearing this alot from the new officers who have recently completed training.
I do not believe that is true–I mean that looking into mouths is a body cavity search. For that to be the case, a court would have to render such an opinion. I certainly have never heard of such a court ruling. Can your officers give you the legal reference? If so, I am interested.
Great blog! I look forward to your posts. You have an excellent approach re: medicine in corrections. Your advice is also relevant to us in Canada.
I know that in our jails in Canada, many inmates request polysporin/neosporin as the “cure all” for skin conditions. As doctors and nurses we have to be cautious when administered what might seem to be “begnin” ointments to our patients. I thought that you might find this article interesting!.
http://vitals.msnbc.msn.com/_news/2012/06/06/12091723-prisoners-using-antibiotic-ointment-as-hair-gel-why-thats-worrisome?lite
Great article Jennifer! Thanks.
Hello Dr. Keller
I just discovered your blog. I truly enjoy it! Thank you
Correctional Medicine is my latest career pursuit (I have practiced physical therapy in virtually every treatment setting. I will be practicing in soon in a large state corrections facility in California,
In reviewing your past issues I was struck by the similarities between CM and workers compensation (an area of focus in my career both as a clinician and peer review expert).
Most notably, are the similarities re: secondary gain and maladaptive behavior among “patients” (CM) versus “clients” (outside world). I look forward to reading and posting comments in future issues. Continued success and best regards.
David, Physical Therapist
Thanks David!
This reply is to David. I am a practicing PT working full time in the Minnesota Correctional facility for the last 18 years. I just found this blog as Dr. Keller is now one of my medical supervisors. I am reaching out to you as in reality- there is very little help/resources for we Correctional Physical Therapy. I have worked in all of correctional facilities which range from Geriatrics, acute care, Boot Camp, women patient, and obviously outpatient Ortho. I would be more than interested in communicating/discussion any correctional PT issues you may have. I would be interested to hear how other states provide PT. Feel free to contact me: dhaugland@centurionofmn.com
best regards,
Darin Haugland PT
Hello Dr. Keller,
I am an Acute Care NP that has just started working my first job in correctional medicine. I have a background in trauma as well as internal medicine private practice. I stumbled upon your site and love it! I work in a prison and have been shocked at the amount of illegal prescription drug use among inmates. Opiates, as well as Suboxone, seem to be readily available and abused. I have had multiple inmates that are using both of these IV. I am trying to prepare a presentation for our providers regarding the use of these drugs, statistics of use while incarcerated, acute/sub-acute opiate withdrawal in prisoners, etc. Can you please tell me of any resources I can find some of this information? Most of everything I come across is dealing with jails as opposed to prisons. Our guys have already been in the system for awhile, so we are not dealing with everyday acute “straight off the street” opiate addiction/withdrawal. Any information would be greatly appreciated. I have been told, that with time, I will not be as shocked at some of the things I have started seeing on a daily basis. I would like to be able to give all of us providers at our facility, a little information on signs and symptoms to look for as well as potential complications. Again, thank you so much for this site, it is wonderful!
Nancy CRNP
Hi Nancy,
Unfortunately, there are few clinical resources available for the practitioner of Correctional Medicine, especially compared to other medical specialties–such as Emergency medicine. That is one reason I started this blog! I work in jails, not prisons, so I admit that my blog has a jail bent. In your case, I assume that the opiates are being smuggled into the system and not prescribed. I also assume that this means that inmates who are purchasing the black market opiates will not have a steady, regular supply. This would mean that the inmates will not likely go through serious opiate withdrawal and will likely need no treatment. Treating addiction is something I know very little about. I leave that to my mental health colleagues.
Thanks for the kind words!
Thank you for sharing your wisdom and experience. I thoroughly enjoy your weekly posts and frequently refer to your articles for guidance.
I am currently researching prison rape and would like to know your thoughts and/or policies on medical/nursing care following such events. We have difficulty providing adequate care in our facility as offenders who report sexual abuse are often segregated (by security) after examination. Have you found measures to avoid this or at least insulate the victim?
Susan, RN
Jeff-thanks for your insights-they are hard to find in this line of work. I currently cover 2 county jails and one juvi unit. How do you evaluate female inmates with problems “down there”. The idea of treating women on the basis of symptoms, in my experience, does not work. That leaves me with a lot of pelvic exams-often helpful but not often diagnostic. After a search for the obvious (herpes, yeast, foreign body and adnexal tenderness) I am left with a “sniff test” for BV and the question of Trich vs GC vs Chlamydia is still unresolved. The price of NAAT puts that option out of our league and Clia requires a different certificate for Microscopy. How do you handle this? Thanks, Mark
Reply via email, Mark!
Mark,
I’m impressed that you even do pelvic exams. I just started in Correctional Medicine and inherited 5 jails. 2 of those have medical areas too small for an exam table, and in another we haven’t got speculums yet. I think that in the past these patients have either been treated empirically or sent out for an exam.
I had a patient in residency who developed Stevens-Johnson from Flagyl (prescribed over the phone without an exam) so I’m not comfotable prescribing based on symptoms.
Fortunately for me, the particular patient I wanted to examine got out fairly quickly, but I’d like to know what you ended up doing so I’m prepared in the future.
Thanks for the comment Jennie! Often, we have to make do with what we have, especially in older facilities. I myself have had to do medical clinics in some odd places!
I am wondering how do other facilities handle inmates who hoard medications. We normally have a no tolerance policy except for medically necessary meds (HTN, diabetes, etc). Lately our providers seem to be giving our inmates “second chance” and continuing the medications. Our nursing staff are becoming frustrated as we put forth extra effort to assure the inmates actually take their medications receiving lots of grief on a daily basis when asked to see their mouths, under their tongue, and in the cup in their hand. Inmates who hoard are referred to the disciplinary commitee but this does not seem to really bother the inmates as it is “just another write up”. Please advise.
Thanks, Cheralee! In order for med pass to work, the detention deputies have to be present and enforce the rules of med pass. These include lining up properly, wear proper attire (no coming to med cart bare-chested, for example), approaching the med cart one at a time, no “chit-chatting,” and showing your mouth appropriately after getting pills. If the inmates are giving you grief on a daily basis, it is because the deputies accompanying you are not doing their job enforcing facility rules. Don’t put up with it! Ask for a meeting with the sergeants or even higher to discuss the problem. That will work. It has when we have had similar problems in my facilities.
As far as the “cheekers,” I will sometimes give inmates a second chance, usually with meds that I want them to continue. We sometimes crush meds of those given a second chance, for awhile at least. The problem is continuing meds that are, well, a problem–the ones with high value in the facility, like gabapentin, trazodone etc. Continuing them tells inmates that it is OK to try to game the system–if you get caught, the practitioners will just continue the med anyway. There has to be some sort of adverse consequence to getting caught cheeking. The deputies should enforce their rules, but the practitioners can also impose appropriate consequences for medication misuse.
Dr. Keller: I enjoy reading the information you post on your blog. I have looked back over the archives and can’t find anything you have addressed about the use of ammonia capsules. In our jail facilitiies, it appears they are a popular “therapeutic” tool to determine “faking” seizure, syncopal episodes and etc. I am concerned about using them and would like to hear your thoughts about the use of ammonia capsules.
I actually am a big fan of ammonia capsules–properly used! Blog article on the subject coming soon!
Dr. Keller,
Your blog has ultimately made my decision on what I want to do my upper-level research paper on for my last year of law school. I work in medical malpractice now and I also work in Mental Health Court- and I work at a pharmacy on the weekends. I wanted to do something…different, and I felt correctional medicine was the way to go. I am currently narrowing down topics for my paper and deciding organization. Is there any literature, published books- anything- that you would be willing to point me to to help further my legal medical research and understanding? Or anything that you feel needs addressing in the correctional medical realm (I know that is probably extremely broad!)?
Without this blog, I would probably be writing about something boring and draining. So thanks for taking the time to write such an amazing blog. You should write a book.
Best-
Sarah
Dr. Keller,
Please send me a copy of your acne protocol; I’m a Family Nurse Practitioner at a juvenile correctional facility and any protocol would be handy.
I love this site. It makes me feel not so alone in my field of work.
Thanks,
Todd H.
Done, Todd. Let me know if you have any questions!
Dr. Keller,
Curious to see how other jails/prison handle fasting during Ramadan. We only KOP inhalers and creams at my facility and have no medical commissary. We do a very early medication pass for those who are fasting, but it does cause occasional problems with the management of diabetics and some other chronically ill patients. How do other facilities handle this?
Thanks,
Jill
Ramadan is not a problem in my jails, since we have essentially no Muslims. I will put the question on the blog and we will see what kind of response we get!
Is there some kind of course preparing MD to be director of a correction facility. Like a county Jail ?
I am thinking about applying for medical directorship in the jail that AI am currently working at. Any suggestion to prepare me for theat venture ? I am interested in some kind of academic or didactic course if that is available on the market. I attended the jail med symposium at Utah 11/2012 and looking forwrd to atending the 2/1014 conference..
The best resource, Than, would be to go to the Medical Director’s course put on every summer in July by NCCHC!
Dr. Keller,
I am looking for something to present to my jail staff regarding DT’. Something like a powerpoint and something that does not get too “medical” for them. Any ideas?
Hi Patrick,
I am unaware of anything like that right now, but coincidentally, I am working right now on a training course for detention deputies/correctional officers on what they need to know about medical issues. It includes alcohol withdrawal (and DTs). I’ll try to remember to let you know when I have the PowerPoint developed!
Hey Jeff,
Like you I am an ER doc and am the Medical director of a 550 bed jail. I would like you thoughts on body cavity searches. We had a case last week where an inmate was seen putting a baggy in his rectum. A search warrant was issued and the inmate was sent to the ER for a body cavity search. The inmate refused to let the ER personal touch him. He told the ER doc that it was a baggy of tobacco. The ER observed him for several hours and sent him back to the jail. No cavity search was done. The ER doc felt she would have to sedate the inmate to do the search and felt uncomfortable doing this against his will. The NCCHC frowns on the jail medical providers doing evidence related procedures or searches. My policy is to do the searches if the inmate will sign an informed consent and allow it to be done. If the inmate were to have a complication of sedation or the removal procedure that was done against his will, I would think a malpractice claim could be supported. How do you handle these types of situations in your Jail?
Thanks,
BJF
Hi Dr Keller,
I want to say it’s great to be reading your blog from the other side of the world (i.e. Hong Kong).
Here’s a real-life patient I’d like to seek your and the readers’ opinion.
Facts are: (1) Tramadol is not available in the formulary of my practice. It is only available in tertiary medical centers, such as the emergency department for a short period of time say a week, (2) Tramadol has “values” in the black market according to the correctional staff.
This is a 50-year-old male heroin addict who complains of a left nipple swelling for two months. It’s not growing and clinically it’s not an abscess. A surgical consult has been arranged. I have been giving him paracetamol and NSAID for his claim of pain over his nipple swelling. Now he insists on getting Tramadol for pain relief since my analgesic cocktail of paracetamol and NSAID is not working. This means having correctional staff escorting him to the emergency department for a prescription of Tramadol. What should I do?
Hi Arthur! This is pretty easy in my mind. No Tramadol. Tramadol comes as close to being a banned substance in my jails as there is. I have written about Tramadol here. I don’t think it has any redeeming features. 1. It is addictive and, of course, abusable. 2. In studies, it has consistently been shown to be a poor pain reliever. In my opinion, it should be thought of as a narcotic, and since it is less effective than hydrocodone (but just as abusable), hydrocodone or some other effective narcotic should be used when we need a narcotic–for example, after surgery. So no Tramadol for this guy.
I also think there is a good chance that he is causing his own nipple swelling. It is pretty easy to do this simply by squeezing the nipple repetitively. Hormonal problems (think pituitary adenoma or testicular cancer) would affect both nipples equally. Breast cancer can occur in men, but usually presents as a discrete painless mass.
Hi Dr. Keller,
I am in charge of creating a protocol that would support our medical directors choice to disconintue Methadone/Suboxone when inmates are brought to our county jail. I have been compiling information to support “for” and “against” and now need to write the protocol to cover ourselves. Could you share some tips on what to include in the protocol for not using these medications….Thank you in advance for your time.
I started as a psychologist in prison recently, and have been learning a lot – thank you so much for this blog. I just found it and I’m looking forward to reading and learning, as I’m trying to get up to speed working with our psychiatrist.
Dr Keller, Thank you so much for sharing your exeriences. It’s nice to know we are not alone in the correctional field. I was wondering if you could share the protocols you are currently using for detoxing patients from opiates, benzo’s, and alcohol? Thank you so much!
Hi Dr. Keller,
I was hoping I could pick your brain (and those of your readers) for ideas regarding Outcome studies.
We are an NCCHC accredited facility with a population of less than 500 inmates. We are required as part of our accreditation to complete 1 Outcome and 1 Process study annually. Outcome studies are more patient specific and Process studies are more global, referring to the process by which we deliver care.
I don’t usually have problems developing Process Studies, but always seem to get stuck on the Outcome studies. I am wondering if you or your viewers might share any suggestions on topics for Outcome studies or comment on topics they have studied in the past.
Thanks for your help
-Bryan
You are not alone, Bryan! Outcome studies are tough. I’ll write about this soon and we’ll see if we can generate a list of potentials.
Thanks very much
I work at a 175 bed jail facility as one of the four nurses who provide on site medical coverage from 0600 to 2200. Nursing staff are on call at nights. Recently we have had some challenges come up. I am wondering how other facilities handle these situations.
1) Pregnant inmates. They can be difficult to manage in a jail setting with OB appt, appropriate medications, previous OB care, street drug use, etc. Recently we had a pregnant mother who approached an officer stating the baby had not moved in two days. She is 6 mo along and not her first pregnancy. Thankfully a trip to the hospital showed baby was fine. Does anyone have a protocol for managing pregnant inmates?
2) Flu season and fevers. 50 year old female inmate with hx pulmonary issues complaining of flu like symptoms and temp of 105.9 (peers had piled five blankets on top of her because she complained of chills). We treated her with Tamiflu per our medical directors orders and we were able to bring temp down with antipyretic and cooling measures. What are some recommendations when caring for such inmates?
3) Placing IV catheters for acute treatment in jail. For example NTG, hypoglycemia, dehydration. Looking for both pros and cons.
I know this is a lot of information to discuss but it has been just one of those weeks.
Thanks – Cheralee
Doc, have you ever written on the ethics / legal requirements for patients who are unable to consent? I am finding that MD’s permit schizophrenics to refuse care, even in extreme cases…
Hi Bruce, That actually is a quite germane topic. I have indeed written about one aspect of it–emergency sedation.
Hi Dr. Keller,
I’m a health reporter and would love to chat with you about correctional medicine. Can you shoot me an email at mandy.oaklander@gmail.com? Thanks!
email sent!
Came across one of your articles on food allergies, “I Can’t Eat That'” want to develop a policy, possibly state regulation for reported food allergy. Taking you up on your offer for assistance. Any assistance is greatly appreciated.
Dr. Keller,
Do you have any advice on “shaving profiles”. It seems to be a greatly abused and misunderstood area in corrections and in the military too. I am not saying there are not legit cases. I just see few legit cases in corrections. It seems more of a get a secondary gain item than a medical problem and we are inundated with several request a month with a non-existent problem…. this = malingering. As medical staff we cannot write malingering tickets….sigh. That would be punitive. Security doesn’t care enough to bother to help with the ticketing.
Plus our facility barber ask all the kids to request one. Profiles mean every two hair/beard trimmings; which if you are contract that’s billable. Profit drives ignorance! The cycle continues. I’m trying to break it with education and stubbornness.
I’m a Family Nurse Practitioner at a juvenile correctional facility and any protocol/advise would be handy. We (I) issue a profile for: 1). Severe acne and 2). Actual pseudofolliculitis barbae ONLY.
I, again, love this site. Keep up the hard work.
Thanks,
Todd H.
Hi Todd! Unfortunately, I don’t have much help for you with this one, except to say “No” a lot, and to work with admin to eliminate the profit motive for your barber to drive this waste of your time!
Dr. Keller,
I have had three inmates within the last two weeks having Lamictal and Keppra on their person when they were arrested. None of them have ever been prescribed these medications as far as I can tell. ( All three I have evaluated before). I’m thinking they are abusing these medications in some way. Any ideas? It just seems more than a coincidence.
Thanks
I agree with you that it seems suspicious. Gabapentin and Topamax are the two more commonly desired seizure drugs. Maybe this is a new trend!
Dr. Keller,
First of all, thank you for your dedicated service in an area of medicine many medical professionals may not know about. I was happy to find your site and am sure will find this resourceful. As a National Recuiter for the Federal Bureau of Prisons, I communicate with physicians daily and who are passionate about what they do and honestly want to serve or better yet they simply just want to, “Be a Doctor.” Correctional Medicine can certainly provide job satisfaction and a wonderful work/life balance.
My best to you!
Alician “Cissy” Lowery
Thanks, Cissy! My best to you, as well!
I am attempting to write a policy manual for the correctional Center that I work in. I read the article about allergies. would you be able to help me in this?
Thank you for your time.
Steve Brooks
With all the news headlines hovering around Ebola, I thought I would see what other facilities are doing to screen for high risk patients.
Are your facilities asking any pre-booking screening questions for travel in the past month? If so, how would you handle an asymptomatic patient that reports foreign travel to west Africa or major cities (like Dallas)?
The CDC recommends BID temp checks for 21days after their last exposure to an Ebola patient. Would you think this is sufficient or would you do anything additional (i.e. separate housing, special precautions)
Thanks for your thoughts
-Bryan
Hi Brian,
Yes, some jails, especially in bigger cities with direct flights to Western Africa, have added some screening questions to assess risk for Ebola. There are only three categories of patients who are at risk for ebola:
1. Just returned within the last 21 days from travel to specific countries in Western Africa (Sierra Leone, Guinea, Nigeria or whichever other countries are identified by the CDC).
2. Close contact with someone else who returned from these countries in the last 21 days.
3. Acted as a caregiver for someone being actively treated for ebola in this country.
If the answer to all three questions is “NO,” the risk of Ebola is basically zero. If any answer is yes (and I am not aware of any such patients being booked into any correctional facility as of this writing), I would contact my local health department and health department and ask them what to do!
Dr. Keller- Thanks for this wonderful and informative website. I am a resident at Hopkins in Baltimore, and we are working to improve our Urban Violence rotation. Would you be willing to discuss ways we could involve the residents in Corrections Medicine? Thanks
I am a paramedic in Atlanta, Ga and commonly respond to jails and prisons in Atlanta. Unfortunately I do not get to spend much time in these facilities to learn about how health care inside jails and prisons work. how do the capabilities of a jail or prison differ from hospitals? do they provide everything but speciality care? Im sure this differs from facility to facility of course but I was just wondering in general? It seems like a sector of health care that is in the shadows. Thank you
In general, think of your typical jail or prison medical clinic as being equivalent in capability of an urgent care center. some of the larger facilities may have an infirmary, which is more like a general hospital floor.
Thank you for the copious and interesting material you have created and posted here!
I’m a PA in Florida and have an interview coming up in a local county jail. Your posts are helping me gain a glimpse into correctional medicine and hopefully some insight into what to be cognizant of during my interview!
I did EM for 5 years in the past and had the benefit of working with some great doctors who were true logical minimalists… We would say “no” when patients needed a “no”, without hesitation. Many of those doctors are being driven out of emergency medicine and that is why I have moved away from it as well.
I was wondering if you have any advice for me?
Thanks for everything!
Well, Steve, as a former ER doctor myself, I can say that the ER is the best training ground for correctional medicine for the very reasons you mentioned. And, yes, I can understand why there is pressure on ER docs to provide “customer satisfaction” and so may get penalized for saying “No.” Life is very different in corrections. The best way to experience it is to do it! If you have developed some Verbal jujitsu skills in the ER, you should do well in the jail. I suspect that you, like me, will really like it!
Diabetics are often a challenge and create a great deal of ruckus. What would your thoughts be about stopping the use of a ‘Diabetic Commissary’? and maybe even diabetic diet? Provide the information / education and hold the inmate responsible for their own choices…
We currently use a fairly consistent process with diabetic diet / commissary and have such mixed success we can clearly see that those who wish to take care of themselves do (often with glucose meter readings that are consistently below 150) and those who do not don’t – and complain the most that they are not being cared for correctly.
Your thoughts…?
Excellent question, Al. In a nutshell, in my opinion, diabetic diets don’t work. Restricting diabetic choices in the commissary doesn’t work, either. I’ll answer in more detail soon.
Do you have any information on the use of intranasal medication use in the jail setting? It seems like it could be a better way to administer medications to a psychiatric inmate who is a harm to himself or others. It would seem this could be a better practice than trying to give an IM injection in an urgent situation. It also would seem to have a lesser chance of injury to the inmate, medical staff or correctional staff. Any thoughts on this newer type of medication administration and its possible use in the jail setting?
Jeff,
Do you have a protocol for pregnant inmates who are addicted to opiates? The NCCHC is recommending that they be put on either Methadone or Buprenorphine so they don’t withdrawal. What do you do in your facilities?
Thanks,
Bruce
Thanks Bruce. This would be a great topic for an upcoming post. In a nutshell, I do not want pregnant inmates to go through opioid withdrawal, but I prefer that the obstetrician prescribe methadone, buprenorphine or whatever they want rather than me. These are, of course, high risk pregnancies and I want the obstetrician to manage all of the high risk therapies. I have not had a problem coordinating this care with my local obstetricians.
Jeff,
What are your thoughts on using intraosseous IV’s in corrections? I have had several cases of IV drug users with no peripheral access needing IV fluids and had thought about popping in an IO but wonder if that is going too far in the correctional setting.
Bruce
Hi Bruce! IO is definitely going too far in a correctional environment. But I feel your pain about the difficulty of IV access in IV drug users!
We have a contracted OB/Gyn practitioner in our community (we are a small jail – about 100 daily census) who all our OB patients see. We only use methadone as it is cheaper and the half-life is much longer. We have some who choose to wean off all opiates while pregnant and in an environment where they cannot get them.
Thanks Cheralee! Sounds like you have an easy-to-work-with OB! For those pregnant inmates who choose to wean off opiates while pregnant, I assume that you meticulously document that they accept the risk of miscarriage!
That is another nice thing about working closely with our OB – we have good communication with his office staff. They explain the risks so the patient may make an informed decision. This example was a mom who was pregnant with her second child (she delivered the first in prison) and was given the option of rehab or prison. Rehab would not take her while on narcotics so she was really pushing to get off the methadone (even though our provider was reluctant). We do monitor our pregnant women asking them daily about cramping, baby movement, etc as we have had women in the past tell us the baby has not moved in 3 days and now it is an emergency. We hope to get a fetal Doppler at some point to use as needed. One more note – we have sent a RN with patients to the OB apt in the past as our addicted patients are often not honest with our provider asking for more narcotics.
Dear Dr. Jeff,
I found your website when I typed “prison residency” on google and honestly going through it made me very excited. Im thrilled 🙂
Wow,! Correctional Medicine!! an independant field with Its very own formal structured residency training with eventual board certification.
Im Dr.Ganesh, an IMG from Malaysia. I have 2 years work experience in the Emergency Department and another 2 years in General Surgery. My dad
was a prison doctor for 10 years. Ive always been interested in working as a prison doctor.
Is it possible for an IMG such as myself to apply for and join a corrective medicine residency program in the United States?
please advice
dr.ganesh1985@yahoo.com
I am a family practice physician who has accepted a part to e job as a contractor for our county jail. We have a protocol book for correctional medicine for various problems that we face on a daily basis. I am trying to see if there is a protocol that is available for purchase or otherwise that would furnish a look at other protocols as opposed to ours alone. I am new at this and as a family doc I find myself dealing in a jail with a host of psychiatric problems. Thanks Gary White MD
Hi Gary,
There is no published general correctional guideline/protocol book that I am aware of. Various jail, prisons and correctional medicine company have their own guidelines, but I am not aware of any who freely publish.
The NCCHC standards for jails, prisons & juvenile facilities would be a good place to start. There texts that may help: “Essentials of Correctional Nursing” & “Clinical Practice in Correctional Medicine”. By participating in NCCHC’s activities, and conferences as well as becoming certified as a CCHP will go a ling way.
Thanks for the info…Gary
We recently had an inmate who was given intranasal Versed (midazolam) by paramedics for repeated seizures (9 seizures in 20 min). We have also discussed having intranasal Narcan (naloxone) on hand for opioid overdose emergencies. Are any other facilities using either of these products? If so, how is it working for them, what challenges/successes have they had, any policies to share?
Thanks – Cheralee
Hi Cheralee, I know of correctional facilities that have Narcan for emergency use, but injectable Narcan, not the intranasal kind. I’ll send you a general draft protocol that you can modify for your own use.
Dear Dr. Keller:
I am an undergraduate student at University of Colorado Denver. I am hoping to have a group of pre-health students begin to volunteer at various correctional facilities throughout Denver. In what capacity do you think these students can serve and what sorts of issues or topics do you think are important for these students to bring to the inmates and understand for themselves? Any advice for us? Thank you so much!
Hi Chris! Do you already have a jail that has agreed to use volunteers? I am interested! I have not heard of a jail using volunteers before. In what capacity will you be volunteering? Tutors maybe? Anyway, most jails require that everyone entering the facility have a security clearance. Everyone probably will have to have federally mandated PREA training. If you were coming to one of my facilities, I would want to do at least a day long orientation that would include security procedures, rules for interacting with inmates, confidentiality, etc. Please let me know how this works! If it becomes a successful program, I would like to write about it!
Hi Dr. Keller,
I am a third year medical student beginning to plan my fourth year electives. I worked in juvenile corrections before medical school after receiving my social work degree and continue to be interested in the criminal justice system. I was wondering if you knew of any facilities that accepted visiting/rotating medical students, or of any resources/contacts to continue my search. I am particularly interested in women’s health in the prison system and am hoping I can find a rotation focused on that.
Thanks for writing!
Sure, there are lots of jails and prisons willing to accept and mentor medical students. I don’t know about your area, though (Oakland California)? You’ll have to call around and ask–but I bet you can find a place to do a rotation!
Hi Dr. Keller:
Thanks for getting back to me. Would you be interested in looking at my project proposal and providing me some feed back about its feasibility?
In short, we hope to serve as a bridge for jail inmates and access to health information. Under the guidance of a healthcare professional, we would bring in informational pamphlets, brochures, on conditions like diabetes, high blood pressure, detrimental effects of smoking, benefits of exercise, etc. that could normally be found at one’s PCP. We would do this under caveat that we are not making any health care advice. Would I be able to email you about this? Thanks so much!
I’m not sure how involved you become in the financial side of correctional health care…
There are occasional issues that arise regarding the funding of certain circumstances. Most of the issues are fairly straightforward: acute care illness / condition / injury – the jail pays; medically necessary chronic care (DM, HTN, etc.) the jail pays – otherwise not. Care that occurred on the way to jail – not so much either. There are situations – auto accident on the way to jail that requires follow on care… that are different (usually we resolve that referring to who ever was the auto insurer. Recently had a case of an offender who had arranged for ‘free care’ to have a series of procedures… then was arrested. Is the jail obliged to provide ‘funding’ for these situations or just access to care that someone else pays for? Usually one of the criteria is ‘Medical Necessity’. Another concern is ‘pre-existing’ condition.
Thoughts?
Mr. Keller, I would like to know your thoughts on the current heroin epidemic, and the best way to treat withdrawals. Any information you can provide will be greatly appreciated.
Hi Erica! We use clonidine for opioid withdrawal at my jails, and in my experience, it works very well. It is certainly the best option out there for heroin withdrawal in a jail setting. Blog post detailing how I do it coming soon.
Thank you Dr. Keller, I will be anxiously awaiting the blog on your clonidine protocol. We currently use gabapentin and clonidine.
Check out the (Clinical Opiate Withdrawal System (COWS).
Hi Charles! I am not a big fan of COWS. I’ll write a post eventually saying why.
Wow! Very interesting. I’d love to know your thoughts on this. Can you summarize, and post details later.
Dr. Keller will you be putting on the correctional healthcare conference again that you used to do and had here in Salt Lake City? It was a great networking and learning opportunity for those of us who can’t get to the NCCHC conferences.
Dear Dr. Keller,
I am editor of a Medline-indexed journal for emergency medicine physicians, and I ran across your photo of a fight bite on a May 9, 2013 post. I would like to publish the photo in an upcoming issue we are doing on mammalian bites, if you own the rights to the picture. https://www.jailmedicine.com/wp-content/uploads/2013/05/Hand-injury.jpg
Could you kindly let me know if this will be possible? Many thanks for your help!
Recently there was a question as to why the nurses in our jail do not participate in defensive tactics/physical restraints. It seems the nurses are often present when help is needed. From what little info I have found, this is outside of our scope of practice as nurses. I have previous experience working 6 years as a detention officer so this is hard for me not to jump in to help. I have received verbal warning from running in to save the day without security staff present. We do not have policy to cover this subject? So what is it – medical personnel need to participate in these types of training/maneuvers or not?
Well, one consideration is that if it is not in your job description, and you get hurt, you and your employer would not be covered by Workman’s Compensation.
Dr. Keller,
Your website is a repository of knowledge. Do you ever provide expert witness testimony?
Dr. Keller, is there a way I can contact you? My name is Laurie Dansby, Nurse Paralegal at Lewis Brisbois in Dallas, Texas. I am trying to find the best way to find an expert witness in the area of jail medicine for one of our cases. We do represent the defense. You can contact me at the above e-mail or 214-722-7124. You are out of state, but thus far I have been unable to find anyone in this area. I didn’t know if you have a national list or could point me in the right direction. Thank you.
I am too busy to work on your case Laurie. I also do not know of any “Clearing House” for correctional expert witnesses.
Dr. Keller, you mentioned that you might write a post about withdrawal treatment. I have a related question. I would love to know your thoughts on county programs involving Vivitrol shots at discharge for inmates who were addicted before incarceration. The primary decision-making seems to be out of the hands of medical care providers, yet the orders themselves are expected to come from us. Are other people in this situation, does it make them nervous, and what do they do? Anything other than just checking the blood work and writing the order?
Thanks, Laura. It is true that Vivitrol is mandated in some states. It would make me nervous, too, to be ordered to provide medical treatment that perhaps I did not believe in. You should document clearly that you are writing the order per the county or state mandate. By the way, Vivitrol does not have a great evidence base: http://www.nejm.org/doi/full/10.1056/NEJMoa1505409 The effects of Vivitro in preventing relapse are not impressive, especially in the long term.
Great article Jerry; I love this site. I’m new to the Correctional Medicine arena. I find it fascinating.
Best,
Hi Dr Keller. I have run across your website before while searching for anything related to EMS in jails. I am a paramedic at Cook County in Chicago. I have worked in two other smaller jails, but I am finding many more issues here than I ever have before! There does not seem to be any kind of set guidelines or SOP’s for jail/prison paramedics anywhere, and nobody really seems to know what to do with us. We are categorized under nursing staff, expected to respond to emergencies like our counterparts on the streets, but we are not given the proper equipment, medical guidance, or standing orders to do so! Do you know of any resources or have any ideas on this subject? Paramedics can be such an asset at bigger facilities like mine, but we are underutilized and overlooked most of the time! Thanks for your time, and the website is wonderful!
Thanks for the post, Tavi. It all boils down to the rules governing paramedic practice written by your state’s legislature and Boards of Medicine and Nursing. It varies from state to state.
Dr. Keller,
What is a prison pap? The version I heard involved six prison guards, two who had been reported by the prisoner, and a nurse.
Dr. Keller,
What is a prison pap?
Dr. Keller:
I just read your articles on malingering and fairness. Both of them are excellent. Honestly, I think you have the beginning of a handbook that would be very useful reading for all physicians, nurses and jail medical officers who practice in the correctional medicine setting.
Let me know if you are ever in Indiana. I would enjoy taking you to lunch or dinner.
Jim Bleeke
Thanks for the invitation, Jim!
Dr. Keller, I’m the psychologist at the Idaho DOC who was stumbling around, trying to recall why I recognized you. It took me a while to place you, but I wanted to say I’ve been reading and valuing your blog for a number of years now. It was great to meet you in person, even if I made a bit of a mess out of that introduction!
Sincerely,
Wally Campbell
Nice to meet you, too, Wally. And Welcome to Idaho!
Greetings, Doc!
I am enjoying your post and that of the contributors. The facility that I currently work at has had some major issues over the past few years. We are getting better, but we have started something new. My medical director as added critical care paramedics to the mix. We support the nursing cadre in the emergent/critical events. Those events that medics are trained for on the streets. I have noticed that the nurses are not as stressed and overworked when we are on duty. Most of the time we help with vital signs, lab draws EKGs and such. By helping out we take some of the busy work from our nurses to free them up to take care of the inmates. I am curious, what’s your take on Critical Care paramedics in corrections?
Regards
I personally have no problem with paramedics working in a correctional facility, as long as they remain within their scope of practice. It sounds like you are!
I am interested in receiving a copy of your food allergy protocol/ policy. Thank you for your website and the information you share. I used to work in a correctional facility with Dr. Zoran Vukcevic and he always spoke very highly of you and your work.
Hi,
Am a Nurse practitioner working in a prison and enjoyed reading your article on gabapentin. I am curious as to what you think of crush and float gabapentin as a form of reducing diversion and abuse.
Dr. Keller, I have been practicing Correctional Medicine for a few years now. During a recent in-service, our trainer suggested that everyone who “works behind the wire” should carry a concealed revolver to protect themselves and their family members. While his opinion is founded on his life-time involvement with the firearms community, he did give me pause to think about the issue even though I believe in gun control; am afraid of guns and understand that they are more likely to harm a loved one than an intruder. Please share your thoughts about self-protection (not trying to discuss politics of Second Amendment rights) in this line of work where threats inside the walls and stalking outside them are not uncommon.
Thanks for the question, Kelly. I am a “show me the evidence” guy. If you were to purchase a gun, would the odds of you or a family member dying by gunshot go down? Or up?
At the risk of being reactionary; that is ridiculous. Don’t use corrections as a justification to do something you want to do anyway. If you want to get a gun; get one. False Equivalency. Rationalization.
DR. Keller – would you consider a discussion of balancing the autonomy of patient decision making and the risk to the facility for not providing appropriate care.
Examples
1. Individual is on disability but wants to sign a ‘waiver’ of responsibility so he/she can work
2. Diabetic (NIDDM) individual that wants to refuse diet and be place don insulin so he/she can eat what ever they wish
3. Individual with cominutes jaw fracture – cut wires on episode of nausia – now wants regular food despite oral surgeon advising limited jaw movement
Documentation of appropriate exam and advice to the individual is, of course, the foundation of addressing the issue – but do you allow the 100% (physically) disabled person work; allow the diabetic to sign a refusal of the diet & prescribe insulin; give the individual with the broken jaw (who is asking for more hydrocodone) a regular diet?
I believe your expert ability to address these thorny issues will help us all
Great topic Al! Look for it in a future post.
Hello Dr. Keller,
Recently at our facility (mid-sized jail), we have been having more difficulty managing some of our Sickle Cell Disease patients. I am looking for input from you and / or your readers regarding strategies for managing Sickle Cell patients.
The problem as I see it is this: Sickling can be brought on by stressful and/or uncomfortable conditions; temperature variations, hydration issues, and physical or emotional stressful conditions – ALL of which occur routinely in a jail environment.
At my facility, I typically allow for more comfort measures when dealing with my Sickle Cell Disease patients. I give an extra mat and extra blanket for comfort and warmth. I give them a small pitcher to fill with water to encourage good hydration. I start off with Tylenol/Motrin for mild everyday pain. We typically avoid opiates in our facility, but allow for opiate medication when it is believed patients are in moderate discomfort. I keep a close eye on things that would suggest infection – heart rate, temp, decreased SPO2, and when clinically indicated, obtain CBC’s, with retic counts, CMP’s and UA’s.
The problem is that there does not seem to be any firm guidelines that I can find that would indicate when a patient is actually in crisis – when and if they need to go to the hospital. At what point to we send them to the ER or look to admit? Do we go by numbers, and if so, is there a retic count or other lab cut-off for when we need to send the patient out? We obviously would like to minimize unnecessary ER send-outs but do not want to compromise the care of our patients.
As you know, pain is often reported by many of our jail patients, and it is very subjective. We want to believe our patients when they say they are in pain, but much or our patient population are in jail to begin with for being somewhat manipulative or untruthful.
Are there guidelines you use at your facility for managing Sickle Cell Disease and evaluating complaints of acute pain? Any feedback would be greatly appreciated. As always, I love your website and find it extremely useful!
Bryan Davis PA-C
Good question, Bryan! Let’s see what ther readers have to say about this question.
I am curious how you recommend handling breastpumping in jail, continuation of birth control, and maternity care. I would think that female inmates would present unique medical challenges.
Current (Oct. 2017) Alcohol detox article header does not properly link to rest of the article. Please fix – looking forward to the insights. Thank you, GS
Fixed now! Let me know what you think . . .
Dr. Keller,
I am a current first year medical student interested in correctional medicine. I’m hoping you will be willing to shed some light on opportunities you may know of for fourth year rotations and residency programs in correctional facilities. I try to do research on it, but there is minimal information published on correctional medicine, as I know you know well. I want to get extensive exposure in this field, as I have worked in a prison before and believe it is where I would like to practice. Any information you can give me would be helpful!!
Thank you!
Hi Aubrey!
This is great! What help I can give you depends on where your medical school is . . .
JeffK
Thank you Dr. Keller for your insight. I am a nurse practitioner and have worked at a county jail with 650 patients on average for three years. I am curious to how you handle requests for glasses and optometry appointments. Any insight you can give me is greatly appreciated.
Thanks for the question, Rachel. The first thing is to differentiate whether the request is for reading glasses or distance lenses. Reading glasses are easy because they are so inexpensive. The best approach is to put reading glasses on the commissary and let the inmates purchase them there without having to go through medical. I would also set up a mechanism by which inmates who are truly indigent can get a pair of reading glasses given to them–that is still less expensive than having to go to the medical clinic.
Distance vision lenses are a different matter, and how distance lenses are handled varies whether the facility is a prison or a jail. Since your facility is a jail, I’ll give you that version. The issue in a jail is one of medical need for distance corrective lenses. The greatest distance that anyone can see within the average jail is rarely greater than, say, 60 feet. We are not out driving a car and looking a mile into the distance. So does the patient need distance corrective lenses to see 60 feet? The answer for most is “No.” I have had only a couple of patients over the years who had a true medical need for distance lenses. A common complaint from others is that they cannot see the TV well. First, that is not a medical issue. Second, if you cannot see something well, there are three ways to improve your vision. The first is with magnification (that would be the glasses). The second is to simply get closer. And the third is to increase the light on what you want to see. So–get closer to the TV.
Hello Dr.Keller – I have been a RN at a county jail for 3 years now. One of our biggest issues is dry skin and itching. Do you come across this issue?? If so, do
You have any advice? It seems to be all the sick call request that we see lately. Thank you!!!!!
Hi Heather,
The quick and easy solution to this problem is to put a good lotion on the commissary and let inmates purchase it without having to go through medical. Then your practitioner has to be firm and fair about not letting patients circumvent the commissary option by going through the medical clinic.
Thank you very much for your response. I will talk to my HSA and the medical provider about this, thats a great idea. We usually get the “i am indegent” when we suggest buying lotions on the commissary. Dry skin and rashes seem to be the main complaint at our facility along with itching.
Dr. Keller: this is a fantastic website. I’m an attorney with a primary practice in correctional medicine. I’ve been working my way through the articles and find relevance to many issues that have arisen in litigation over the years. Keep up the great work!
Read your opinion on Facebook – Who Gets the Best Care in America? Prisoners. I have worked Correctional Health in many states for years as a nurse practitioner. This is untrue on all levels – Federal, State, Regional, and County (have not worked city jail). I know you would be hard pressed to find staff who work in these places of incarceration to agree with your blog. MedPage Today should have prefaced this article as this being your opinion limited by your experience as a former ER physician who decided to work in corrections and has only been employed in one facility. I am so aggravated about the idea these people receive great care that I had to write and express my great displeasure. The situations I have observed and actually been an unwilling participant are reprehensible and could meet the definition of malpractice but often are negligent. Shame on you.
Thanks for the comment, Ellen. Please go back to the article in question and read my follow up comment. In the meantime, when you worked in corrections, did you yourself provide good medical care? Did you advocate for your patients when “the system” didn’t work to their benefit? Your comment sounds like your correctional work was in the past. If so, why did you leave? Are those who stepped up to replace you making the lives of their correctional patients better by their presence?
In the end, the quality of medical care provided to inmates is decided for the most part by the dedication of those medical professionals who are working in correctional facilities. If you are still there “fighting the good fight,” I applaud you!
Having surveyed for NCCHC accreditation well over 100 facilities of all types, I’ve seen “The Good, The Bad & The Ugly”. I’m yet to draw a general conclusion; other than those surveyed are generally The Good. But how about those who are never surveyed??? I imagine some are awful, like the ones described by Ellen. The real questions I have are: 1) why those who get surveyed want to? and 2) why those who do not, don’t want to? Those that do either: 1) are mandated by court order, 2) part of a contract offering and/or 3) want the prestige of being accredited. Whatever the reason is mute. Those who don’t, chose not to because of 1) the expense, 2) they don’t care, 3) don’t have to and/or 4) are so bad they know they would fail. MY opinion: “ALL facilities should be required to be surveyed!!!” Good luck on that.
Ellen, I agree with Dr. Keller: the quality of medical care at correctional facilities is determined by the medical professionals delivering such care. I myself am an ex ER doc and currently a Regional Medical Director for NY State DOCCS. I oversee medical care in 10 State facilities and I must say the quality of care is quite good. As any organization there are “The Good, the Bad, and the Ugly,” and some physicians are more dedicated than others. The ER and community medicine is no different. I have known many physicians in the community that I would not want caring for a relative of mine. Also I find that in recent years, as private practice has become more difficult, Correctional Medicine has been able to attract more dedicated individuals. I, for one, will not tolerate bad medical practices and make that very clear to the physicians and mid-levels I work with.
Thanks, Paula! Well stated . . .
Hi Dr. Keller,
I’m a nurse practitioner in a 580 bed county jail. In the next few weeks our facility will be implementing the use of body scanners in the booking area. Do you have any insight on traditional ‘dry cell’ protocols for medical monitoring in a situation where a patient has a positive body scan? I know this can vary widely depending on the initial assessment and what the suspected object is in the scan, but we are just trying to find a place to start.
Thank you!
Thanks for the question, Erin. With your permission, I’ll address it in a post soon . . .
Absolutely!
Hi Dr. Keller,
I host Quality Talk, a podcast dedicated to creating a better understanding of healthcare. I’m inviting you to be a guest for a 30 to 45 minute recorded phone interview about your role in correctional medicine, how that came about, and the ways the practice of medicine is similar/different from practice outside the walls.
Your work and perspective fascinates me, and your inside-the-walls insight often resonates with some of my own experiences. My father was the director of chaplaincy services for the Missouri Department of Corrections following a long career as the chaplain at a medium security prison in north-central Missouri. I occasionally got called on for preaching duty there when I was a young pastor/journalist.
Please consider this invitation and let me know the best date(s)/time(s) to make a connection, and I’ll accommodate your schedule.
I just read Dr. Keller’s article “Why I gladly waste my talents in prison.” I have been sayin the same for a long time.
I am also an ex ER doc and share many of Dr Keller’s experiences. After enjoying every minute of my 22 year carrier in EM, I felt I needed a slower pace to take me into retirement. I stumbled into correctional medicine which I have been doing now for 10 years. I have found it challenging and very rewarding. I think ER physicians are very well suited to work in jails. However, I no longer impress people at cocktail parties anymore! I used to get, “WOW, you are an ER doc?! How cool!” Now when I tell them I work in a prison, I get an “Oh,” a skeptical glance and then people just move away. Even the inmates, when I am trying to convince them they need some treatment they have been refusing, remind me, “Why should I listen to you? If you were any good, you wouldn’t, be working in a prison!” It is however very rewarding when you finally reach someone and can make a difference in their life.
Thanks for the comment, Paula! ER is indeed a great initiation for Correctional medicine.
JeffK
Interesting article but I am not sure I agree with some of the info presented. But then again I work in a jail vs a prison. http://www.emcdda.europa.eu/attachements.cfm/att_146300_EN_UK51_Safer_Prescribing_in_Prison%20(2011).pdf
VERY interesting article! Thank you for sharing.
NCCHC standards have surprisingly little to say about the relationship of the jail to its pharmacy. True, there must be quarterly inspections. However, I see nothing that would prevent a jail from simply dispensing all medications from stock. My assumption has always been that the pharmacy needs to have a list of the prescription meds each patient gets, and that most are issued on a card (or cassette or similar) with that patient’s name on it. Otherwise, who is monitoring for interactions when multiple prescribers are involved? And are nurses really trained well enough to administer safely from stock? Do you know if there are in fact any guidelines on this?
Good question! Strongly suggest posting this matter on the NCCHC Connect Online Community blog under Accreditation, and/or Surveyors and/or Nurses.
The only guidelines I am aware of are the various state pharmacy laws. I know of jails that dispense most medications from stock bottles–but I do not believe that this practice is legal.
Only a pharmacist can dispense meds; nurses may administer meds. One must review the nurse practice act and pharmacy rules for definitions that apply to their state. If a nurse violates them, their license may be in jeopardy.
Thank you (and thanks also to Charles) for the reply. This is helpful. It is always best to look in the right place for an answer!
Generally, if medication is in a stock bottle with no patient’s name and put in a container with a patients name, it is dispensing; if taken from a container or blister pack, with a patient’s name and given to the patient, it is administering. Nurses may not dispense.
Charles is right, only a pharmacist or a medical practitioner may legally repackage medications
Just wanted to mention that your ‘subscribe’ button is no longer working! Excited for future articles, though!
Hi Dr. Keller, I’m a reporter looking for a little guidance for a story I’m working on about alcohol detox in jail. I thought you might be able to help. This isn’t for publication – just background. Please email me if possible. Thx.
Hello Dr. Keller,
My name is Kwame and I am a 3rd year family medicine resident interested in Correctional Medicine. I had a couple of questions:
1. Is it limiting to get a job in a correctional facility right after completing residency? Is it preferable to get experience and other skills sets outside in the public setting prior to looking for a job in corrections?
2. What skill sets (clinically, surgically-minimal procedures,etc.) should I strive to cultivate prior to entering the field?
3. Are procedures abundant in this setting?
4. How do I go about finding a job in this field? I have some ideas but what way would you recommend?
5. I currently work for the city hospital and we have a prison/jail floor (on lock down) so I am quite experienced with this population but on our end while inpatient there are many times where we question the care that was given prior to the inmate arriving to our hospital. I have also been warned by other nurses of poor care and limits on physicians attempting to give great care to the inmates.————– Are jails or prisons more suitable in terms of being able to provide holistic, compassionate, up to date and thorough care for the inmates/patients? I have heard some companies providing healthcare to these facilities can be shady, what red flags can I look for?
6. In terms of contracts, what average/minimal benefits, income, etc. should I expect? How long are the contracts for?
7. Do they, as with other private entities, start you off with fewer patients and ramp you up in terms of quantity over a few months or do they just throw you in?
8. Any cautions for me in terms of looking for a job in this field? I currently live in Clarksville, TN if you have any contacts or feel as if this is something I should pursue.
Thank You
My email address is kfrimpong@mmc.edu
Hi Kwame!
1. My opinion: Go into corrections right out of residency. Correctional practice is different than outside practice. You’ll also likely see more medical pathology in corrections.
2. Standard general practice procedures that you probably already have learned: How to suture, splint, I&D, reduce dislocations, etc.
3. You will do about as many procedures as you would in a standard community practice.
4. What companies provide medical care at the prisons/jails near where you live? Get on their website(s) and ask for a recruiter to call you!
5. Talk to the physicians already working there–privately, so that will not feel restrained in giving their real opinion. My opinion is that good medicine is cost effective. Bad medicine is expensive.
6. No quick answer here! It depends on which company and which setting.
7. Good companies will have a period of training and ease you into full practice.
8. I have taken the liberty of referring you to some Tennessee representatives that I know!
Good morning,
I am looking for advice and strategies to manage patients with Sickle Cell Anemia in a jail setting. As you know, stressful conditions, both physical and environmental, can lead to sickle cell crisis. Patients need to avoid physical exertion, stay very well hydrated, and stay warm. Jail temperatures are not always evenly regulated, the bedding is uncomfortable, and many patients do not drink enough water due to the taste. Additionally, many sickle cell patients are on chronic opiate medications for pain control, which brings up concerns about abuse or diversion.
At our facility, we try to keep out sickle cell disease patients as comfortable as we can by allowing for extra mats for comfort, extra blankets for warmth, pitchers of water to promote good hydration and medication management that may include folic acid, NSAIDS, and opiates when needed. We consult with Hematologists when needed as well.
Despite best efforts however, patients can and do go into crisis and require outside management in either an ER or hospital setting. At our facility, one of the problems we face in managing our sickle cell patients is determining whether a patient is or is not truly in crisis. In clinic, we look for hypoxia, hypertension, tachycardia, and fever. We order labs when indicated to rule out an elevated WBC or a low H/H. We look at the Retic count, but that is often chronically elevated in this patient population. None of these measures are truly reliable. Unfortunately, much of what we have to go on is subjective.
I want to make sure we are doing everything we can to help our patients avoid sickle cell crisis. Are there different things you do in your jails to best manage this challenging condition? Any advice would be greatly appreciated!
Hi Bryan! Sounds to me like you are doing a great job already. Sicklers are challenging, especially when incarcerated. I have a Sickle Cell guideline that I’ll put in the sample guideline section soon, but it doesn’t say anything that you are not doing already . . .
Thank you, I’ll keep an eye out for it.
Happy Thanksgiving!
Dr. Keller – I just read your piece entitled Opioid Withdrawal Not Deadly? Wrong on Medpage Today. I plan to share it with my friends and colleagues. But before I do, I’m going to need to fix some of the language. Because there are words in here that are – although widely-used – still offensive and perpetuate stigma. Which no patient needs. You do a brilliant job referring to those you care for as “patients, ” “people,” and “heroin users.” So I wish you would consider discarding terms like “addicts” and “abusers.” Because the words we use matter. They shape how we see and treat each other. Besides, it’s easy to do. And it’s not as if these are clinical terms that add anything to our understanding of substance use or Substance Use Disorders. Take this sentence for example, “When heroin ‘users’ (replacing ‘addicts’) are young and otherwise healthy, it is probably true that most can weather the storm of withdrawal. But, in fact, not all heroin users (again replacing ‘addicts’) in the modern era are young. I’ve seen heroin users in their 50s and 60s.” It’s clear, concise, and preserves your message without using words that might get in the way of delivering your message of improving care for all patients who use substances.
Thank you, Erika, for your excellent comments about the negative connotations of the words addict and addicted. I, of course, was not intending a judgement. I was using the term in the same way that I would say that a patient who has diabetes is a diabetic. But you are right that the term “addict” carries negative connotations in a way that “diabetic” does not. But it is also true that patients refer to themselves as addicted to heroin. And once my patients who are heroin users leave the jail, I would like to get them into long term treatment, preferably someone Board Certified in Addiction Medicine. So it may be impossible to get rid of the word “addicted” all together.
Erika: Let’s not become Politically Over-correct. They are addicted; and are addicts. Using a different word does not change the reality of their disease. If we change the word it will change the seriousness of the problem. What are they narcotically challenged?? Come-On-Now; be real.
Dr. Keller – I wanted to ask permission to reprint your article “Faking It in Jail” for my correctional facility staff. I put out a weekly publication and would love to put this in one of the newsletters, with you name and attribution of course. If you grant permission, just let me know what link or info you would like me to include (and I’ll be happy to send you a copy). This is such an important topic for corrections. Thanks. Dr. Hickman
Absolutely! Everything I publish is “Open Access.” Feel free to redistribute.
Are there any rules, regulations or protections for doctors working in prisons to keep their home addresses and other information private? Do inmates have a right to information about where a doctor or her/his family lives?
Hi Gudrun! No prison I know of would give out a doctor’s home address or phone number, just like they would not give out a Correctional Officer’s home address. This is just basic security. I don’t believe that there is any law, either Federal or in any State that deals with this, however. JeffK
Hello,
I was told that we can go to the Tax Collectors office to have our addresses “unlisted “.
Dr. Keller,
How are you handling patients that come in on PREP (Truvada) for prophylactic use? Do you continue it while incarcerated?
Hi Jennifer! That is a great question and I assume that this issue would be handled differently in different jails. At my jails, we would not prescribe Truvada for prophylactic use but would probably allow inmates access to it if they brought it in. I say probably because that has never happened at any of my jails, yet!
Jeff,
This is John Wood. I am the medical director for the Weber County and Davis County jails in Utah. We have met a few times. I am trying to work out a policy for transgender inmates. I couldn’t find an article on your site that addresses this issue. Do you have any places you could point me as I try to research this issue?
HI Dr. Wood! I sent you the World Health Organization guideline for transgender patients, which is the best reference that I know of and the one that is relied on by prison systems I am familiar with. I will address this issue in a future JailMedicine report!
This question was recently posted to our jail medical.
Please read…does anyone already give meds for addiction while incarcerated if they have a current Rx?
https://www.npr.org/sections/health-shots/2019/05/04/719805278/setting-precedent-a-federal-court-rules-jail-must-give-inmate-addiction-treatmen
This question was just posted to our detention nurses. Please read…does anyone already give meds for addiction while incarcerated if they have a current Rx?
https://www.npr.org/sections/health-shots/2019/05/04/719805278/setting-precedent-a-federal-court-rules-jail-must-give-inmate-addiction-treatmen
Has anyone ever heard of Jailhouse Meth. The inmates are saying they use the Ammonia Nitrate in an ice pack and mix it with Sudogest. Our disposable ice packs only have Urea and water.
I personally have not heard of this, Mary.
Good morning. I just started a new position as a correctional nurse practitioner in a state jail. I love it and I love helping the inmates. However I’m a new nurse practitioner ( I was an ICU nurse for 12 years). I was thrown in the new role during the COVID19 pandemic without proper orientation to jail medicine. I have many questions. When it comes to jail medicine how do we ensure the inmates get all the recommended health screenings needed? I recently saw a diabetic inmate with severe neuropathy, he had never seen a podiatrist, he last had eye check 6 years ago, lacking urine microalbumin level, last a1c done 2 years ago, I was behind myself. I mean, are these not things we should check in diabetic patients or is it different in jail??? Also do you have any correctional medicine manual you would recommend to a newbie like me??
There is, unfortunately no Correctional Medicine “How-To” manual yet. But generally, you would do the same things for your jail patients as you would if you were seeing them in an outside clinic. In a jail, though, you have to take into account how long they will be in jail, how urgent the need for the screening procedure you have in mind is, and what kind of medical care the patient will be getting when they get out of jail. With the diabetic you described, I would start with the easy stuff you can do yourself right there in your jail clinic: A good physical exam, A1C, labs, especially kidney function, certainly dip urine for microalbumin. Then develop a treatment plan depending on what you find. I personally like the guidelines published by the American Academy of Family Physicians.
I am a third year medical student and I have always wanted to be a correctional physician so I’m glad I found your website! I was just wondering if fields other than emergency medicine (like family or internal medicine) are good fits for correctional medicine? Also, what would you recommend doing as a medical student and future resident to get exposure and knowledge necessary for this field?
Have you encountered any SPICE overdoses in your facility? IF so, would you do a commentary about how to handle overdoses of K2/spice in facility. Also, we have noticed that due to the spice, we are seeing an increase in requests for BPH drugs and asthma drugs. I understand the asthma, but have not been able to find any reasoning for the BPH complaints and requests for those drugs. Do you have any experience that you could share?
Thanks for the question, Carla! I’m going to refer to the whole K2/Spice/Bath salts phenomenon as “Designer drugs.” It is interesting that the preferred drugs of abuse in a community varies over time. In my community, we did have quite a bit of designer drug abuse a few years ago, but now we see mostly opioid abuse. I suspect that the designer drugs will reappear here at some time in the future. To answer your question, the “antidote” for designer drug effects are the benzodiazepines. These can be supplemented, if necessary, by a little bit of Haldol. The main issue on patients intoxicated on designer drugs at the jail is whether they are cooperative enough to be treated at the jail. If they are, then some oral Valium plus close monitoring usually will help them. If they are not cooperative enough to be treated at the jail, or if they cannot be monitored, then they should be sent to the emergency department.
I have seen patients overuse albuterol inhalers to get a stimulant-like effect but I have not ever seen an increase in requests for BPH drugs associated with designer drug abuse.
Pingback: Introducing Sharen Barboza | Jail Medicine
Amazing, the brashness of the commentary.
More than 90% of medications (after verification of necessity / appropriateness) are administered in correction facilities.
The remainder are frequently held due to compliance issues and / or outright abuse.
Also, ad hominum attacks are unprofessional and the last resort of the uninformed.
Dr Keller, I am a dentist and experienced in private, corporate and public health dentistry. I am considering working for correctional facility. I am still hesitant and am trying to understand the pros and cons of this job. Morever I am a petite woman and trying to imagine myself it is going to be okay. What is your advise for a dentist entering into correctional dentistry? Also, my question is that by working in correctional dentistry will my future career and job prospects be affected? i.e in the future if I move into private or corporate practice or community health centers where I have to work with kids and adults, how are the people going to view me with my experience in correctional dentistry.
Looking forward for your response and advise.
Correctional medicine/dentistry is an honorable profession. The patients are the most thankful for the medical/dental/mental health care they receive, you’ll ever encounter. They may have done something against the law; they are not bad people. They will respect you for wanting to help them. I’m proud to be a correctional medical professional and gladly express it to my colleges. They are more curious; than disrespectful. You will get more experience than in a general practice and if looking for a job, that will be a benefit. A prospective employer will know that you have a lot of dental experience under unusual circumstances and can manage it. Have no fear, check it out, you’ll love it and may not want any other job!
I work in the WA DOC. We currently have restrictions on certain inhalers because they have components that could be used for illicit means if taken apart. One example would be Respimat. I am curious if others have had issues such as this. I am not sure if this was a hypothetical concern or there have been cases where these devices have been used to this detriment.
The offenders are better [practical] chemists than we are. Almost any medication can be [often has been] misused. Insulin used in low dose to drop glucose and get ‘high’; diflucan (requested for vaginal yeast) used to prolong benzo / buprenorphine; and creams for abrasions for chapped lips.
Inhalers have been modified and used in attacks. The best you can do is try to ensure the accuracy of diagnosis and choose which are directly observed therapy due to risks.
The short answer, Dr. Aurich, is Yes! Respimat components can be repurposed for other uses, such as giving prison tattoos. Caution is warranted. There are two easy solutions to this particular problem:
1. Since tiotropium in a Respimat inhaler is a scheduled drug rather than a prn drug, don’t allow patients to keep it on person (KOP). The patient would have to go to the pill call line once a day for their inhalation. If the patient is already going to pill call anyway (which most patients taking tiotropium will be), there should be no problem doing this.
2. Prescribe a different medication that does not carry the same risk. The published guidelines on asthma and COPD therapy offer several alternative meds and treatment pathways.
The list of seemingly benign medications that are diverted, sold, and abused in jails and prisons is long. Practitioners in correctional settings need be careful about prescribing potential problematic drugs, like the Respimat inhaler. We do not want to unintentionally harm our patients!
Dr Keller,
Do you truly believe that topomax (topirimate) only has a legitimate use as a seizure medication? It has been a god send for preventing my chronic migraines. I don’t see why a inmate shouldn’t be able to take this same medication. Perhaps I read your potential abuse article incorrectly.
Hello. My name is Stan Bennett and I’m an occupational therapist in the Federal Bureau of Prisons. I’m also a certified hand therapist. Thank you for this great resource and for making a place for people who work daily to combine the best of medicine and corrections. I will enjoy scrubbing this site for other great information to help me be a better therapist.
v/r
Stan
Hey folks. I was wondering if any of you prison doctors are aware of an skin affliction going round the prisons that cause intense itching?
I seem to have picked it up, and can’t get rid of it. It’s not “in my head” as I’ve had countless people around me get visibly itchy, without my even touching them! It seems to effect their eyes, inner ears, face, scalp etc. I don’t know who else to turn to, as no one knows what I’m talking about. Please help! Thanks in advance.
Jon