Well, JailMedicine is now over six months old and has been more fun to write and much better received than I had imagined it would be. JailMedicine has had over 30,000 hits! Thank you especially to those of you who have written comments. I have my opinions on certain topics (as you have read) but I realize that smart and accomplished people sometimes disagree with me–and sometimes they are right and I am wrong! We all learn and become more effective clinicians when alternative views are expressed and debated–so please comment!
Staged medical clinic at the Bonneville County Jail, Idaho Falls, Idaho. (The “patient” is actually one of the medical staff)
We recently had a 46-year-old male patient booked into our jail who reported a history of diabetes but who had not seen a physician or taken any medications for “years.” He said he used to take a medication for diabetes “a long time ago” but he could not remember the name. He also could not remember the name of the doctor he had once seen. He reported basically no other medical history. Continue reading →
In my previous post on Rethinking Diabetic Snacks for Type 2 Diabetics, I mentioned that there are two theoretical justifications for the practice or prescribing bedtime snacks for type 2 diabetics. I would like to expound on these two issues here and also comment on another issue that I failed to mention in the first article but that is important: the non-medical security issues of having diabetic snacks.
Myth: Four Meals are Better than Three for Type 2 Diabetics
The first justification for diabetic snacks is the idea that if Type 2 diabetics eat several small meals rather than 3 big meals, there will be more even absorption of calories and carbs. This would cause smaller blood sugar spikes at meals. In other words, four meals (counting the bedtime snack) is better than three meals. Continue reading →
I had an obese Type 2 diabetic patient at one of my jails recently who wrote a long grievance about not receiving a bedtime snack. He argued in the grievance that he had received a bedtime snack at previous facilities where he was incarcerated (which was true) and a bedtime snack was “the standard of care” for Type 2 diabetics. I thought that this argument was ridiculous, especially since this patient routinely purchases lots of candy bars and Ramen Noodles from the commissary (think 30-40 candy bars a week).
However, despite the fact that bedtime snacks are routine at many correctional facilities, I believe that bedtime snacks for Type 2 diabetics in a correctional setting is, in most instances, a bad idea and bad medical care. I would like to discuss why this is so by discussing what our overall goals for Type 2 diabetic management are, where the whole idea of diabetic snacks came from in the first place, and then present three cases. Continue reading →
People come to jail taking the weirdest insulin regimens. Often times, I don’t know whether these insulin schems are the result of a practitioner who does not understand insulin dosing well, or whether the patient “tinker” with their insulin dosing, themselves. Here is a case from one my jails (I have changed some of the data and patient characteristics to protect patient privacy).
Banting and Best, Discoverers of insulin
A type 1 diabetic comes to jail taking Lantus 15 units in the morning and 40 units in the evening. He says he takes his Humalog on a sliding scale, but when asked to define exactly what the parameters of his sliding scale are, it becomes apparent that he basically decides his Humalog dose based on gut-feeling. He may take nothing; he may take up to 15 units. He certainly has no concept of counting carbs. He thinks his average Humalog dose is 6 units. His admission HbA1C is 12.8, or an average blood sugar of over 300. In other words, he is not doing a very good job of controlling his blood sugars on the outside.
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 →
Patient weight is a powerful diagnostic tool that is underutilized in corrections.
The reason for this, probably, is that not much attention is paid to weights in outside medicine. In a general medical clinic, say, a patient’s weight could be compared to their last routine visit and some general conclusions might be reached–such as “You have gained 10 pounds since last year. This is not good for your general health.”
However, things are different in corrections. Our patients are with us all the time–they never go home. Many are “frequent fliers” in the medical clinic, either due to their medical problems or because they complain a lot. I have found that patient weights in correctional clinics are a gold mine of useful information. So much so, that I think a patient weight should be the Fifth Vital Sign.
Let me give you several situations where weights will help you. Often, the patient weight is the only objective evidence you have to assess a patient complaint!
I have found, in my years of practicing correctional medicine, that few practitioners who come to corrections are comfortable with insulin dosing. In my experience, this is especially true for physician assistants and nurse practitioners, but many physicians have problems, too. Insulin dosing can be complicated and tricky at times, but for most patients, 10 simple rules will get you to where you need to be.
We first need to cover some groundwork and some terms. Insulin terminology can be confusing. First, it is very important to remember that this discussion applies to type 1 diabetics only. Type 2 diabetics sometimes use insulin, but that’s a “whole ‘nother ballgame.”
Self Monitoring of Glucose in Type 2 Diabetics Does Not Work
The Cochrane Review did an analysis of 9 studies of self monitoring of blood glucose. In these studies, There was no beneficial long term effect of self monitoring of blood sugars in Type 2 diabetics not on insulin. The authors say “We did not find good evidence for an effect on general health-related quality of life, general well-being, patient satisfaction, or on the decrease of the number of hypoglycaemic episodes. “
I had run into this concept before. This study randomized Type 2 diabetics into two groups. The first group received glucometers and were encouraged to check their blood sugars as frequently as they wanted. The second group had no glucometer and could not check their own blood sugars. At one year, there was no significant benefit to self-monitoring of blood sugars. In fact, the only significant difference between the groups was that the self-monitoring group had more depression!
Of course, all patients on insulin, whether Type 1 or Type 2, need to have their blood sugars checked at least every time they get insulin.
However, the take home message from these studies for me is that doing a lot of glucometer checks in Type 2 diabetics who are not on insulin is probably a waste of time, despite the fact that it is heavily marketed on TV. The proper way to follow diabetic control in these patients is by using the HbA1C every 3-6 months.
If you do frequent blood sugar checks in these patients at your facility, bring up the Cochrane Study at your utilization review committee meetings and talk about it!
I know that this can be a controversial topic. Any feedback?