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:
Perhaps the strangest aspect of practicing medicine in a jail or prison is “comfort requests.” This is when an inmate comes to the medical practitioner asking for something like a second mattress, the right to wear their own shoes, a second pillow, a second blanket, etc. This, of course, never happens in an outside medical practice. When was the last time you heard of a patient asking for a prescription for a pillow? Yet such requests are extremely common in correctional medicine. You might think, “Well, just give them the second pillow—what harm can it cause?” But it is not that simple. Like every medical issue, there is a right way and a wrong way to handle these requests. To understand why, let’s consider the single most commonly requested comfort item in a correctional medical clinic: a second mattress.
Today’s post is the first in a series of sample clinical guidelines. These will be placed under the “Guidelines” tab (above) as they are published. These guidelines are open access; you may use them in whole or in part as you see fit. I view these sample guidelines as a group effort! If you have a suggestion, critique or simply a better way to phrase some concept, say so in comments.
This particular clinical policy addresses a common problem in jails (less so in prisons). I addressed the issue of allowing personal shoes in jail previously in “A Quick-and-Easy Solution to those Pesky ‘Own Shoes’ Requests,” (found here). As a result of that post, I have had many email requests for a sample “Own Shoes” guideline.
Medical Approval of Personal Footwear in Jails
This clinical guideline is intended to be used as a template to help clinicians and administrators create their own policy on personal footwear. This sample guideline must be modified to make it applicable to each unique correctional facility. This guideline is not intended to apply to all patients. Practitioners should use their clinical judgement for individual patients.
Introduction. Inmates housed in county jails are provided footwear by security personnel. Occasionally, inmates will state that they have a medical condition that requires them to wear their own personal shoes. If an inmate asks medical personnel to authorize him to wear his own personal shoes, medical providers should re-frame the question as “does this patient have a legitimate medical need to wear his own personal shoes?” Inmates may desire to wear their own shoes for many non-medical reasons, such as convenience, as a sign of increased status among other inmates and as a way to smuggle contraband. This guideline addresses the question of when inmates have a medical need to wear their own personal shoes.Continue reading →
I am often asked by my non-correctional colleagues what it is like to work in a jail. I tell them that practicing correctional medicine is different in many ways than medicine in the “free” world. Many of them scoff at this. How could the practice of medicine be different in a jail than it is anywhere else? “Medicine is medicine,” they say.
But correctional medicine is different. In my experience, if you just throw a practitioner into a jail or prison clinic without any training, he likely will not do well. It took me two full years before I was comfortable in my sick call clinics and I am still learning things as I go. Experience matters in Corrections!
This is obvious to those of us who have experience working in jails and prisons. But how do you explain the intricacies of a jail medical clinic to an outside physician? I have thought about this a lot over the many years I have practiced correctional medicine and I have come up with several concrete examples of how correctional medicine is different from medicine “on the outs.” The first, and perhaps the most important, difference is the Principle of Fairness.Continue reading →
Today’s JailMedicine post was written by Bruce Boynton, MD. Dr. Boynton has been a Regional Medical Director of the prisons in New Mexico and currently is the Statewide Medical Director in Mississippi. He wrote this article to help introduce newly hired practitioners to the world of Correctional Medicine. I think it is excellent!
MD: Hi, I’m Doctor Jones and I’ve just started working here at Riverbend. I’ll be holding my first sick call this afternoon and I understand you’re the officer assigned to the clinic.
CO: It’s good to meet you Doc; welcome to Riverbend.
MD: There is something I’d like to ask you. I have a lot of experience in Family Practice but I’m new to corrections. Is there anything special you think I need to know? I suppose that people are people and medicine is medicine no matter where you go. Isn’t that right?
For many years, the American Heart Association and other Big Hitters in medicine have extolled the health benefits of a very low salt diet. Patients who have known heart disease were commonly counseled to eat a very low salt diet of less than 1,500 mg a day (compared to the average U.S. daily salt consumption of 3,400 mg a day).
I experienced this myself. When I was growing up, my father had three separate heart attacks and, among other things, was told to eat low salt. So, for several years, that is what my mother cooked for all of us.
Very Low Salt Diets as a treatment and preventative for heart disease has become the prevailing wisdom. Since these less-than-1,500 mg-of-salt-a- day-diets were so commonly prescribed in the community, most jails and prisons had to have such a Very Low Sodium Diet among the various medical diets that could be ordered by a practitioner.
However, I personally have never been a big fan of these Low Salt Diets in general and especially in Corrections.
There are two reasons for this. The first, as I can tell you from my own experience as I was growing up, is that very low salt diets are not very palatable. Most people find the food quite bland and will not eat it long term. Correctional inmates experience this, too, and commonly sabotage the diet by liberally salting the Low Salt Diet at the table (as I myself used to do) and by ordering lots of salty commissary foods like Ramen, and chips.
We practitioners commonly sabotage the Low Sodium Diets as well, by ordering medications with lots of attached sodium, such as naproxen sodium or omeprazole sodium.
So I challenge you to check the commissary purchases and prescriptions of the inmates at your facility who are prescribed a Low Salt Diet and find out how many truly ingest less than, say, 2,300 mg of salt a day. I guarantee, it won’t be many.
The second problem with the Very Low Salt Diet hypothesis is that the science for its efficacy has been pretty tenuous. Basically, eating less salt lowers blood pressure slightly in some individuals. Since people with lower blood pressures tend to have fewer heart attacks and strokes, then, the theory goes, eating less salt will lower blood pressure which will thereby decrease heart attacks and strokes. The Magic Number for salt consumption was pegged at less than 1,500-2,300 mg a day, compared with the average U.S. daily salt intake of 3,400 mg. But until 2006, no one had studied salt consumption directly.
Now comes this report, Sodium Intake in Populations: Assessment of Evidence,
from The Centers for Disease Control and Prevention’s Institute of Medicine, which analyzed the data directly linking salt consumption to death, heart attacks and strokes—no blood pressure middle-man. It turns out, according to the CDC, that all of these bad things (death, heart attacks, strokes, congestive heart failure) did increase with salt intake greater than 7,000 mg a day—but also (and who would have guessed this) for salt intake of less than 3,000 mg a day.
The report has already come under criticism. Most of the criticism I have read so far has been of the “I don’t believe it” variety. But one good observation, in my mind, is that the most common source of big-time salt in American diets is fast food and processed food, rather than overly salted prepared foods. I think we all will agree that most fast foods and processed foods are not the best health-wise, and for more than just their excessive salt content.
This is true in jails and prisons, as well. The biggest source of excess salt in most inmate diets is the junk food found in the commissary, not the food prepared in the kitchen. That is certainly the case at my jails. The prepared meals in my jails do not have a huge amount of salt.
So what is the take home message from the CDC report?
1. It may be OK to get rid of your Very-Low Salt Medical Diet (1,800 mg a day) as long as the standard diet served to your inmates has reasonably low salt content, like less than 3,400 mg a day. It probably does, unless you are serving lots of processed foods.
2. If you do order Very-Low Salt Medical Diets anyway, perhaps it would be prudent to check commissary purchases and NSAID prescriptions to make sure that the patient is really ingesting low amounts of sodium. If, despite the Very-Low Salt Diet, your patients are still ingesting over 3,400 mg a day, what is the point of the diet? It is a lot of time and effort that is not accomplishing anything.
How many Low Sodium Diets do you prescribe? What do you think of the CDC report? Please comment!
Sgt. Tracy Cox has permission to wear her own shoes in the jail.
Everyone who works in corrections is familiar with inmates wanting medical authorization to wear their own shoes. A typical case would go something like this: “I have chronic back pain and walking on these hard concrete floors makes it worse. Will you authorize me to wear my own shoes? You did last time I was in here and it really helped.”
We need to keep in mind, however, that allowing an inmate to wear his own shoes gives that inmate secondary gain. Shoes from home are, indeed, more comfortable than the typical jail sandals. Also, any inmate who is granted a special privilege, like wearing his own comfy shoes, gains status among the other inmates. When we approve inappropriate requests for “own shoes,” we are bestowing prestige upon that inmate. And we are denying that prestige to those who we refuse. The unfairness of this is not lost on inmates. Finally, “own shoes” are occasionally used to smuggle contraband into the facility. I remember one pair that had an ingenious hollow space carved out of the sole that was not easy to find on a typical security examination. If you routinely grant requests for “own shoes,” you will inevitably get burned in this way. Continue reading →
Those of us who practice medicine in jails frequently (Frequently? Daily!) run into the thorny issue of our relationship to the doctors who care for our patients outside of the jail.
When patients are in our jails, we are responsible for them; they are our patients. But these patients also have doctors outside of the jail that perhaps they have been seeing for years. The inmate considers their outside physician to be their “real” doctor, not us. (Throughout this article, I am going to use the term “doctors” rather than the more generic “practitioners.” I do not mean to slight nurse practitioners or physician assistants. What I say applies to them, as well.)
What brought this topic to mind is a case that occurred in one of my jails recently. A patient came to jail with a prescription pad filled out by his outside physician authorizing him to have a double mattress, an extra blanket and an extra pillow. (There was no note requiring us to feed him pizza every Friday night—he must have forgotten to ask for that.) So I was left in a little dilemma. What should I do about this note? Ignore it? Allow the inmate to have the extra comfort items?
Dealing with inmates’ outside physicians can be tricky, but I have found (mostly through sad experience) that there is definitely a right way and a wrong way to handle these encounters. The right way involves recognizing three important points:
I have a quick ‘n easy solution for those pesky requests for a second mattress that plague all correctional facilities. But before I get to that, though, there are two important points to consider in any discussion about second mattresses in correctional facilities.
First, providing inmates with mattresses, like inmate clothes and toiletries, is the purview and duty of the correctional officers, not the medical staff. What this means is that when an inmate asks for a second mattress, the question being put to us is this: Is there a medical need for this patient to have a second mattress? This is critically important. The inmate would prefer to frame the question differently, something like this: “The correctional officers only issued me one mattress, but you can over-rule them and authorize me to have a second mattress. Will you do me this favor?” This is a totally different question than “Does this patient have a medical need for a second mattress.”
Secondly, having a second mattress is a status symbol inside the correctional community. When an inmate receives a benefit that other inmates do not, he gains status and prestige. Sometimes this motivation is as important for an experienced inmate as is the extra comfort of a second mattress. I believe that if a jail provided two mattresses to every inmate in the facility, there would be requests to medical for three mattresses. (Pretty soon inmate beds would rival “The Princess and the Pea!”) So when we grant inappropriate requests for second mattresses, we are conferring status on the inmate in question. And we are denying status to those who we refuse. This also, in my mind, is important to consider.
So now to the main topic of the day: What constitutes a “medical need” for a second mattress? In my opinion—there are none! Zero. Nada. There is no medical need ever for a second mattress. I challenge anyone to find a reference in any medical literature saying that second mattresses are a treatment for anything. For example, a common reason given by inmates requesting a second mattress is that they have chronic back pain. However, if you pull out any medical textbook that deals with the treatment of chronic back pain, you will not find second mattresses mentioned in any. Go ahead! Look!