Todd Wilcox, New JailMedicine Editor, The Seton I&D Technique

Hi, my name is Todd R. Wilcox, MD and I want to introduce myself as the incoming editor of jailmedicine.com.  I have followed Dr. Keller’s work and this website since it was first published and I’ve been a big fan of the level of practicality and informative insights he has brought to the practice of medicine in correctional facilities.  I hope to be able to continue that trend and to broaden the input with some additional specialists who see incarcerated patients and manage their unique healthcare needs.  I have worked in correctional healthcare as a physician for 26 years and I am the medical director of the Salt Lake County Jail System in Salt Lake City, UT.  I completed my undergraduate work at Duke University and then attended medical school at Vanderbilt University School of Medicine.  I also have a Masters of Business Administration from the University of Utah. I am board certified in Urgent Care Medicine and my clinical interests include wound care, pain management, orthopedic injuries, and HIV medicine.  I am a frequent lecturer at NCCHC, ACA, AJA, and the National Sheriff’s Association and I look forward to engaging with colleagues who are similarly interested in the challenges of delivering healthcare to our incarcerated patients.

Skin Abscess Treatment with the Seton Technique

In correctional health settings, we encounter a lot of skin abscesses on various parts of the body. The traditional technique of doing an incision and drainage (I&D) of an abscess has many limitations which has prompted the development of a new technique called a seton placement. This technique originally started with the colorectal surgeons who were treating pilonidal cysts and peri-rectal abscesses and it has been adopted for skin abscesses by the emergency medicine physicians.

A traditional I&D is generally accomplished using lidocaine infiltrated into the skin and into the abscess cavity and then a number 11 or 15 blade is used to open up the entire abscess and squeeze all of the pus out which then creates a cavity that needs to be packed. While this technique is effective and is the traditional treatment for skin abscesses, there are many limitations for using this technique in a correctional setting.

  • it is difficult to anesthetize an abscess due to the acidic nature of the pus that deactivates the local anesthetic
  • I&D technique is generally very painful for the patient
  • I&D tends to be very messy with a lot of pus and blood produced that is often under pressure and squirts all over
  • the wound backings that are necessary to get this wound to heal by secondary intention are painful for the patient
  • the wound packings take a lot of time for the nursing staff
  • the cosmetic result is unfavorable
  • the total treatment time to get a wound to heal by secondary intention is often two weeks or more

The new technique of seton placement was designed to address many of these shortcomings. The technique is described below:

Necessary equipment

  • Local anesthetic.  I generally use 1% lidocaine with epinephrine.
  • 5cc syringe with 18 g and 25-27 g needles
  • Chux pad
  • 4×4’s
  • #11 scalpel
  • Silicone vessel loops (we stock 2 sizes)
  • Noyes alligator forceps
  • Island gauze dressing

The Technique

  1. This technique does not require sterile technique or prepration.  It is a clean technique, not a sterile one. 
  2. The abscess is palpated and the edge of the abscess is identified in two spots 180° opposite each other.
  3. You can use a pen to draw on X at your marked spot.
  4. In identifying the two spots for the incisions it is important to locate one of them at the most dependent area of the abscess so that drainage of the entire abscess will occur.
  5. A wheal of local anesthetic is raised at those two spots
  6. A number 11 blade is then used with the cutting edge facing away from the body to make two small stab incisions at the identified spots and they need to extend into the abscess cavity completely.  This should result in a return of pus and blood as the scalpel is taken out.  It is much easier to shield and divert the pus in this technique compared to a traditional I&D
  7. Once the two incisions are made, a Noyes passer is used to connect the two incisions and the passer goes in one incision, through the middle of the abscess cavity, and then out the other incision.  A Noyes passer is much easier to use and to pass than a hemostat, but you can use a hemostat if needed.  Your incision holes will need to be bigger to accommodate the width of the hemostat. 
  8. The teeth of the Noyes passer are then used to grab the silastic vessel loop and that is pulled back through the abscess cavity.
  9. The silastic vessel loop is then tied in a loose air knot with usually 6 to 8 throws of knots on top.
  10. The tails of the vessel loop are then cut leaving a very loose suture with the silastic vessel loop in the skin.
  11. An island dressing is applied over the top of this and the patient is free to go.
  12. The patient may shower and generally the only dressing necessary for this technique is an island dressing every day for the next few days.
  13. The patient is instructed to grasp the knot and move the silastic loop back and forth once a day to break up any crusting or adhesions to keep the holes open.
  14. The general order for removal is done on day five and a nurse goes and clips the silastic loop with a scissor and removes it just like a suture.
  15. By day five the abscess is generally completely resolved and the overlying skin has adhered back down to the deeper tissue and the treatment for the abscess is resolved at that time.

This technique affords many advantages over the traditional technique:

  • Because you are anesthetizing the very edge of the abscess you are actually anesthetizing normal skin which is much easier to achieve good anesthesia with a local anesthetic than attempting to anesthetize the top of an abscess.
  • Properly done, this technique is almost painless for the patient.
  • From a provider standpoint, this technique is far faster than doing a traditional I&D. In my experience I can do a seton loop placement in about one third the time it would take me to do a traditional I&D.
  • With this technique, the initial rush of pus and blood can be controlled and it is much less messy for everyone and the risk of an exposure is much less.
  • Because the skin over the top of the abscess cavity remains intact and vascularized, there is no need for this wound to heal by secondary intent. This results in a much faster healing of the abscess.
  • The post technique nursing care is virtually nothing. All you have to do is provide a Band-Aid or an island dressing to put over the top of the seton for five days and the patient can apply that themselves after they shower. Your nurses will thank you profusely for not making them pack a big abscess cavity.
  • Because the skin overlying the abscess is not cut, the cosmetic result from this technique is substantially superior to a traditional I&D.

The preceding description is a basic description of how this technique is done. Once you gain experience there are some advanced hints and tricks that are possible to use with this technique.

  1. I generally do not use a pen to place an X on the skin except in unusual circumstances where the placement of the anesthesia will obscure the edge border. This typically happens on the thicker skin of the face. Generally my technique uses lidocaine with epinephrine and I utilize the placement of the lidocaine with epinephrine to make my mark for me because the vasoconstrictive effects of the epinephrine will make it very obvious where to make your incision.
  2. Most abscesses require the placement of one seton through the abscess. There are occasionally abscesses that have loculations or are large enough that additional setons need to be placed.
  3. I have use this technique with very large abscesses in breast tissue a well as over the deltoid and in those the vessel loops are not large enough to accomplish the drainage. In larger areas I have used sterile tourniquets to place through the abscess cavity as my seton and that has worked beautifully.
  4. For simple abscesses, I have not found antibiotics to be necessary above and beyond the drainage technique for complete resolution of the abscess.  Clearly this is a matter of professional judgment as well as anatomy, and there are certain abscess presentations where supplemental antibiotics would be advisable.  There is some evidence in the emergency medicine literature supporting adjunctive use of anbiotics for some clinical presentations.   

The American College of correctional physicians has a video of this technique on their website.

What technique do you use to I&D abscesses? Please comment!

JailMedicine and ACCP

I recently turned 65 and decided that it was time to slow down a little bit. Part of this slowing down is to retire from the administration of JailMedicine and turn JailMedicine over to a new caretaker. Fortunately, I have found the perfect organization to take JailMedicine over–the American College of Correctional Physicians, better known as ACCP.

ACCP is THE professional organization for all Correctional Medicine Practitioners, including affiliate membership for Nurse Practitioners and Physician Assistants. It is the perfect organization to continue publication of articles devoted to Correctional Health Care. ACCP has assigned Todd Wilcox MD the primary responsibility of running JailMedicine, assisted by a committee of other ACCP members (including me) who will contribute articles, answer comments, update the blog and generally make JailMedicine better than ever!

JailMedicine has been a big part of my life for the last ten years. I very much appreciate everyone who has read my thoughts and rants, subscribed and commented.

The work we do as Correctional Medical Practitioners is important! We provide healthcare to an underserved and often neglected population. We soldier on despite often being underfunded, working in a difficult environment and having to pay attention to security issues that other medical practitioners are not even aware of!

Thank you for your work in Correctional Medicine and for your support of JailMedicine!

Here’s to the continued success of JailMedicine and to the continued success of our work!

Jeffrey E. Keller MD

What Do These Five Patients Have In Common?

What do these five patients have in common (Fill in the Blank).

As you arrive to work at a jail medical clinic, you are told about five different jail patients. Each of the five carries a totally different diagnosis, but all have one thing in common.

Patient one is a 52 year old man booked into the jail four days ago for a DUI. He seemed all right for the first two or three days, but now, you are told, he has not eaten anything for 24 hours and last night he ____________________.

Patient two is a 24 year old woman who was arrested yesterday for refusing to leave a grocery store as it was closing. Since her arrival at the jail, you are told, she has been talking non-stop in a very loud voice and last night she _____________ .

Patient three is a 19 year old man who was arrested for drug possession. The deputies have not been able to book him because he also has been talking loudly and nonstop, although, unlike patient number two, his speech is largely non-sensical. But like patient number two, last night he also ________________.

Patient four is a 28 year old homeless man who was arrested two days ago for taking his clothes off in the library. He is cooperative mostly but spends most of his time talking about being spied on by the FBI through the jail loudspeaker. He thinks any food prepared by the jail is poisoned so will only eat pre-packaged commissary items. Last night, he _______________ .

The last patient is a 76 year old man who has been incarcerated in the jail for over six months. He has never caused any trouble in all of that time until last night, when he was incontinent, resisted any efforts to change his clothes, and threatened the deputies. Oh, and also he __________________________.

I’m sure that you have figured out how to fill in the blanks with what these five very different patients have in common. They all did not sleep last night.

Patient number one is going through alcohol withdrawal. If he is disoriented and having “different place” hallucinations plus severe tachycardia, he already has Delirium Tremens and needs to go to the hospital. However, some withdrawal patients will become sleepless before they become delirious and so may be able to be successfully treated at the jail. Either way, the treatment for this patient is benzodiazepines and rehydration. You’ll know you have given him enough Valium or Ativan when he sleeps.

Patient number two is manic. Depending on how cooperative she is and the capabilities of the jail, she also may need urgent evaluation by a psychiatrist. Typical maintenance therapy for her would be a mood stabilizer like Lithium or divalproex. However, an acutely manic patient who is not sleeping may first benefit from an antipsychotic and and a benzodiazepine. First and foremost, she needs to slow down enough to sleep.

Patient number three is high on methamphetamine. The “antidote” to meth toxicity is benzodiazepines. Once he gets enough benzos on board to counteract the meth effects, he will sleep. Whether this takes place at the jail or the hospital depends, again, on how sick he is and the capabilities of the jail.

Patient number four is acutely psychotic. He should receive antipsychotics and, at least initially, benzodiazepines. Since he is paranoid, he may be resistant to taking these voluntarily. A psychiatric consult and court order may be needed to treat him and get him to sleep.

Patient number five is acutely delirious. There can be many causes for this, but in this particular case, the patient is septic from a urinary tract infection. He will need to go to the hospital, where treatment will include antibiotics and benzodiazepines to help him to sleep.

Lessons

I have often heard jail practitioners say something like “We don’t treat insomnia in our facility.” This is, of course, incorrect. All of these sleepless patients, for example, must be treated and one important guide to the success of the treatment is that each patient goes to sleep. Of course you will treat sleeplessness when medically appropriate to do so!

You might argue that these patients are not really insomniacs; insomnia implies wanting to sleep but being unable to do so. None of these patients complain about not sleeping. In my opinion, this semantic argument misses the point. Our patients need to sleep. We will treat those who are truly not sleeping, from whatever cause. Sleepless is almost always an important symptom pointing to a more serious underlying medical condition.

Since none of these patients will fill out a kite complaining of not sleeping, we medical practitioners have to rely on our deputies and correctional officers to alert us about about patients who are not sleeping. This underscores the importance of training our non-medical coworkers (who are often our eyes and ears) on what conditions and behaviors should be referred to medical.

Personally, even though I get a lot of calls when I am on-call, the problem is that I am not called enough rather than that I get called too much. One reason for this is that correctional officers sometimes have had bad experiences in the past from a cranky practitioner. We need to remember that deputies and correctional officers do not have our medical training and so are going to worry about things that maybe we wouldn’t.

Even if nine calls out of ten are perhaps unnecessary, that tenth call is critically important! Always thank the officer for calling, be kind and follow up.

As always, what I have written here is my opinion, based on my expereince, training and research. I could be wrong!

Please share an experience you have had in your facility with a sleepless patient in comments!

The Problem of Sleep

The first patient I am going to see today wrote on his Kite: “I need something to help me sleep.” Over the course of my career in correctional medicine, I have seen literally hundreds of such requests. I have empathy for the patient who submitted this kite. There is no question that it is hard to sleep in a jail. 

First, there are the physical impediments to sleep.  They never turn the lights all the way off!  If you are someone who likes it to be really dark when you go to bed, too bad for you. And it is loud!  Most inmates are housed in large dorms with 40-60 (or more) inmates who are talking, snoring, yelling.  There are no carpets or drapes to absorb noise, which bounces and echoes in the cavernous concrete space. The large metal doors clang loudly when they close. Even footsteps on the concrete floor are surprisingly loud.

The mattresses and pillows are not designed to be comfortable.  They are designed to be secure, i.e. hard to hide contraband in. That means the mattresses and pillows are thin with little padding. Jails are cold, even in the summer, but the blankets are also often thin and may itch to boot. Inmates are not issued two blankets.

Finally (and most importantly for many inmates), there is the mental anguish that prevents sleep.  This is an alien and frightening environment.  You are sleeping in the same room with 50 other inmates, some of whom can be quite scary.  You worry about being away from your family, what will your family and neighbors think, will you lose your job, how will you make bail, what about court, what if I get convicted?

For all of these reasons and more, complaints of insomnia are common in a jail. Jail medical providers need to have a policy or guideline on how to deal with complaints of insomnia. But before I see my first patient who wants a sleeping aid, I need to review the following guiding principles in my mind:

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Reader Questions Benzo Withdrawal and Inhaler Abuse

(With regard for The Rules for Treating Benzodiazepine Withdrawal) I practice in a jail on the East Coast. I totally agree that Benzo’s must be used, but I can’t find anything in the literature concerning length of treatment to avoid life-threatening vs. annoying symptoms. The months-long tapers are not well accepted by either Correctional Healthcare companies or Correctional institutions. Most providers here go with a week of tapering diazepam. I usually go with 10-14 days. I would like to try your general formula of choosing the dose of diazepam, then tapering down every 4-6 days. Do you have any literature or expert panel opinion on how long to taper in order to avoid life-threatening consequences? Do you see any benefit to using other meds after the benzo taper simply to decrease annoying symptoms from withdrawal?  Steven Wilbraham MD

Thanks for the question, Dr. Wilbraham!  Yes, the psychiatry literature talks about tapering benzodiazepines very gradually over many months or even years. But what they are doing is different than what we are doing.  They are treating benzodiazepine addiction and we are treating withdrawal with a detoxification protocol.  It is analogous to the difference between treating opiate addiction in a methadone clinic (which also can last for months or years) versus what we do when we treat opiate withdrawal for at most a couple of weeks. 

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What Does “Medically Necessary” Mean?

Let’s say one of my jail patients has a moderate-sized inguinal hernia.  I want to schedule surgery to have the hernia fixed, but to do so, I have to get authorization.  This is not unusual.  Just like the outside, before I can do medical procedures or order non-formulary drugs, I must get the approval of the entity that will pay the bill.  By contract, my jails house inmates from a variety of jurisdictions, such as the Federal Marshals, ICE, the State Department of Corrections and other counties.  This process of “Utilization Management” is very similar to getting pre-authorization from an insurance company or Medicaid in the free world, probably because Corrections simply copied the outside pre-authorization process.

Having done this process hundreds of times over the years, both in the free world and in Correctional Medicine, I am struck by a phrase that keeps coming up: “medically necessary.”  When authorization for a procedure is denied, the reason often given is that it is “not medically necessary.”  I then have to argue that what I am requesting is, indeed, medically necessary.  The problem is that there are many possible definitions of “medically necessary,” and I believe many disagreements arise because two parties understand “medical necessity” differently.

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Documenting Test Results the Ed and Midge Way

I have a ten-year-old Yorkie named Ed. Ed is experienced and knows the daily routine of our house. Last year, we got a Yorkie puppy named Midge. She initially knew nothing.  It has been entertaining to watch Ed educate Midge on what to do. Midge watches Ed closely and then does whatever Ed does. She is a true Ed Mini-Me. If Ed lays down, Midge lays down.  If Ed asks to go out, Midge wants to go out, too. If Ed begs for a treat, so does Midge.

Since Ed is a pretty good dog, most of what he has taught Midge have been good things, like ask to go outside when you need to potty and sit to say “please” when you want a treat.  But Ed also has some bad habits that he has imparted to Midge.  Ed still has the Yorkie propensity to yap at the door when the doorbell rings, and so Midge has also learned to also sound the alarm.

Medical education is like this. I remember being a young dog medical intern and watching my heroes, the senior residents. Not everything in medicine is taught in medical textbooks and didactic lectures!  Much of what we actually learn as medical practitioners is an imitation of our elders.  For example, I watched what the senior residents ate (junk), when they slept (rarely) and how they treated nurses (some good, some poorly), among other things. Like Ed, most of what my senior residents taught me by example was good. But there are a few sketchy practices handed down from medical resident to medical student that can become bad habits.

Ed: Do what I do. Midge: Ok!
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What is the most common mistake made when treating withdrawal?

What is the most common mistake made when treating withdrawal in a correctional facility?

Consider these two patients:

  • A jail patient booked yesterday is referred to medical because of a history of drinking.  He has a mild hand tremor and “the look” of a heavy drinker. But he says he feels fine and has no complaints. His blood pressure is 158/96 and his heart rate is 94.
  • A newly booked jail patient says that she is going to go through heroin withdrawal.  She is nauseated but still eating and has no gooseflesh or rhinorrhea.  Her heart rate mildly elevated.

In many jails, neither of these patients would be started on treatment for withdrawal at their first visit to medical.  But this would be a mistake!  Both patients should be started on treatment for withdrawal immediately.

The most common mistake made when treating withdrawal in a jail is not to treat the withdrawal at all!

Both of these patients have the potential to slide downhill rapidly.  And in both cases, the potential benefits of starting treatment far, far outweigh any potential liability.

Let’s look at these cases in more detail.

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Beware the Bounce-Back!

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 patients we do not know well. But bounce-backs also happen 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. 

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Introducing Sharen Barboza

I am pleased to be joined on JailMedicine by my colleague Dr. Sharen Barboza! Dr. Barboza has been providing correctional mental health care for more than 20 years. Her complete bio can be found in the About The Authors tab (here). Besides her broad experience, intelligence and common sense, Dr. Barboza is simply the best speaker I have heard at any correctional medicine conference. I am honored to have her as my co-editor at JailMedicine! Jeffrey Keller

Dr. Sharen Barboza

I am truly honored, grateful and humbled to join Dr. Keller on JailMedicine.com.  I think that now, more than any other time in the past, we are all realizing the impact that our mental health has on our ability to function in the world.  For so many of us, we take the “health” part of our “mental health” for granted.  We trust our thoughts to be based in reality; we rely on our emotions to adequately and appropriately meet the moment; and we have confidence in our ability to cope with what comes our way.  Most days. 

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